With the increasing use of computed tomography (CT), the detection of pulmonary nodules has become very frequent, and up to 25-30% of CT scans can reveal these incidental lesions.1 The management of these findings is challenging for professionals and the healthcare system due to the slight but existing probability of diagnosing lung cancer at an early stage.2 To address this problem, guidelines from different medical societies have been published over the years. The Fleischner Society guidelines for the management of incidental pulmonary nodules were first published in 2005 with respect to solid nodules3 and in 2013 with respect to subsolid lesions,4 and both guidelines were updated in 2017.5 These guidelines provide recommendations to act according to nodule characteristics, the clinical profile of patients and the derived risk of malignancy.

Nevertheless, decisions made in clinical practice often do not conform to these standardized recommendations, with studies showing disturbing figures ranging from approximately 30 to 60% adherence.6-9 One of the initiatives that has emerged to address this problem is multidisciplinary nodule clinics. This highly recommended model of care seeks to provide integrated, evidence-based and high-quality assistance, combining the evaluation of various specialists and the application of guidelines.5,10,11 After being implemented in different centers, encouraging results, such as increased adherence to guidelines and a more judicious use of healthcare resources, have been reported.12-15 Moreover, work on the virtual management of pulmonary nodules have also come to light in recent years, with studies mostly concentrated in the United Kingdom (UK).16-21 The related results seem truly promising in terms of adherence to guidelines, patient satisfaction and even economic and time savings for the health system and patients.

Since 2010, our Respiratory Department has implemented a monographic on-site consultation service for the management of incidental pulmonary nodules carried out by pulmonologists. In March 2018, a virtualization and multidisciplinary adaptation process was implemented, giving rise to the virtual lung nodule clinic (VLNC). The objective of this work is to describe the first year of operation of our VLNC, its evaluated population and issued decisions. Secondarily, among discharged patients, we aim to analyze their follow-up prior to the existence of our consultation, evaluating its adherence to guidelines. To our knowledge, this is the first description of a multidisciplinary and virtual assistance model for the management of incidental pulmonary nodules in our country.

A total of 365 patients were evaluated during the first year of the VNLC, and their data were included in the analysis. The clinical and radiological characteristics of the study population are shown in Tables 1 and 2, respectively. Briefly, approximately 60% of the patients were men, with a median [25th; 75th percentile] age of 64 years old [54; 71], and 64% had a smoking history. Additionally, 23% were diagnosed with COPD, and 12.9% reported relevant environmental or occupational exposure.

Regarding radiological characteristics, more than one-half of the patients (57.5%) had multiple nodules, and the majority of these nodules were solid (87.4%). Spiculated nodules were identified in 3.84% of the patients. In addition, 8.22% of nodules were subsolid, including 73% pure ground-glass nodules and 27% part-solid nodules. The median [25th; 75th percentile] size of the nodules was 6.00 [5.00; 8.00] mm. The most frequent locations of the nodules were the lower lobes, with 41.4% located in the RLL and 38.2% located in the LLL. Concerning concomitant radiological findings, 27.4% of the patients had emphysema, and 17.8% had bronchiectasis. Prior to the current CT evaluation at the VLNC, these patients had a median number of 1.00 [1.00; 3.00] previous CTs. The median time of the interval between the first CT and the current one was 11 [3.17; 23.7] months.

After the first VLNC evaluation, 43.8% of the patients were discharged (Fig. 2). The characteristics of the discharged patients according to their previous follow-up are shown in Table 3. Among these patients, only 27.5% underwent “adequate follow-up". However, 66.9% received non-adherent care, of which 50% underwent a “prolonged follow-up” and 50% were classified as “non-indicated follow-up” patients. Upon further characterization of these subgroups, we observed that patients who underwent a “prolonged follow-up” were significantly older (67.0 [56.0; 73.0] vs 60.5 [49.2; 68.0] years old) and presented larger nodules, with a median nodule size of 6.00 [5.00;8 .00] vs 5.00 [4.00; 7.00] mm compared to patients with “adequate follow-up”. No differences were noted according to subtype, number or location of nodules, or clinical characteristics. In addition, the “non-indicated follow-up” group included significantly more patients who were non-smokers (77.8% vs 31.8%) and presented with smaller nodules (4.00 [4.00; 5.00] vs 5.00 [4.00; 7.00] mm) with a higher proportion located in the LLL (51.9% vs 27.9%) compared to patients in the “adequate follow-up” group.

Figure 2.

Issued recommendations. Recommendations issued during the first year of operation of the VLNC.

Figure abbreviations: VLNC: virtual lung nodule clinic; FDT: fast diagnostic track.

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Thirteen patients (3.56%) were redirected to the FDT consultation service. The characteristics of the patients who were evaluated through the FDT consultation service are shown in Supplementary Table 1. This group showed a significantly higher percentage of COPD history (53.8% vs 21.9%) and emphysema on CT (61.5% vs 26.1%), and their nodule median [25th; 75th percentile] diameter was larger (9.00 [8.00; 11.0] vs 6.00 [5.00; 8.00] mm). Lung cancer was confirmed in five of these patients (1.37%) (Supplementary Table 2). At the time of writing (February 2021), the survival rate of these patients with confirmed malignancy was 100%.

