Reports From the Field

Improved Coordination of Care for Patients with Abnormalities on Chest Imaging: The Rapid Access Chest and Lung Assessment Program

Journal of Clinical Outcomes Management. 2014 October;22(10)

References

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Methods

Setting

Anne Arundel Medical Center is a 385-bed acute care hospital in Annapolis, Maryland, with a medical staff of nearly 1000 physicians and mid-level providers. There are nearly 30,000 admissions and 95,000 emergency department visits annually. The medical center operates 5 regional diagnostic imaging sites that collectively perform 159,000 imaging studies annually, including 3995 chest CT scans and 5243 abdominal CT scans in 2013. The images are interpreted by 20 radiologists from a single private practice contracted to provide services at these locations. Specialist readers are deployed in nuclear medicine, musculoskeletal, neuroradiology, and breast imaging, but not in thoracic imaging.

Program Description

The goal of the Rapid Access Chest and Lung Assessment Program (RACLAP) is to perform a rapid multidisciplinary assessment of pulmonary findings related to patient symptoms or presenting as incidental findings. First contact with the primary care provider was made by either the interpreting radiologist or the nurse navigator to obtain approval for entrance into the program. At that point, the patients were contacted and offered evaluation. Once evaluated, patients provided informed consent to have their data and outcomes collected and analyzed. The assessment team included a nurse navigator to gather elements of the history, and thoracic surgeons, pulmonologists, and radiologists to make recommendations about further follow-up based on the guidelines of the Fleishner Society [5] and American College of Radiology [6] and knowledge of patient characteristics and risk factors. Patients who were judged to have lower-risk abnormalities were followed within the program for at least 2 years to document stability.

Keeping in close contact with the patient’s primary care physician, the team designed a plan for additional evaluation as necessary. If multidisciplinary consultation was required, the nurse navigator coordinated and facilitated visits to avoid duplication and delays. The RACLAP established a dedicated phone number to receive calls and messages from radiologists at any of the 5 diagnostic facilities and from emergency department or other physicians who encounter patients with abnormal chest imaging findings. Institutional review board approval was obtained for this project.

Analysis

The percentage of RACLAP patients presenting with early stage (IA–IIB) lung cancer diagnosed in the RACLAP was compared with both concurrent controls (those diagnosed during the same time period through traditional referral patterns) and with historic controls (those diagnosed in the 24 months prior to the institution of the RACLAP). A 2-sample test for binomial proportions was used for both of these comparisons.

Physician satisfaction with the program was assessed with an online survey tool sent to the 63 individual referring physicians. The survey tool consisted of 11 questions asking respondents to rate their satisfaction with various aspects of the program on a 1–10 scale where 10 was excellent.

Results

There were 238 patients referred to the RACLAP. Their demographic characteristics, type of imaging abnormality, and source of referrals are described in Table 1 . In 11 cases, primary care physicians used the RACLAP as a facilitated referral access line for patients who did not have lugn abnormalities but who need to be seen by to other parts of the cancer center. These 11 patients are excluded from further analysis. None of the RACLAP patients were enrolled in a lung cancer screening program. One or more pulmonary symptoms that can be a sign of thoracic malignancy [14]were present in 169 (74%) of patients, though in many cases the symptoms either subsequently resolved or clinical judgment suggested that the imaging abnormality was unrelated to the symptom. The disposition of the 227 patients is shown in Table 2