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BACKGROUND: Pulmonary nodules are a common incidental finding on chest Computed Tomography scans (CT), most of the time outside of lung cancer screening (LCS). We aimed to evaluate the number of incidental pulmonary nodules (IPN) found in 1 year in our hospital, as well as the follow-up (FUP) rate and the clinical and radiological features associated with FUP. METHODS: We trained a Natural Language Processing (NLP) tool to identify the transcripts mentioning the presence of a pulmonary nodule, among a large population of patients from a French hospital. We extracted nodule characteristics using keyword analysis. NLP algorithm accuracy was determined through manual reading from a sample of our population. Electronic health database and medical record analysis by clinician allowed us to obtain information about FUP and cancer diagnoses. RESULTS: In this retrospective observational study, we analyzed 101,703 transcripts corresponding to the entire CTs performed in 2020. We identified 1,991 (2 %) patients with an IPN. NLP accuracy for nodule detection in CT reports was 99 %. Only 41 % received a FUP between January 2020 and December 2021. Patient age, nodule size, and the mention of the nodule in the impression part were positively associated with FUP, while nodules diagnosed in the context of COVID-19 were less followed. 36 (2 %) lung cancers were subsequently diagnosed, with 16 (45 %) at a non-metastatic stage. CONCLUSIONS: We identified a high prevalence of IPN with a low FUP rate, encouraging the implementation of IPN management program. We also highlighted the potential of NLP for database analysis in clinical research.

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Purpose: This study evaluates the efficacy of a commercial medical Named Entity Recognition (NER) model combined with a post-processing protocol in identifying incidental pulmonary nodules from CT reports. Methods: We analyzed 9165 anonymized CT reports and classified them into 3 categories: no nodules, nodules present, and nodules >6 mm. For each report, a generic medical NER model annotated entities and their relations, which were then filtered through inclusion/exclusion criteria selected to identify pulmonary nodules. Ground truth was established by manual review. To better understand the relationship between model performance and nodule prevalence, a subset of the data was programmatically balanced to equalize the number of reports in each class category. Results: In the unbalanced subset of the data, the model achieved a sensitivity of 97%, specificity of 99%, and accuracy of 99% in detecting pulmonary nodules mentioned in the reports. For nodules >6 mm, sensitivity was 95%, specificity was 100%, and accuracy was 100%. In the balanced subset of the data, sensitivity was 99%, specificity 96%, and accuracy 97% for nodule detection; for larger nodules, sensitivity was 94%, specificity 99%, and accuracy 98%. Conclusions: The NER model demonstrated high sensitivity and specificity in detecting pulmonary nodules reported in CT scans, including those >6 mm which are potentially clinically significant. The results were consistent across both unbalanced and balanced datasets indicating that the model performance is independent of nodule prevalence. Implementing this technology in hospital systems could automate the identification of at-risk patients, ensuring timely follow-up and potentially reducing missed or late-stage cancer diagnoses.

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Introduction: Incidental pulmonary nodules (IPN) are common radiologic findings, yet management of IPNs is inconsistent across Canada. This study aims to improve IPN management based on multidisciplinary expert consensus and provides recommendations to overcome patient and system-level barriers. Methods: A modified Delphi consensus technique was conducted. Multidisciplinary experts with extensive experience in lung nodule management in Canada were recruited to participate in the panel. A survey was administered in 3 rounds, using a 5-point Likert scale to determine the level of agreement (1 = extremely agree, 5 = extremely disagree). Results: Eleven experts agreed to participate in the panel; 10 completed all 3 rounds. Consensus was achieved for 183/217 (84.3%) statements. Panellists agreed that radiology reports should include a standardized summary of findings and follow-up recommendations for all nodule sizes (ie, <6, 6-8, and >8 mm). There was strong consensus regarding the importance of an automated system for patient follow-up and that leadership support for organizational change at the administrative level is of utmost importance in improving IPN management. There was no consensus on the need for standardized national referral pathways, development of new guidelines, or establishing a uniform picture archiving and communication system. Conclusion: Canadian IPN experts agree that improved IPN management should include standardized radiology reporting of IPNs, standardized and automated follow-up of patients with IPNs, guideline adherence and implementation, and leadership support for organizational change. Future research should focus on the implementation and long-term effectiveness of these recommendations in clinical practice.

