Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules
Association of the Intensity of Diagnostic Evaluation With Outcomes in Incidentally Detected Lung Nodules
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DOI：
10.1001/jamainternmed.2020.8250
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发表时间：
2021-01-19
影响因子：
39
通讯作者：
Buist, Diana S. M.
中科院分区：
文献类型：
--
作者：
Farjah, Farhood;Monsell, Sarah E.;Buist, Diana S. M.
重要性指南一致的肺结节评估是否导致更好的结果仍然未知。目的检查肺结节诊断评估的强度与结果、安全性和健康支出之间的关联。设计、设置和参与者这项比较有效性研究分析了华盛顿西雅图的Kaiser Permanente华盛顿和威斯康星州马什菲尔德的马什菲尔德诊所的健康计划登记者，在2005年1月1日至2015年12月31日期间检测到偶然的肺结节。纳入的患者年龄≥ 35岁，无高度感染怀疑，无恶性肿瘤病史，结节检测无晚期肺癌证据。数据分析于2020年1月7日至8月19日进行。EXPOSURES以2005年Fleischner Society指南（选择其适用于研究时间范围）作为比较，定义了2种其他肺结节评价强度。指南一致性评价遵循指南。不太密集的评估是缺乏推荐的测试，比推荐的监测间隔更长，或比推荐的侵入性测试更少。当指南建议不进行进一步的检测、监测间隔短于推荐的时间、或比推荐的更具侵入性的检测时，更密集的评估包括检测。主要结果和测量主要结果是患有III或IV期疾病的肺癌患者的比例、辐射暴露、操作相关的不良事件、结果在5057名患者中，1925人（38%）接受了与指南一致的治疗，1863人（37%）接受了较低强度的治疗，和1269（25%）更密集的诊断评价。整个队列包括2786例女性患者（55%），平均（SD）年龄为67（13）岁。调整后的分析显示，与指南一致性评价相比，不太密集的评价与较少的手术相关不良事件相关（风险差异[RD]，-5.9%; 95% CI，-7.2%至-4.6%），平均辐射暴露较低（-9.5毫西弗[mSv]; 95% CI，-10.3 mSv至-8.7 mSv），平均卫生支出较低（-10916美元; 95%CI，-16112至-5719美元）;在诊断为肺癌的患者中，III期或IV期疾病无差异（RD，4.6%; 95%CI，-22%至+31%）。更密集的评估与更多的手术相关不良事件相关（RD，+8.1%; 95% CI，+5.6%至+11%），平均辐射暴露较高（+6.8 mSv; 95% CI，+5.8 mSv至+7.8 mSv），平均卫生支出较高（20 132美元; 95% CI，+14 398美元至+25 868美元）;未观察到III期或IV期疾病的差异（RD，-0.5%; 95%可信区间，-28%至+27%）结论和相关性本研究发现，与肺癌诊断相比，符合指南的护理;诊断评估强度越高，手术并发症、辐射暴露和费用越高。这些发现强调了需要更多的证据来更好地评估肺结节，并避免对肺结节进行不必要的密集诊断评估。
IMPORTANCE Whether guideline-concordant lung nodule evaluations lead to better outcomes remains unknown.OBJECTIVE To examine the association between the intensity of lung nodule diagnostic evaluations and outcomes, safety, and health expenditures.DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness research study analyzed health plan enrollees at Kaiser Permanente Washington in Seattle, Washington, and Marshfield Clinic in Marshfield, Wisconsin, with an incidental lung nodule detected between January 1, 2005, and December 31, 2015. Included patients were 35 years or older, had no high suspicion of infection, had no history of malignant neoplasm, and had no evidence of advanced lung cancer on nodule detection. Data analysis was conducted from January 7 to August 19, 2020.EXPOSURES With the 2005 Fleischner Society guidelines (selected for their applicability to the time frame under investigation) as the comparator, 2 other intensities of lung nodule evaluation were defined. Guideline-concordant evaluation followed the guidelines. Less intensive evaluation was the absence of recommended testing, longer-than-recommended surveillance intervals, or less invasive testing than recommended. More intensive evaluation consisted of testing when the guidelines recommended no further testing, shorter-than-recommended surveillance intervals, or more invasive testing than recommended.MAIN OUTCOMES AND MEASURES The main outcome was the proportion of patients with lung cancer who had stage III or IV disease, radiation exposure, procedure-related adverse events, and health expenditures 2 years after nodule detection.RESULTS Among the 5057 individuals included in this comparative effectiveness research study, 1925 (38%) received guideline-concordant, 1863 (37%) less intensive, and 1269 (25%) more intensive diagnostic evaluations. The entire cohort comprised 2786 female patients (55%), and the mean (SD) age was 67 (13) years. Adjusted analyses showed that compared with guideline-concordant evaluations, less intensive evaluations were associated with fewer procedure-related adverse events (risk difference [RD], -5.9%; 95% CI, -7.2% to -4.6%), lower mean radiation exposure (-9.5 milliSieverts [mSv]; 95% CI, -10.3 mSv to -8.7 mSv), and lower mean health expenditures (-$10 916; 95% CI, -$16 112 to -$5719); no difference in stage III or IV disease was found among patients diagnosed with lung cancer (RD, 4.6%; 95% CI, -22% to +31%). More intensive evaluations were associated with more procedure-related adverse events (RD, +8.1%; 95% CI, +5.6% to +11%), higher mean radiation exposure (+6.8 mSv; 95% CI, +5.8 mSv to +7.8 mSv), and higher mean health expenditures ($20 132; 95% CI, +$14 398 to +$25 868); no difference in stage III or IV disease was observed (RD, -0.5%; 95% CI, -28% to +27%).CONCLUSIONS AND RELEVANCE This study found inconclusive evidence of an association between less intensive diagnostic evaluations and more advanced stage at lung cancer diagnosis compared with guideline-concordant care; higher intensities of diagnostic evaluations were associated with greater procedural complications, radiation exposure, and expenditures. These findings underscore the need for more evidence on better ways to evaluate lung nodules and to avoid unnecessarily intensive diagnostic evaluations of lung nodules.