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Observational Study
. 2017 Aug;152(2):263-270.
doi: 10.1016/j.chest.2017.01.018. Epub 2017 Jan 20.

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation

Nichole T Tanner  1 , Alexander Porter  2 , Michael K Gould  3 , Xiao-Jun Li  2 , Anil Vachani  4 , Gerard A Silvestri  5
Affiliations
Observational Study

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation

Nichole T Tanner et al. Chest. 2017 Aug.

Abstract

Background: The annual incidence of pulmonary nodules is estimated at 1.57 million. Guidelines recommend using an initial assessment of nodule probability of malignancy (pCA). A previous study found that despite this recommendation, physicians did not follow guidelines.

Methods: Physician assessments (N = 337) and two previously validated risk model assessments of pretest probability of cancer were evaluated for performance in 337 patients with pulmonary nodules based on final diagnosis and compared. Physician-assessed pCA was categorized into low, intermediate, and high risk, and the next test ordered was evaluated.

Results: The prevalence of malignancy was 47% (n = 158) at 1 year. Physician-assessed pCA performed better than nodule prediction calculators (area under the curve, 0.85 vs 0.75; P < .001 and .78; P = .0001). Physicians did not follow indicated guidelines when selecting the next test in 61% of cases (n = 205). Despite recommendations for serial CT imaging in those with low pCA, 52% (n = 13) were managed more aggressively with PET imaging or biopsy; 12% (n = 3) underwent biopsy procedures for benign disease. Alternatively, in the high-risk category, the majority (n = 103 [75%]) were managed more conservatively. Stratified by diagnosis, 92% (n = 22) with benign disease underwent more conservative management with CT imaging (20%), PET scanning (15%), or biopsy (8%), although three had surgery (8%).

Conclusions: Physician assessment as a means for predicting malignancy in pulmonary nodules is more accurate than previously validated nodule prediction calculators. Despite the accuracy of clinical intuition, physicians did not follow guideline-based recommendations when selecting the next diagnostic test. To provide optimal patient care, focus in the areas of guideline refinement, implementation, and dissemination is needed.

Keywords: guideline adherence; nodule management; nodule risk prediction; pulmonary nodules.

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Figures

Figure 1
Figure 1
Consort diagram.
Figure 2
Figure 2
Physician and model receiver operator characteristic curve accuracy.
See this image and copyright information in PMC

Comment in

References

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