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A5988 - Incidental Pulmonary Nodule Characterization in Primary Care Progress Notes
Author Block: J. Thornton1, K. Black2, E. Stott3, A. Huml4; 1Pulmonary and Critical Care Medicine, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States, 2Internal Medicine, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States, 3School of Medicine, Case Western Reserve University, Cleveland, OH, United States, 4Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, OH, United States.
Rationale: Incidental pulmonary nodules (IPNs) are increasingly identified as the number of CT scans performed continues to increase. Although evidence-based guidelines exist, primary care physicians (PCPs) face challenges in identifying the features of IPNs that are most concerning for malignancy and making decisions regarding follow-up based on the guidelines. We sought to understand PCPs’ medical decision-making by examining their documentation of IPNs in progress notes.
Methods:This mixed methods analysis of PCPs’ progress notes was performed at a large, urban safety-net medical system in Cleveland, OH, with a level 1 trauma center. All primary care patients who underwent a CT scan in 2010 incorporating all lung fields were included if an IPN was documented in their radiology report. Patients were excluded if they had a diagnosis of cancer, did not have a subsequent primary care appointment within the medical system, or if the nodule was previously known. Two coders independently reviewed up to three progress notes (if available) following the CT scan as well as interim telephone encounters which referenced the IPN. PCP notes were coded for IPN diagnosis, cancer risk assessment, plan for treatment or evaluation, and patient discussion and counseling using NVivo 11 Software (QSR International).
Results: 245 patients with IPNs had a subsequent visit with a primary care provider. IPNs were described in the notes of 122 (50%) patients; the most common terms used were “lung nodule” (47 or 19%) and “cancer” (15 or 6%). Documentation of cancer risk occurred in 60 (25%) patients with the most common being a change in IPN size (14 or 6%), smoking history (14 or 6%), or COPD diagnosis (7 or 3%). Smoking cessation counseling was documented in 14 (6%) patients’ progress notes. 123 (50%) patients had documentation of PCP plans for IPN follow-up. 59 (24%) patients were counseled about their IPN. There were only 4 (1.6%) patients who were counseled but declined further recommendations for follow-up. Antibiotics (12 [4.8%]) or steroids (4 [1.6%]) were prescribed for some patients. Referrals to pulmonology, oncology and thoracic surgery were documented in 57 (23%) patients. Of the 34 patients who underwent a biopsy, 26 (76%) were found to be cancerous.
Conclusions: Primary care providers infrequently documented the presence of, characterization of, and plans for follow up of IPNs. Further understanding of the medical decision-making of PCPs regarding IPNs is needed to develop successful interventions to optimize the care of affected patients.