Neighborhood-Level Socioeconomic Disadvantage and Adherence to Guidelines for the Evaluation of Patients With Incidentally Detected Pulmonary Nodules.

Abstract

The management of incidental pulmonary nodules is guided by recommendations set forth by the Fleischner Society. Although most pulmonary nodules are benign, timely and evidence-based follow-up can reduce morbidity and mortality. There are known socioeconomic disparities for engagement with recommended cancer screenings; however, it is unclear whether disparities exist for follow-up of incidentally detected pulmonary lesions. Do patients residing in more socioeconomically deprived neighborhoods have reduced likelihood of adherence to guideline-recommended follow-up of incidentally detected pulmonary nodules? We assembled a retrospective cohort of 32,965 patients within a large, regional integrated health care system with a defined membership who had a pulmonary nodule ≤ 30 mm identified on diagnostic CT scan between 2012 and 2016. Patients with prior history of malignancy were excluded. Participants were subsequently divided into quartiles using the Neighborhood Deprivation Index as a metric for socioeconomic status. Adherence was ascertained using International Classification of Diseases, Ninth Revision-coded or Current Prodecural Terminology-coded imaging or biopsy to determine if follow-up was performed within an interval specified by 2005 Fleischner Society guidelines (with a ± 33% margin of error) based on each patient's nodule characteristics. Negative binomial regression was performed to determine the association between neighborhood-level deprivation and adherence to guideline-concordant care, with and without adjustment for plausible confounders. Only 49.6% of patients had follow-up imaging or other diagnostic procedure performed within the guideline-recommended time frame. There was a 3% reduction in adherence to follow-up for patients residing in the most socioeconomically deprived neighborhood quartile (relative risk [RR], 0.97; 95% CI, 0.94-1.0) compared with the least deprived quartile. Smoking status was also associated with worse adherence (previous tobacco use vs does not smoke: RR, 0.67; 95% CI, 0.65-0.69; active tobacco use vs does not smoke: RR, 0.73; 95% CI, 0.70-0.76). Multimorbidity, and congestive heart failure in particular, was associated with decreased adherence to guideline-recommended care (Charlson Comorbidity Index 3 vs 0: RR, 0.93; 95% CI, 0.89-0.97; history of congestive heart failure: RR, 0.93; 95% CI, 0.90-0.97). In the context of poor adherence overall, patients residing in the most socioeconomically deprived neighborhoods were shown to be less likely to receive care in concordance with Fleischner Society recommendations for management of incidental pulmonary nodules.