Systems-Level Resources for Pulmonary Nodule Evaluation in the United States: A National Survey

To the Editor:

Each year, more than 1.5 million Americans are found to have a pulmonary nodule (1). As lung cancer screening becomes prevalent, still more nodules will be identified. Whether detected incidentally or through screening, guidelines recommend evaluating pulmonary nodules in a timely fashion to identify the subset that are malignant. Yet patients with pulmonary nodules often do not receive appropriate evaluation, seemingly “falling through the cracks” (2, 3). Systems-level structures and processes of care have been proposed to facilitate appropriate, efficient nodule evaluation (4–8), and indeed, clinicians have indicated that such system-level resources are essential to avoid loss to follow-up (9). However, the degree to which these structures and processes of care have been implemented nationally is unclear, and the American Thoracic Society (ATS) has called for more research in this area (10). We conducted a survey of ATS clinicians to characterize the availability of system-level resources to facilitate pulmonary nodule evaluation in the United States.

Methods

We surveyed clinician members of the ATS Respiratory Cell and Molecular Biology and Clinical Problems Assemblies (the parent assemblies of the Section of Thoracic Oncology at the time of survey administration). Eligible clinicians included physicians or midlevel providers who regularly saw patients in an outpatient clinic. ATS sent three e-mails in March and April 2014, inviting clinicians to participate in an anonymous online survey, with a $50 incentive for completion. The 32-item survey asked about demographics, practice setting, and practices regarding lung cancer screening and nodule evaluation. The Boston University Institutional Review Board approved this study.

Although this was an international survey, we restricted analysis to responses from U.S. clinicians, given differences in resource availability and practice patterns across countries. Proportions were compared using chi-squared tests, and medians with the Kruskal-Wallis test, with two-sided α < 0.05 as the threshold for statistical significance. All data were analyzed using Stata 10.1 (College Station, TX).

Results

Of 5,872 ATS members with a valid e-mail address, 1,444 opened the survey invitation and 428 eligible clinicians participated (response rate, 7% overall; 30% of those who opened the e-mail). Table 1 shows the characteristics and practice settings of the 320 U.S. respondents.

Table 1.

Respondent Characteristics

Characteristics	%
Male	74.3
Physician	99.1
Clinical specialty
Pulmonary/critical care/sleep	90.5
Primary care/internal medicine	7.5
Cardiothoracic surgery	0.9
Radiology	0.6
Outpatient versus inpatient effort
Exclusively outpatient	6.0
Mostly outpatient	49.2
Mostly inpatient	44.8
Practice type
Academic	62.2
Community/health maintenance organization/other	30.0
Department of Veteran Affairs	7.8
Practice setting
Urban	69.5
Suburban	24.8
Rural	5.7
Practice location
Northeast	37.8
South	15.3
Midwest	27.8
West	19.1

The most common structures and processes of care in place were inclusion of Fleischner Society guidelines in radiology reports (82.7%), flagged prompts to the ordering provider on radiology reports with new nodules (59.4%), and staff members to facilitate nodule evaluation (e.g., scheduling appointments, 55.2%) (Figure 1). Most respondents reported some (median, 3; interquartile range, 2–5) system-level resources to facilitate nodule evaluation. Veterans Affairs (VA) sites tended to have more resources in place, with 88.0% reporting at least three (vs. 69.8% at academic centers and 53.1% at community/health maintenance organization facilities; P < 0.001). There was a broad distribution of reported resources within all groups, however, with 11 respondents (3.5%) reporting no structures or processes of care to facilitate nodule evaluation and eight respondents (2.5%) reporting nine or more system-level resources in place.

Figure 1.

Systems-level resources in place to facilitate pulmonary nodule evaluation. E-consults = electronic consults; EMR = electronic medical record; HMO = health maintenance organization; VA = Veterans Affairs.

When comparing types of facilities, VA sites were significantly more likely to report electronic consults (64.0% VA, 15.7% academic, 7.4% community; P < 0.01; Figure 1). Clinicians in VA and academic settings were significantly more likely to report dedicated pulmonary nodule clinics than community/health maintenance organization physicians (48.0% VA, 49.5% academic, 10.6% community; P < 0.01). Academic settings were significantly more likely to report availability of same-day consults for pulmonary nodules (8.0% VA, 17.3% academic, 5.3% community; P < 0.01).

Discussion

This national survey identifies great variation in the availability of systems-level resources to facilitate pulmonary nodule evaluation across the United States. Although several structures and processes of care have been implemented to facilitate nodule evaluation, particularly in VA sites, only the use of templated reporting including guideline recommendations, radiology flags, and staff for scheduling have diffused to the majority of sites. Hence, at most sites, there is a missed opportunity to ensure patients with pulmonary nodules receive appropriate care. This raises questions about the preparedness of sites to implement comprehensive lung cancer screening programs, as professional societies recommend that screening programs have standardized structures and processes of care in place not only for screening but also for downstream evaluation and treatment of screen-detected nodules (7, 8).

This study has limitations. First, our response rate was relatively low. Moreover, respondents from urban academic centers were disproportionately represented, whereas VA clinicians represented a small minority of respondents. Thus, our results may not be broadly generalizable. Second, this survey was anonymous: We do not know what centers are represented and whether some sites may be represented by more than one respondent. Finally, our survey does not evaluate the actual resources in place or their quality.

The ATS has identified a need for research to establish which structures and processes most effectively improve outcomes of patients with pulmonary nodules so that facilities know how best to invest limited resources (10). As lung cancer screening is implemented, these studies are all the more urgently needed to assure appropriate resources are in place to facilitate pulmonary nodule evaluation. This study provides the first national data on availability of systems-level processes of care to facilitate pulmonary nodule evaluation, which is critical data to inform readiness for widespread implementation of lung cancer screening.