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OBJECTIVE: To quantify the relative importance of demographic, contextual, socio-economic, and nodule-related factors that influence patient adherence to incidental pulmonary nodule (IPN) follow-up visits and evaluate the predictive performance of machine learning models utilizing these features. METHODS: We curated a 1,610-subject patient data set from electronic medical records consisting of 13 clinical and socio-economic predictors and IPN follow-up adherence status (timely, delayed, or never) as the outcome. Univariate analysis and multivariate logistic regression were performed to quantify the predictors' contributions to follow-up adherence. Three additional machine learning models (random forests, neural network, and support vector machine) were fitted and cross-validated to examine prediction performance across different model architectures and evaluate intermodel concordance. RESULTS: On univariate basis, all 13 predictors except comorbidity were found to have a significant association with follow-up. In multiple logistic regression, inpatient or emergency clinical context (odds ratio favoring never following up: 7.28 and 8.56 versus outpatient, respectively) and high nodule risk (odds ratio: 0.25 versus low risk) are the most significant predictors of follow-up, and sex, race, and marital status become additionally significant if clinical context is removed from the model. Clinical context itself is associated with sex, race, insurance, employment, marriage, income, nodule risk, and smoking status, suggesting its role in mediating socio-economic inequities. On cross-validation, all four machine learning models demonstrated comparable and good predictive performances, with mean area under the curve ranging from 0.759 to 0.802, with sensitivity 0.641 to 0.660 and specificity 0.768 to 0.840. CONCLUSION: Socio-economic factors and clinical context are predictive of IPN follow-up adherence, with clinical context being the most significant contributor and likely representing uncaptured socio-economic determinants.

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Background and Objective: Incidental pulmonary nodules (IPNs) are common and increasingly detected with the overall rise of radiologic imaging. Effective IPN management is necessary to ensure lung cancer is not missed. This study aims to describe the current landscape of IPN management in Canada, understand barriers to optimal IPN management, and identify opportunities for improvement. Methods: We performed a narrative literature review by searching biomedical electronic databases for relevant articles published between January 1, 2010, and November 22, 2023. To validate and complement the identified literature, we conducted structured interviews with multidisciplinary experts involved in the pathway of patients with IPNs across Canada. Interviews between December 2021 and May 2022 were audiovisual recorded, transcribed, and thematically analyzed. Key Content and Findings: A total of 1,299 records were identified, of which 37 studies were included for analysis. Most studies were conducted in Canada and the United States and highlighted variability in radiology reporting of IPNs and patient management, and limited adherence to recommended follow-up imaging. Twenty experts were interviewed, including radiologists, respirologists, thoracic surgeons, primary care physicians, medical oncologists, and an epidemiologist. Three themes emerged from the interviews, supported by the literature, including: variability in radiology reporting of IPNs, suboptimal communication, and variability in guideline adherence and patient management. Conclusions: Despite general awareness of guidelines, there is inconsistency and lack of standardization in the management of patients with IPNs in Canada. Multidisciplinary expert consensus is recommended to help overcome the communication and operational barriers to a safe and cost-effective approach to this common clinical issue.

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Incidental pulmonary nodules are common. Although the majority are benign, most are indeterminate for malignancy when first encountered making their management challenging. CT remains the primary imaging modality to first characterize and follow-up incidental lung nodules. This document reviews available literature on various imaging modalities and summarizes management of indeterminate pulmonary nodules detected incidentally. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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Lung cancer (LC) is one of the leading causes of cancer deaths worldwide. In India, the incidence of LC is increasing rapidly, and a majority of the patients are diagnosed at advanced stages of the disease when treatment is less likely to be effective. Recent therapeutic developments have significantly improved survival outcomes in patients with LC. Prompt specialist referral remains critical for early diagnosis for improved patient survival. In the Indian scenario, distinguishing LC from benign and endemic medical conditions such as tuberculosis can pose a challenge. Hence, awareness regarding the red flags-signs and symptoms that warrant further investigations and referral-is vital. This review is an effort toward encouraging general physicians to maintain a high index of clinical suspicion for those at risk of developing LC and assisting them in refering patients with concerning symptoms to specialists or multidisciplinary teams as early as possible.

