Quality Review: Fleischner Criteria Adherence by Radiologists in a Large Community Hospital

Purpose: Solitary pulmonary nodules are a common incidental finding on CT and unnecessary follow-up affects cost, radiation exposure, and patient anxiety. The aim of this study was to evaluate the adherence of one institution's radiologists with published criteria in their follow-up recommendations. Methods: A data set of 3,000 CT scans with the word nodule used in the report history or conclusion from 2008 to 2010 was generated. This pool was increased as each study was traced back to the examination when the pulmonary nodule was first identified. The follow-up recommendation of the radiologist was then classified as "adherent," "incomplete/no recommendation," "earlier than recommended by the criteria," "later than recommended," or a "wider follow-up time frame than recommended." Results: After the implementation of exclusion criteria, 1,432 examinations were satisfactory for classification. The adherence rates of radiologists for nodules followed in up to 4 consecutive examinations were 57%, 48%, 70%, and 79%, respectively. Overmanagement was the most common deviation from the Fleischner criteria, ranging from 15% to 28% of evaluated reports. Conclusions: Radiologists at the authors' hospital do not always adhere to the Fleischner criteria, most often recommending closer follow-up. The possibility of missing a malignancy while it is still treatable, medicolegal concerns, and lack of familiarity with the Fleischner criteria are all potential factors in nonadherence.