The Chain of Adherence for Incidentally Detected Pulmonary Nodules after an Initial Radiologic Imaging Study: A Multisystem Observational Study

Grady H. Hedstrom, Elizabeth R. Hooker, Matthew Howard, Sarah Shull, Sara E. Golden, Mark E. Deffebach, John D. Gorman, Katherine Murphy, Angela Fabbrini, Anne C. Melzer, Christopher G. Slatore

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Rationale: Millions of people are diagnosed with incidental pulmonary nodules every year. Although most nodules are benign, it is universally recommended that all patients be assessed to determine appropriate follow-up and ensure that it is obtained. Objectives: To determine the degree of concordance and adherence to 2005 Fleischner Society guidelines among radiologists, clinicians, and patients at two Veterans Affairs healthcare systems with incidental nodule tracking systems. Methods: Trained researchers abstracted data from the electronic health records of patients with incidental pulmonary nodules as identified by interpreting radiologists from 2008 to 2016. We classified radiology reports and patient follow-up into three categories. Radiologist–Fleischner adherence was the agreement between the radiologist’s recommendation in the computed tomography (CT) report and the 2005 Fleischner Society guidelines. Clinician/patient–Fleischner concordance was agreement between patient follow-up and the guidelines. Clinician/patient–radiologist adherence was agreement between the radiologist’s recommendation and patient follow-up. We evaluated whether the recommendation or follow-up was more (e.g., sooner) or less (e.g., later) aggressive than recommended. Results: After exclusions, 4,586 patients with 7,408 imaging tests (n = 4,586 initial chest CT scans; n = 2,717 follow-up chest CT scans; n = 105 follow-up low-dose CT scans) were included. Among radiology reports that could be classified in terms of Fleischner Society guidelines (n = 3,150), 80% had nonmissing radiologist recommendations. Among those reports, radiologist–Fleischner adherence was 86.6%, with 4.8% more aggressive and 8.6% less aggressive. Among patients whose initial scans could be classified, clinician/patient–Fleischner concordance was 46.0%, 14.5% were more aggressive, and 39.5% were less aggressive. Clinician/patient–radiologist adherence was 54.3%. Veterans whose radiology reports were adherent to Fleischner Society guidelines had a substantially higher proportion of clinician/patient–Fleischner concordance: 52.0% concordance among radiologist–Fleischner adherent versus 11.6% concordance among radiologist–Fleischner nonadherent. Conclusions: In this multi–health system observational study of incidental pulmonary nodule follow-up, we found that radiologist adherence to 2005 Fleischner Society guidelines may be necessary but not sufficient. Our results highlight the many facets of care processes that must occur to achieve guideline-concordant care.

Original languageEnglish (US)
Pages (from-to)1379-1389
Number of pages11
JournalAnnals of the American Thoracic Society
Issue number8
StatePublished - Aug 2022

Bibliographical note

Funding Information:
Supported by an award from the Department of Veterans Affairs Health Services Research and Development (CSRD EPID-007-15S and HSRD IIR 16-003 to C.G.S.). The study was also supported by resources from the Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. government.

Funding Information:
The authors acknowledge the help and support of Tara Thomas, B.S., Sujata Thakurta, M.P.A.:H.A., and Philip Tostado, M.A. and offer thanks for their countless hours of manual chart review.

Publisher Copyright:
Copyright © 2022 by the American Thoracic Society.


  • adherence
  • guidelines
  • pulmonary nodule
  • surveillance


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