Using Radiology Reports to Encourage Evidence-based Practice in the Evaluation of Small, Incidentally Detected Pulmonary Nodules. A Preliminary Study

Abstract

RATIONALE: Standard radiology report forms do not guide ordering clinicians toward evidence-based practice. OBJECTIVES: To test an enhanced radiology report that estimates the probability that a pulmonary nodule is malignant and provides explicit, professional guideline recommendations. METHODS: Anonymous, institutional review board-approved, internet-based survey of all clinicians with privileges at the Dartmouth-Hitchcock Medical Center comparing a standard versus an enhanced chest computed tomography report for a 65-year-old former smoker with an incidentally detected 7-mm pulmonary nodule. MEASUREMENTS AND MAIN RESULTS: A total of 43% (n = 447) of 1045 eligible clinicians answered patient management questions after reading a standard and then an enhanced radiology report (which included the probability of malignancy and Fleischner Society guideline recommendations). With the enhanced report, more clinicians chose the correct management strategy (72% with enhanced versus 32% with standard report [40% difference; 95% confidence interval (CI) = 35-45%]), appropriately made fewer referrals to pulmonary for opinions or biopsy (21 vs. 41% [-40% difference; 95% CI = -25 to -16%]), ordered fewer positron emission tomography scans (3 versus 13%; -10% difference; 95% CI = -13 to -7%), and fewer computed tomography scans outside the recommended time interval (2 versus 7%; -5% difference; 95% CI = -7 to -2%). Most clinicians preferred or strongly preferred the enhanced report, and thought they had a better understanding of the nodule's significance and management. CONCLUSIONS: An enhanced radiology report with probability estimates for malignancy and management recommendations was associated with improved clinicians' response to incidentally detected small pulmonary nodules in an internet-based survey of clinicians at one academic medical center, and was strongly preferred. The utility of this approach should be tested next in clinical practice.

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