With advances in diagnostic radiology over the past two decades, there has been a big rise in incidental findings. Among the 4.8 million people in the U.S. who get computed tomography (CT) scans each year, 33% will have a newly discovered lung nodule that qualifies as an incidental finding.
“While most of these nodules are clinically insignificant, a small number of these are precancerous and can become life-threatening if not addressed,” said Yatin Mehta, MD, a pulmonologist with Geisinger health system, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
The traditional pulmonary or thoracic surgery specialty-referral process for evaluation and management of patients with pulmonary nodules is inefficient. That is due to the sheer volume of these nodules and access limitations, leading to unacceptably high follow-up failure rates and more importantly, clinic visits are often unnecessary. To address these shortcomings, which are prevalent in most health care systems, Geisinger implemented the System to Track Abnormalities of Importance Reliably, known as the STAIRprogram for short.
Following up—all the way
STAIR is an alternative consultative model composed of three key elements—people, process and technology. The STAIR lung-nodule team is composed of a team of coordinators and pulmonary nurse practitioners. Once a patient is enrolled in the program, a coordinator will call the patient, explain what the program is and learn about the patient’s risk factors for lung cancer. This information is used by the nurse practitioners to come up with a guideline-based care plan. This plan is communicated and executed by the coordinators.
“This can be a repeat CT scan down the line because we want to assure stability or a bronchoscopy and biopsy, depending upon the size of the nodule and risk factors for a potential lung cancer,” said Dr. Mehta, who leads the STAIR program.
The process continues until there’s a final outcome, meaning that a nodule is benign and there’s no need for follow up, or there’s a cancer diagnosis, which means the patient may need a referral to a lung-cancer clinic.
“Reliability of follow up is what makes this unique and we see patients all the way through,” said Dr. Mehta. By diligently following all patients, the aim is to diagnose cancer at earlier stages when it is curable, he added.
AI helps spot what’s in reports
Geisinger encompasses nine hospitals and 40-plus outpatient clinics and does imaging studies at multiple locations. However, STAIR is a centralized management system, Dr. Mehta explained. Patients get referred to the program if their physician sees an incidental nodule on a scan, or through Geisinger’s lung-cancer screening program, which screens high-risk patients.
Geisinger also uses natural language processing technology—a form of augmented intelligence, or AI—to automatically detect nodules in the radiology report.
“When a radiologist reports a finding of a nodule, we have the ability to pick that up and enroll that patient into the program,” said Dr. Mehta.
Since its inception in 2020, the Geisinger STAIR program has provided care to more than 7,500 patients with lung nodules. Before the program’s implementation, the time from nodule discovery to referral to a clinic visit averaged about three months at Geisinger.
The STAIR program has reduced that time to eight days, with 94% of all patients not requiring traditional clinic visits.
“Not only are we delivering the right care, but we are delivering it in the right setting, at the right time, and every time,” said Dr. Mehta.
Moving beyond lung cancer
Geisinger has since expanded the STAIR Program to abdominal aortic aneurysm (AAA). The model operates similarly to the lung nodule program, enrolling patients whose imaging study detects abdominal aortic aneurysm either via screening or as an incidental finding. Since its launch last year, the program manages 4,700 patients, with new patients added daily.
“When aneurysm size meets treatment threshold, elective interventions provide the best outcomes for the patients as ruptured AAA is associated with high morbidity and mortality,” Dr. Mehta said.