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Small pulmonary nodules (≤1.5 cm) are frequently detected on routine chest imaging and lung cancer screening studies. Our goal was to determine the clinical value of CT-guided core needle biopsy (CNB) in the evaluation of such nodules. In this single-center study, we retrospectively analyzed patient data (n = 44) for CNBs on lung nodules (≤1.5 cm) performed at our biopsy center between May 2017 and March 2020. We analyzed for the rate of pathology diagnosis, molecular/biomarker analysis, complications, and change in clinical management and outcome over a period ranging up to 60 months after biopsy. A pathology diagnosis of malignancy or benign lesion was obtained in 97.9% of biopsies in this cohort. The rate of complications was low with only 6.8% of patients requiring the insertion of a temporary small profile interventional radiology (IR) pigtail chest tube for pneumothorax. Out of the subset of biopsy specimens that were sent for tissue molecular analysis, 90% had enough tissue preserved after initial pathological analysis to obtain at least one molecular marker. Our data show that CT-guided CNB is safe and reliable, and should be considered for the evaluation of small, suspicious lung nodules found on routine screenings for the early detection and evaluation of malignant lesions.

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PURPOSE: Despite established guidelines, radiologists' recommendations and timely follow-up of incidental lung nodules remain variable. To improve follow-up of nodules, a system using standardized language (tracker phrases) recommending time-based follow-up in chest CT reports, coupled with a computerized registry, was created. MATERIALS AND METHODS: Data were obtained from the electronic health record and a facility-built electronic lung nodule registry. We evaluated two randomly selected patient cohorts with incidental nodules on chest CT reports: before intervention (September 2008 to March 2011) and after intervention (August 2011 to December 2016). Multivariable logistic regression was used to compare the cohorts for the main outcome of timely follow-up, defined as a subsequent report within 13 months of the initial report. RESULTS: In all, 410 patients were included in the pretracker cohort versus 626 in the tracker cohort. Before system inception, 30% of CT reports lacked an explicit time-based recommendation for nodule follow-up. The proportion of patients with timely follow-up increased from 46% to 55%, and the proportion of those with no documented follow-up or follow-up beyond 24 months decreased from 48% to 31%. The likelihood of timely follow-up increased 41%, adjusted for high risk for lung cancer and age 65 years or older. After system inception, reports missing a tracker phrase for nodule recommendation averaged 6%, without significant interyear variation. CONCLUSIONS: Standardized language added to CT reports combined with a computerized registry designed to identify and track patients with incidental lung nodules was associated with improved likelihood of follow-up imaging.

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PURPOSE: The aim of this study was to evaluate racial/ethnic disparities in follow-up adherence for incidental pulmonary nodules (IPNs) using a cascade-of-care framework, representing the multistage pathway from IPN diagnosis to timely follow-up adherence. METHODS: A cohort of 1,562 patients diagnosed with IPNs requiring follow-up in a tertiary health care system in 2016 were retrospectively identified. Racial/ethnic disparities in follow-up adherence were examined by developing a multistep cascade-of-care model (provider communication, follow-up examination ordering and scheduling, adherence) to identify where patients were most likely to fall off the path toward adherence. Racial/ethnic adherence disparities were measured using descriptive statistics and multivariate modeling, controlling for sociodemographic, communication, and health characteristics. RESULTS: Among 1,562 patients whose IPNs required follow-up, unadjusted results showed that nonwhite patients were less likely to meet each step on the cascade than White patients: for provider-patient IPN communication, 55% among Black patients and 80% among White patients; for follow-up ordering and scheduling, 42% and 41% among Black patients and 66% and 64% among White patients; and for timely adherence, 29% among Black patients and 54% among White patients. Adjusting for provider communication, sociodemographic, and health characteristics, Black patients had increased odds of never adhering to and delaying follow-up compared with White patients (odds ratios, 1.30 [95% confidence interval, 0.90-1.89] and 2.51 [95% confidence interval, 1.54-4.09], respectively). CONCLUSIONS: These findings demonstrate substantial racial/ethnic disparities in IPN follow-up adherence that persist after adjusting for multiple characteristics. The cascade of care demonstrates where on the adherence pathway patients are at risk for falling off, enabling specific targets for health policy and clinical interventions. Radiologists can play a key role in improving IPN follow-up via increased patient care involvement.

