The British Thoracic Society has previously published guidelines for follow-up of pulmonary nodules, including the suggested service organisation template.[[1]] As awareness of lung cancer has increased, there has been an increasing trend in referrals to the respiratory specialist service for abnormal imaging reports by both primary care physicians and other healthcare professionals within secondary care. The reasons health professionals end up seeing patients in a contact clinic is to minimise risk and get a first-hand overview of the patient. But, with limited staff resources, it is not possible to see all the referred patients for evaluation in a timely manner. As a result, the combined respiratory radiology non-contact specialist meeting (virtual clinic) has been used not only to review the radiology images but also to triage the patients and allocate specialist appointments to appropriate patients. Such non-contact specialist clinics are not new. There is evidence that, with the correct set up, such services are effective at streamlining who actually gets a first specialist appointment (FSA) and who can be managed through either the primary care physician or secondary care virtual clinic.[[2–4]] It is not clear what the risks of such non-contact services are to either the patient or the healthcare provider. Our service is in keeping with some non-contact specialist clinics run by others worldwide that have showed the effectiveness of the service.

Aim

The aim of the study was to assess the efficacy of the respiratory radiology non-contact specialist virtual clinic in triaging patients referred following abnormal chest radiology reports.

Description of the non-contact respiratory radiology clinic

Palmerston North Hospital is a 350-bed secondary care hospital in New Zealand that services a population catchment of 160,000 people. There are two respiratory physicians. The combined respiratory radiology virtual clinic is held once every week and one hour has been reserved for the meeting to discuss the referrals. Referring clinicians base their referrals on the radiologist reports. The sources of the radiology reports include the hospital, public community radiology centres and private radiology centres. Radiology images that clearly confirm lung cancer are not routinely discussed in the radiology meeting but are triaged directly for an FSA (Figure 1). The average number of patients discussed per meeting was 15 in 2013, but since the 2013 there has been an increase in referrals for abnormal radiology.

Figure 1: Pathway of referral for abnormal chest imaging report.

The virtual clinic comprises one radiologist, two respiratory physicians and one respiratory clinic nurse, who prepares the patient referral list, all necessary documentation and the registrar write down and requests any chest radiograph or CT scan forms recommended in the meeting. An administrative clerk retrieves any old radiology images (most films before 2004 are still in hard-copy form). For lung nodules or lung masses, the morphology of the lesion, smoking status, previous malignancy and other factors are taken into consideration in deciding outcome. In difficult cases, the Brock model is used to assess the risk, help decide on further imaging and follow-up and minimise risk.[[5]] The threshold for reviewing these radiographic abnormalities is low, and therefore abnormalities are not ignored. However, there is the advantage of (1) having previous imaging to enable discounting these abnormalities, which the reporting radiologist may not have access to, and (2) having an experienced chest radiologist who can confidently discount the previous report. A decision is made and each referral triaged as follows: (A) for FSA, (B) for immediate further investigation with another radiology image, such as CT scan or another chest x-ray, (C) for ongoing long term surveillance CT scan or (D) for discharge. The final list therefore will comprise both new referrals and previously discussed patients due for review of their interval radiology images. Patients who are not offered an FSA are contacted after the meeting with a formal letter notifying them of the meeting outcome.

Study method

This was an observational, retrospective audit of all patients referred for imaging abnormalities that were discussed during a respiratory radiology virtual clinic between 1 January 2016 and 31 December 2016. Only patients with a new referral were included in the audit. Data sources included records of the virtual clinic outcomes for each patient; the hospital electronic patient data base (Clinical Portal), which provided information on the initial radiology report triggering the referral; any outcome letters written to the referrer by the respiratory physicians; any letters from oncology services to confirm treatment of cancer; any contact with other departments that would highlight whether the discharged patients developed any malignancy in subsequent years; and the electronic radiology Picture Archiving and Communication System (PACS)  for reviewing the radiology images and clarifying what was discussed if the information is not clear. Information retrieved included gender, origin of referral, date of referral, type of radiology image initiating referral (ie, chest radiograph or CT scan), type of radiology abnormality, date of discussion in respiratory radiology virtual clinic, outcomes of meeting (ie, further imaging, discharged, not discharged) and cancer outcome for each patient at 12, 18 and 24 months. For radiology abnormalities suggesting a pulmonary nodule, Fleischner’s updated nodule criteria were used during the study period.[[6]] Data were entered into an Excel spreadsheet. Analysis was performed using Excel spreadsheet functions. For risk assessment, a simple statistical program was used to calculate the relative risk of developing cancer in those discharged. This was a quality improvement audit and therefore no ethics approval was required. However, the audit was registered with the Hospital Quality and Clinical Risk department.

Results

There were a total of 479 new referrals discussed at respiratory radiology virtual clinics in 2016. The mean age was 67.5 years old, with a range from 17 to 97 years old (Table 1). Gender distribution was relatively equal with a marginally greater number of females at 51.8% compared to 48.2% male. The majority of referrals (over 60%) were from general practitioners, with the rest coming from hospital specialists from both inpatient and outpatient settings. Reports of abnormal chest x-rays were the most common cause of referral, making up almost two-thirds of referrals, with the rest being for abnormal CT scans. Over 50% of referrals were for pulmonary nodules (30.5%) and lung masses (24.6%).

Table 1: Demographics and outcome. View Table 1.

