Streamlining Interstitial Lung Disease Diagnosis in Primary Care Clinic

October 8, 2024

BOSTON – Diagnosis of interstitial lung disease (ILD) poses a significant challenge for clinicians and is often delayed by several years. The factors underpinning these delays are multifactorial, driven by misdiagnoses as more common cardiopulmonary diseases and delayed referrals to pulmonary specialists. Primary care providers (PCPs) are at the frontline of evaluating patients with symptoms consistent with ILD, and a targeted intervention in this setting could facilitate expedient diagnosis and referral.

Through a quality improvement grant from the American College of Chest Physicians (CHEST), lead researcher, Kavitha Selvan, MD, implemented the Bridging Specialties^®: Timely Diagnosis for ILD Clinician Toolkit into practice at the Universite of Chicago to shorten time to diagnosis for ILD.

The toolkit includes educational support for PCPs and an ILD questionnaire for patients. A Plan-Do-Study-Act approach was utilized. In the “Plan” phase (11/2023 to 1/2024), an ILD order set was developed for the electronic health record (EHR) system, and PCPs completed a baseline survey on evaluating suspected ILD. In the ongoing “Do” phase (2/2024 to 6/2024), PCPs have access to toolkit educational support, and patients checking in for a primary care clinic visit are asked to fill out the ILD questionnaire prior to their visit. Questionnaire responses are entered into the EHR and are available for PCP review during/after the visit. For preliminary results, ordering and referral practices were measured before and during the intervention and compared with descriptive statistics.

All 151 PCPs received the baseline survey, and 72 (48%) completed it. The majority (n=65/72, 90%) reported managing between zero and three patients with ILD in clinic. PCPs were most likely to order chest X-rays (n=60, 83%) or empiric treatment (n=59, 82%) for patients presenting for the first time with chronic respiratory symptoms. Over half (n=31, 51%) of PCPs never included ILD in their differential diagnosis at initial visits for chronic respiratory symptoms, and approximately half (n=34, 47%) felt extremely or somewhat uncomfortable ordering diagnostic tests for suspected ILD without specialist consultation. The majority (n=50, 69%) of PCPs saw patients with chronic respiratory symptoms two to three times before considering pulmonary referral, and the most common barriers to referral were not knowing which patients to refer (n=40, 57%) or which tests to order prior to referral (n=31, 44%).

In the first month of the “Do” phase, 444 ILD questionnaires were administered, and 193 patients (43%) were identified as having two or more risk factors for ILD. In the same month, the number of ILD-specific orders placed by PCPs increased compared with the monthly average of the preceding three months (pulmonary function tests: n=25 to n=36, chest CTs: n=15 to n=16, pulmonary referrals: n=18 to n=22).

“Implementation of an ILD toolkit in primary care clinic improved the evaluation and referral of suspected ILD at our institution,” Dr. Selvan said. “Improved evaluation and referral of ILD in primary care clinic will save lives through early diagnosis.”

Further results will be shared at the CHEST 2024 as part of the Diffuse Lung Disease Abstracts Posters presentation titled, Streamlining Interstitial Lung Disease Diagnosis in Primary Care Clinic: Preliminary Results of a Quality Improvement Demonstration Project. The study abstract can be viewed on the journal CHEST^® website.

CHEST gratefully acknowledges Boehringer Ingelheim Pharmaceuticals, Inc. as a Sustaining Partner of the Bridging Specialties: Timely Diagnosis for ILD initiative.