This study of the first year of operation for our VLNC provides several important findings. First, it presents a detailed description of the operational functioning of this multidisciplinary and virtual new assistance model for the management of pulmonary nodules. Second, from our experience, a notable 43.8% of the patients were discharged directly after our first evaluation. However, with only 27.5% of discharged patients having received adequate follow-up according to the guidelines, low adherence to recommendations and a serious tendency to overmanage were evident. Third, a general profile of the evaluated population, largely with a history of smoking (64%) and a considerable proportion of patients with COPD (23%), was drawn. This clear risk profile for lung cancer was significantly higher in patients referred to lung cancer FDT, who had more COPD (53.8% vs 21.9%), emphysema (61.5% vs 26.1%) and larger nodules (9.00 [8.00; 11.00] vs 6.00 [5.00; 8.00]).

The creation of our VLNC has been based on the previously known evidence and benefit of multidisciplinary clinics for the management of pulmonary nodules as reported in the literature.12,14,24 Additionally, benefits from virtualization of lung nodule clinics have been previously described as varied.16-21 In addition to economic and time savings benefits for health systems and patients20, an improvement in adherence to guidelines has been described,25 with figures of 40% improvement in concordance of care with the Fleischner Society recommendations reported by Grundy et al.16 Virtual lung nodule clinics have also been shown to be efficient services. Similar to our study, Higgins et al21 reported 30% of discharged patients during the first 14 months of operation of their virtual lung nodule clinic, among which 83% were discharged directly after the first evaluation.

In line with our study, other works have shown that overmanagement is the most frequent form of lack of guideline adherence, with described rates ranging from modest figures, such as 18%25 or 26%,26 to greater figures, such as 61.5%. The dangers of overmanagement are well known and include exposure to unneeded radiation27 or unnecessary invasive tests28 and emotional stress.29,30 Our results invite us to reflect on the potential risks inherent in seemingly harmless excessive radiological monitoring.

Smoking and COPD history have been described in similar proportions in previous studies developed in lung nodule clinics.12,15,24,25 In addition to cigarette smoking,5 COPD and emphysema have also been demonstrated to have an important relationship with lung cancer that extends beyond their shared etiology, with five- and fourfold increases in the likelihood of developing lung cancer, respectively.31-33 From this point of view, the VLNC targets a high-risk population, whose management should be more accurate and adherent to guidelines.

Our study has several limitations that need to be mentioned. This report is focused on a single-center experience of only one-year duration. In addition, submission to our clinic is not mandatory or automatic; therefore, some pulmonary nodules may not have been assessed through our consultation service. To date, there has been no longitudinal prognostic evaluation of our discharged patients; therefore, it will be interesting for future studies to evaluate the suitability of the issued recommendations. In addition, the percentages of discharged patients in the coming years, when the evaluation of pulmonary nodules is carried out routinely by the VLNC and the data are not from previous years, remains to be seen. Moreover, to date we do not have an analysis on the cost effectiveness of our consultation, and the economic impact that its implementation has entailed. However, based on previous literature, the expected outcome and goal is to save resources. Finally, our consultation service is based on human factors and depends exclusively on the skills of the professionals in charge. This could be considered a weakness in some sense, as prior training is required and a learning curve is expected.

As far as we know, this work constitutes the first description of a multidisciplinary and virtual model of care for the management of incidental pulmonary nodules in our country. The implementation of the VLNC has represented an evolution from the standard method of care of pulmonary nodules in our department. The integration of different professionals into a single team allows a multidisciplinary, high-quality approach to cases. The fact that this method is based on human resources may make the VLNC a readily generalizable model applicable to other centers. However, an organizational change to a virtual, multidisciplinary and centralized model of care for pulmonary nodules is needed to make this possible. In addition, due to the current pandemic caused by SARS-CoV-2 and COVID-19, medical assistance should enhance models of off-site assistance in all fields are possible, and the VLNC fits in this strategic line. The objective of this paper is to show the scientific community a new assistance device for the management of pulmonary nodules, based on multidisciplinary, virtual and adjusted to guidelines care. The adoption of this operating model in other centers would allow us to evaluate its adaptation to other hospitals and, finally, validate externally this new service.

In conclusion, in our center, the development of a multidisciplinary and virtual model of care for the management of pulmonary nodules in our healthcare system has been possible. During its first year of operation, the evaluated population has shown a remarkable risk profile for lung cancer development, which should make us look for cautious management and adherence to guidelines. The consultation has proved to be an efficient service, with approximately one-half of the patients evaluated for the first time being discharged. It should be noted that only one-quarter of these discharged patients underwent follow-up that adhered to guidelines during this initial period of operation, and a clear tendency to overmanagement has been observed. The VLNC seeks to provide accuracy for pulmonary nodule management, and its benefits may be clearer in the future.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.