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A5991 - E-Consult Management of Lung Nodules: Do Primary Care Providers Follow Recommendations?
Author Block: M. Van Buskirk, S. Kumari, C. W. Atwood; Pulmonary Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States.
Backgound: Electronic (E)-Consults are a method of clinical evaluation of patients for various conditions in which a specialist performs a chart and relevant imaging review and provides management recommendations to the patient's primary care provider (PCP) . E-consults have the advantage of providing rapid clinical attention to a patient, since an office visit need not be scheduled, and may decrease the need for a patient to travel a long distance to a medical center appointment. The VA Pittsburgh Healthcare System Lung Nodule Evaluation program has been using E consults for some lung nodule referrals (those less than 1cm) since 2012. We were interested in determining if primary care providers referring patients to this program for small lung nodules follow the recommendations provided in terms of repeat imaging timing. Methods: We reviewed a convenience sample of 52 lung nodule consults from fiscal year 2015. The referrals were from 40 fulltime VA primary care practitioners, including both physicians and CRNP/PA’s. The patient age range was 37 to 90 and the gender distribution was 51 males and 1 female. The pulmonary service practitioners followed the 2005 Fleischner Society guidelines for determining the appropriate interval for follow-up imaging. We categorized PCP imaging orders as meeting or not meeting our recommendations based on whether the follow-up imaging was performed within the recommended time +- 1 month. Results: Out of 52 referrals we found 16 instances in which the PCP did not follow the recommendations provided by the pulmonary service. In 5/14 cases, the PCP ordered the follow-up imaging earlier than recommended and in 9/14 cases the imaging was performed at an interval longer than recommended. Discussion: Our study demonstrated that in 31% of cases primary care providers did not follow the pulmonary service recommendations for interval repeat imaging. Primary care providers tended to order repeat imaging (CT scans) at an interval longer than recommended by the pulmonary service. Patient delays may also have affected the timing of the imaging. Although the majority of PCPs followed our recommendations for repeat imaging, this study demonstrates an opportunity for improved education for some PCPs around the appropriate timing of follow-up imaging for small lung nodules. There are possible clinical ramifications, such as an increased frequency of CT scans leading to excessive radiation exposure and increased expenditures without clinical benefit, which deserve further exploration, as well.