Data from: Physician assessment of pretest probability of malignancy and adherence with guidelines for pulmonary nodule evaluation

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.