• Andrew B Rosenkrantz, Xi Xue, Soterios Gyftopoulos, Danny C Kim, and Gregory N Nicola.
• Department of Radiology, NYU School of Medicine, NYU Langone Medical Center, 660 First Avenue, New York, NY 10016 USA. Electronic address: Andrew.Rosenkrantz@nyumc.org.
• Acad Radiol. 2019 Jun 1; 26 (6): 798-802.

Rationale And ObjectivesTo explore downstream costs associated with incidental pulmonary nodules detected on CT.Materials And MethodsThe cohort comprised 200 patients with an incidental pulmonary nodule on chest CT. Downstream events (chest CT, PET/CT, office visits, percutaneous biopsy, and wedge resection) were identified from the electronic medical record. The 2017 Fleischner Society Guidelines were used to classify radiologists' recommendations and ordering physician management for the nodules. Downstream costs for nodule management were estimated from national Medicare rates, and average costs were determined.ResultsAverage downstream cost per nodule was $393. Costs were greater when ordering physicians over-managed relative to radiologist recommendations ($940) vs. when adherent ($637) or under-managing ($166) relative to radiologists recommendations. Costs were also greater when ordering physicians over-managed relative to Fleischner Society guidelines ($860) vs. when under-managing ($208) or adherent ($292) to guidelines. Costs did not vary significantly based on whether or not radiologists recommended follow-up imaging ($167-$397), nor whether radiologists were adherent or under- or over-recommended relative to Fleischner Society guidelines ($313-$444). Costs were also higher in older patients, patients with a smoking history, and larger nodules. Five nodules underwent wedge resection and diagnosed as malignancies. No patient demonstrated recurrence or metastasis. Average cost per diagnosed malignancy was $3090.ConclusionDownstream costs for incidental pulmonary nodules are highly variable and particularly high when ordering physicians over-manage relative to radiologist recommendations and Fleischner Society guidelines. To reduce unnecessary utilization and cost from over-management, radiologists may need to assume a greater role in partnering with ordering physicians to ensure appropriate, guideline-adherent, and follow-up testing.Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

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