Interventions to improve adherence to clinical guidelines for the management and follow-up of pulmonary nodules: a systematic review

Background: Lung cancer is the leading cause of global cancer mortality. It is also the third most common cancer in the UK and the most prevalent worldwide. Pulmonary nodules can indicate early-stage lung cancer, but adherence to guidelines for radiological surveillance is suboptimal, which affects early detection and treatment. Interventions have been developed to improve follow-up, but which approaches are most effective is unclear.

Research question: Which interventions have been developed for improving adherence to guidelines for the management of pulmonary nodules and/or the follow-up of patients, and how effective are they?

Study design and methods: We conducted a systematic review, searching Ovid MEDLINE, Cochrane, and Embase databases in March 2024. We included reports of interventions of all designs that measured outcomes including follow-up completion, guideline adherence, or early diagnosis of lung cancer. Studies relating to diagnosis, reporting screening programmes, or not in English, were excluded. Screening and data extraction were performed independently. Risk of bias was assessed using three measures depending on study design.

Results: We identified 3664 titles and abstracts, including 31 studies. Six intervention types were identified: tracking systems, process improvement approaches, natural language processing systems, radiologist reporting templates, clinical decision-making support tools, and patient involvement improvements. All studies reported being effective. Tracking systems and clinical decision support tools showed significant improvements in follow-up, guideline adherence, and early cancer detection. Tracking systems may have most potential for effectiveness because they modify more of the care pathway, and use automation, reducing human error. Risk of bias was serious or critical in most nonrandomized studies.

Interpretation: There was significant variation in achieved follow-up rates across interventions; however, tracking systems appeared most effective in improving patient follow-up. Review limitations included high risk of bias and heterogeneity of included studies. Future evaluations should include more comprehensive outcome measures and rigorous designs.