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OBJECTIVE: Incidental pulmonary nodules (IPNs) are common. Up to 70% are not followed up according to current guidelines. Follow-up recommendations are based on the characteristics of the patient and the IPN. However, many IPNs are incompletely characterized in CT reports. Structured radiology reports have been shown to reduce missing information. We sought to improve IPN reporting by assessing the feasibility, acceptability, and effectiveness of a structured dictation template to increase the presence of six key nodule descriptors. METHODS: We performed a mixed methods, pre- and postimplementation assessment. A template was developed with a multidisciplinary group based on Fleischner Society guidelines. A standardized checklist was used to determine the presence of documented descriptors pre- and postimplementation for sequential radiology reports of patients with an IPN present (n = 400 pre-implementation and n = 400 postimplementation) on a CT performed at the Minneapolis Veterans Affairs Health Care System. We conducted qualitative interviews with radiologists (n = 4) and members of the lung nodule tracking team (n = 2) to elicit their experiences of the template implementation process. RESULTS: The proportion of radiology reports including all six elements increased from 12% to 47% (P < .001). Postimplementation, the template was used in 40% of interpretations involving lung nodules, 67% of follow-up scans, and 8% of initial identifications. Response to the template was overall positive. DISCUSSION: Use of a dictation template seems to be effective in increasing compliance with full IPN documentation, streamlining the follow-up process. Low utilization rates of the template for initial nodule identification is a limitation, which may be combated through clearer communication and advances in technology.

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OBJECTIVE. The purpose of this study is to assess radiologists' adoption of a closed-loop communication and tracking system, Result Alert and Development of Automated Resolution (RADAR), for incidental pulmonary nodules and to measure its effect on the completeness of radiologists' follow-up recommendations. MATERIALS AND METHODS. This retrospective study was performed at a tertiary academic center that performs more than 600,000 radiology examinations annually. Before RADAR, the institution's standard of care was for radiologists to generate alerts for newly discovered incidental pulmonary nodules using a previously described PACS-embedded software tool. RADAR is a new closed-loop communication tool embedded in the PACS and enterprise provider workflow that enables establishing a collaborative follow-up plan between a radiologist and referring provider and helps automate collaborative follow-up plan tracking and execution. We assessed RADAR adoption for incidental pulmonary nodules, the primary outcome, in our thoracic radiology division (study period March 9, 2018, through August 2, 2018). The secondary outcome was the completeness of follow-up recommendation for incidental pulmonary nodules, defined as explicit imaging modality and time frame for follow-up. RESULTS. After implementation, 106 of 183 (58%) incidental pulmonary nodules alerts were generated using RADAR. RADAR adoption increased by 75% during the study period (40% in the first 3 weeks vs 70% in the last 3 weeks; p < 0.001 test for trend). All RADAR alerts had explicit documentation of imaging modality and follow-up time frame, compared with 71% for non-RADAR alerts for incidental pulmonary nodules (p < 0.001). CONCLUSION. A closed-loop communication system that enables establishing and executing a collaborative follow-up plan for incidental pulmonary nodules can be adopted and improves the quality of radiologists' follow-up recommendations.

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OBJECTIVE: Lung cancer screening programs have become increasingly prevalent within the United States after the National Lung Screening Trial results. We aimed to review the financial impact after programmatic implementation of Advanced Registered Nurse Practitioner-led programs of Lung Cancer Screening and Tobacco Related Diseases, Incidental Pulmonary Nodule Clinic, and Tobacco Cessation Services. METHODS: We reviewed revenue from 2013 to 2016 by our nurse practitioner-led program. Encounters were queried for charges related to outpatient evaluation and management, professional procedures, and facility charges related to both outpatient and inpatient procedures. Revenue was normalized using 2016 data tables and the national Medicare conversion factor (35.8043). RESULTS: Our program evaluated 694 individuals, of whom 75% (518/694) are enrolled within the lung cancer-screening program. Overall revenue associated with the programs was $733,336. Outpatient evaluation and management generated revenue of $168,372. In addition, professional procedure revenue accounted for an additional $60,015 with facility revenue adding an additional $504,949. CONCLUSIONS: A nurse practitioner-led program of lung cancer screening, incidental pulmonary nodules, and tobacco-cessation services can provide additional revenue opportunities for a Thoracic Surgery and Interventional Pulmonology Division, as well as a health care system. The current national, median annual wage of a nurse practitioner is $98,190, and the cost associated directly to their salary (and benefits) may remain neutral or negative within certain programs. However, the larger economic benefit may be realized within the division and institution. This potential additional revenue appears related to evaluation of newly identified diseases and subsequent evaluations, procedures, and operations.