There were 242 patients (51%) discharged from the department following the radiology meeting. Of those discharged, 132 (27.5%) were discharged after the first discussion, 67 (14%) after the second discussion following further imaging and the rest after the third discussion following further requested imaging. Of those discharged, the majority were for a presumed lung nodule(s) or lung mass (59.0%), lung infiltrate or consolidation (14.0%), atelectasis (11.1%) and suspected interstitial lung disease (9.5%). Of the total patients, 237 (49.0%) were followed-up for further assessment with either a contact FSA or long-term surveillance imaging. Of those not discharged, 65 (27.5%) were diagnosed with cancer: 42 patients following concern from the first meeting discussion, and 23 following concern from the second meeting discussion. Primary lung cancers made up 75% of these cancers, with the rest being cancers from other primary sites. There were 172 patients who did not have cancer but remained under surveillance (Table 2).

Table 2: Cancer diagnosis after the first investigations in those not discharged (n=237).

Of those discharged (n=242), two patients developed lung cancer: one at 12 months and another at 24 months. The first patient had initially been discussed for a lingular opacity that had resulted in the patient being discharged. However, it was noted the patient had an apical scar that was considered non-significant at the time. The scar became the focus of the cancer at 12 months. The second patient had been cleared for any lung lesions with a chest CT scan at the time of discharge but was subsequently found with a new lung nodule at 24 months that turned out to be metastasis from an undiagnosed colon cancer. Within the surveillance group (n=172), four patients were diagnosed with lung cancer: two patients at 12 months and two at 18 months (Table 3). The cancer rate in those discharged after the first meeting was only 0.8%, compared to 2.6% in those under surveillance, with a relative risk of 0.3 (p=0.16). There was therefore no statistically significant difference between the two groups.

Table 3: New lung cancers in the discharged group and surveillance group at 12-, 18- and 24-months follow-up.

Out of the 479 referred patients, 132 (27.5%) did not require any further imaging. These were the patients discharged after the first meeting discussion. The remainder of the patients went on to have further imaging (either another chest x-ray, CT scanning or MRI) after the first meeting to better characterise their abnormality (Table 4). Only a total of 153 patients required further CT scanning and two patients required an MRI (Table 4).

Table 4: Further imaging requested post-first respiratory radiology virtual clinic, based on referral image.*

Discussion

This audit confirms that the weekly non-contact respiratory radiology virtual clinic is safe and effective in reducing specialist contact clinics and unnecessary CT scans. Out of the 479 patients discussed at the meeting, the majority of them were discharged without any specialist contact clinic, and without any difference in risk of developing cancer compared to those who were followed-up and placed under surveillance. Almost one-third of patients who were referred avoided further CT scanning after the first meeting discussion. In a study in neurology, Cariga et al showed that, out of 1,107 referrals to the neurology service for an FSA, 802 (72.5%) were allocated FSA, 83 (7.5%) returned to referrer and 222 (20%) were triaged into a non-contact FSA and investigated with a six-month observational study of safety and efficiency indicators.[[2]] Our audit demonstrated a higher proportion of patients discharged without an FSA (27.5%) compared to the study in neurology. The results of the current audit are also consistent with a 2014 audit at the same hospital looking at referrals between 2011 and 2013, which demonstrated the consistent efficacy of the virtual clinics (unpublished). However, note that this audit from 2014 had 423 patients over two years, whereas the current audit had 479 over one year. Our audit further confirms a significant increase in referrals to the respiratory service over a five-year period without any change in the service’s resources. A study in the USA, where a lung nodule surveillance pathway was implemented based on an automated search of radiology reports on any CT scan, showed similar findings of about 1% cancer diagnosis in the surveillance group at 12 months.[[7]] Furthermore, an 11% increase in referrals was noted to the pathway over two years. Our study is different as we used actual referrals from other clinicians and did not limit our discussion to lung nodules only.

We used lung cancer as a surrogate maker for risk assessment as it is the most worrisome diagnosis that clinicians do not want to miss. We acknowledge that we did not report the outcomes of the other conditions that were followed-up in clinic or with continued surveillance imaging. We also did not report the survival outcomes of those patients diagnosed with cancer, as this was not the objective of the audit. We also acknowledge that the threshold for requesting a PET scan in the radiology meeting at the time (2016) was high. Our practice has now changed and more PET scans are requested in the radiology meeting when indicated. Given that one patient who had an apical scar initially felt to be non-significant was discharged but later developed cancer in that scar, our practice now provides further surveillance imaging in patients with apical scaring with a high-risk score using Brock model of risk assessment.

Although respiratory radiology meetings are a usual occurrence in most hospitals, we are not aware of any published study on the effectiveness of these meetings, especially pertaining to triaging referrals and assessing risk. One strength of the audit is the availability of all data due to a robust database and access to the clinical portal allowing for accurate collection of all data for this audit. The likelihood of having missed data is low. Another strength is the period of follow-up (24 months), which allows sufficient time to detect any cancer among both the discharged and surveillance groups to provide a better risk assessment. A limitation of the study is its retrospective design. There is still potential for bias and incorrect coding, which can affect the results. But, as outlined above, the databases used are reliable. We also did not check the central cancer registry. Therefore, a patient’s cancer at follow-up could have been missed if they had moved out of the region. Furthermore, although we used 24 months as a reasonable period to assess transformation of any suspicious lesion to malignancy, we acknowledge that sub-solid and ground-glass lesions require five years of follow-up, and therefore the study results may underestimate the true incidence of cancer among the patients kept under surveillance. We also did not perform a cost–benefit analysis with regard actual cost saved from unnecessary CT scans.

In conclusion, this study confirms that in healthcare centres with limited resources, a non-contact respiratory radiology virtual clinic is effective at triaging referrals following an abnormal chest imaging report and that there is no significant risk of missing lung cancer in those not offered a specialist appointment. Furthermore, there is need for funding to be allocated to improve the service delivery provided by such non-contact virtual clinics.