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Pulmonary Nodule Management-Guideline Consistent Care in a Community Setting
Critical Care SESSION TITLE: Late-Breaking Abstracts: Clinical Pulmonary and Critical Care Medicine SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, April 17, 2016 at 01:00 PM - 02:00 PM
Pulmonary Nodule Management-Guideline Consistent Care in a Community Setting Archan Shah MD* Dinesh Kotak MD Swapna Parikh MD Antoine Sayegh MD Jeffrey Moore MD Rick Peng MD Wilson Sohoo MD; and Anandray Patel DO Kaiser Permanante, Roseville, CA PURPOSE: Pulmonary nodule work-up is guideline inconsistent. Reasons for this are multifactorial, including provider bias, practice differences, lack of referral to appropriate specialist(s), prevalence of malignancy, patient preference and others. The risks of guideline inconsistent care include misdiagnosis, delayed diagnosis, patient dissatisfaction, inefficiency and others. To address this we created the Lung Nodule Pathway (LNP) to manage pulmonary nodules (6-30mm) following evidence based guidelines. METHODS: Referrals are initiated directly from radiology. The findings are reviewed by a multidisciplinary group of physicians leveraging secure web based conferencing and our robust electronic medical record system. This group reviews the images and other relevant clinical information to formulate a plan based on NCCN and ACCP guidelines. This plan is discussed with the patient by the coordinator and additional tests /treatment are scheduled. The patients’ primary care physician is updated and encouraged to attend the multidisciplinary meeting. A designated coordinator plays a central role in ensuring expeditious work up. The patient meets only the specialist(s) who would provide direct medical care - i.e surgeon for surgery, pulmonologist or radiologist for biopsy or oncologist for chemotherapy. For patient requiring radiologic surveillance, the coordinator schedules the scans and sends reminders.
CRITICAL CARE
RESULTS: Since 2011 we have reviewed a total of 1164 patients. 228 (19.6%) of the patients had proven malignancy. The median time from nodule detection to LNP review was shortened from 31.9 days to 11 days. The median time from formulation of plan to diagnosis was shortened from 28.6 to 16.1 days and the time to treatment was also reduced from 33 days to 22 days. Review of the SEER database for NSCLC for our facility has interestingly shown a trend towards stage migration with a higher proportion of patients being diagnosed with localized disease (18.1% in 2010 0 27.6% for 2014) with a corresponding reduction in patients diagnosed with distant disease (52.4% in 2010 0 44.7% in 2014). CONCLUSIONS: Guideline consistent work-up of pulmonary nodule(s) at Community centers involving a multidisciplinary approach from time of detection improves time to diagnosis, reduces unnecessary tests and may lead to early detection of lung cancers. CLINICAL IMPLICATIONS: Pulmonary Nodules can be efficiently investigated in community setting in a multidisciplinary fashion leveraging technology. Multidisciplinary care improves outcomes. DISCLOSURE: The following authors have nothing to disclose: Archan Shah, Dinesh Kotak, Swapna Parikh, Antoine Sayegh, Jeffrey Moore, Rick Peng, Wilson Sohoo, Anandray Patel No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.02.184
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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Pulmonary Nodule Management-Guideline Consistent Care in a Community Setting Archan Shah MD* Dinesh Kotak MD Swapna Parikh MD Antoine Sayegh MD Jeffrey Moore MD Rick Peng MD Wilson Sohoo MD; and Anandray Patel DO Kaiser Permanante, Roseville, CA PURPOSE: Pulmonary nodule work-up is guideline inconsistent. Reasons for this are multifactorial, including provider bias, practice differences, lack of referral to appropriate specialist(s), prevalence of malignancy, patient preference and others. The risks of guideline inconsistent care include misdiagnosis, delayed diagnosis, patient dissatisfaction, inefficiency and others. To address this we created the Lung Nodule Pathway (LNP) to manage pulmonary nodules (6-30mm) following evidence based guidelines. METHODS: Referrals are initiated directly from radiology. The findings are reviewed by a multidisciplinary group of physicians leveraging secure web based conferencing and our robust electronic medical record system. This group reviews the images and other relevant clinical information to formulate a plan based on NCCN and ACCP guidelines. This plan is discussed with the patient by the coordinator and additional tests /treatment are scheduled. The patients’ primary care physician is updated and encouraged to attend the multidisciplinary meeting. A designated coordinator plays a central role in ensuring expeditious work up. The patient meets only the specialist(s) who would provide direct medical care - i.e surgeon for surgery, pulmonologist or radiologist for biopsy or oncologist for chemotherapy. For patient requiring radiologic surveillance, the coordinator schedules the scans and sends reminders.
CRITICAL CARE
RESULTS: Since 2011 we have reviewed a total of 1164 patients. 228 (19.6%) of the patients had proven malignancy. The median time from nodule detection to LNP review was shortened from 31.9 days to 11 days. The median time from formulation of plan to diagnosis was shortened from 28.6 to 16.1 days and the time to treatment was also reduced from 33 days to 22 days. Review of the SEER database for NSCLC for our facility has interestingly shown a trend towards stage migration with a higher proportion of patients being diagnosed with localized disease (18.1% in 2010 0 27.6% for 2014) with a corresponding reduction in patients diagnosed with distant disease (52.4% in 2010 0 44.7% in 2014). CONCLUSIONS: Guideline consistent work-up of pulmonary nodule(s) at Community centers involving a multidisciplinary approach from time of detection improves time to diagnosis, reduces unnecessary tests and may lead to early detection of lung cancers. CLINICAL IMPLICATIONS: Pulmonary Nodules can be efficiently investigated in community setting in a multidisciplinary fashion leveraging technology. Multidisciplinary care improves outcomes. DISCLOSURE: The following authors have nothing to disclose: Archan Shah, Dinesh Kotak, Swapna Parikh, Antoine Sayegh, Jeffrey Moore, Rick Peng, Wilson Sohoo, Anandray Patel No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.02.184
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
178A
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149#4S CHEST APRIL 2016
]