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PURPOSE: Incidental pulmonary nodules that require follow-up are often noted on chest CT. Evidence-based guidelines regarding appropriate follow-up have been published, but the rate of adherence to guideline recommendations is unknown. Furthermore, it is unknown whether the radiology report affects the nodule follow-up rate. METHODS: A review of 1,000 CT pulmonary angiographic studies ordered in the emergency department was performed to determine the presence of an incidental pulmonary nodule. Fleischner Society guidelines were applied to ascertain if follow-up was recommended. Radiology reports were classified on the basis of whether nodules were listed in the findings section only, were noted in the impression section, or had explicit recommendations for follow-up. Whether the rate of nodule follow-up was affected by the radiology report was determined according to these 3 groups. RESULTS: Incidental pulmonary nodules that required follow-up were noted on 9.9% (95% confidence interval, 8%-12%) of CT pulmonary angiographic studies. Follow-up for nodules was poor overall (29% [28 of 96]; 95% confidence interval, 20%-38%) and decreased significantly when the nodules were mentioned in the findings section only (0% [0 of 12]). Specific instructions to follow up nodules in radiology reports still resulted in a low follow-up rate of 29% (19 of 65; 95% confidence interval, 18%-40%). CONCLUSIONS: Incidental pulmonary nodules detected on CT pulmonary angiography are common and are frequently not followed up appropriately. Although the inclusion of a pulmonary nodule in the impression section of a radiology report is helpful, it does not ensure follow-up. Better systems for appropriate identification and follow-up of incidental findings are needed.

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OBJECTIVE: In areas with endemic histoplasmosis, incidental pulmonary nodules are common. Rate of malignancy and applicability of current tracking guidelines in these regions remain unclear. METHODS: A total of 148 cases of incidental pulmonary nodules tracked with chest computed tomography were reviewed for radiologic characteristics, diagnosis, number, and size. RESULTS: Of the nodules, 87.8% were benign and 12.2% malignant; 30% of nodules >20mm were malignant. Number of nodules (P=.14) and granulomatous disease (P=.71) were not related to malignant diagnosis. CONCLUSION: Malignancy was lower than expected in nodules >20mm. Appropriate tracking guidelines for incidentally discovered nodules in histoplasmosis endemic regions must be determined.

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PURPOSE: Incidental pulmonary nodules that require follow-up are often noted on chest CT. Evidence-based guidelines regarding appropriate follow-up have been published, but the rate of adherence to guideline recommendations is unknown. Furthermore, it is unknown whether the radiology report affects the nodule follow-up rate. METHODS: A review of 1,000 CT pulmonary angiographic studies ordered in the emergency department was performed to determine the presence of an incidental pulmonary nodule. Fleischner Society guidelines were applied to ascertain if follow-up was recommended. Radiology reports were classified on the basis of whether nodules were listed in the findings section only, were noted in the impression section, or had explicit recommendations for follow-up. Whether the rate of nodule follow-up was affected by the radiology report was determined according to these 3 groups. RESULTS: Incidental pulmonary nodules that required follow-up were noted on 9.9% (95% confidence interval, 8%-12%) of CT pulmonary angiographic studies. Follow-up for nodules was poor overall (29% [28 of 96]; 95% confidence interval, 20%-38%) and decreased significantly when the nodules were mentioned in the findings section only (0% [0 of 12]). Specific instructions to follow up nodules in radiology reports still resulted in a low follow-up rate of 29% (19 of 65; 95% confidence interval, 18%-40%). CONCLUSIONS: Incidental pulmonary nodules detected on CT pulmonary angiography are common and are frequently not followed up appropriately. Although the inclusion of a pulmonary nodule in the impression section of a radiology report is helpful, it does not ensure follow-up. Better systems for appropriate identification and follow-up of incidental findings are needed.

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