B80-4-14 Closing the Gap: Post-Imaging Follow-up Disparities in Never-Smokers With Incidental Lung Nodules

Rationale Incidentally detected lung nodules (ILNs) are increasingly identified in never-smokers as imaging utilization rises, yet subsequent management remains inconsistent and may contribute to missed or delayed diagnoses. Variation in follow-up and diagnostic evaluation reflects both nodule characteristics and social determinants of health, including race/ethnicity and insurance status, which shape access, timeliness, and completion of care. We examined whether, among never-smokers with ILNs, race/ethnicity and insurance status are associated with outpatient follow-up, completion of diagnostic procedures, and cancer detection. Methods We conducted a retrospective cohort study of adults with ILNs identified via Natural Language Processing of radiology reports from January 2023 through October 2025. Only never-smokers were included. Demographic data, nodule characteristics, personal and first-degree family cancer histories, and clinical outcomes were abstracted from the electronic health record. Exclusion criteria included any history of smoking, imaging for suspected or active malignancy, false-positive or stable nodules, imaging not requiring follow-up, or reports lacking follow-up recommendations. Results The study included 1,081 never-smokers with ILNs; the mean age was 65.2 ± 15.2 years (median 66.0; interquartile range [IQR] 21.0). The mean nodule size was 6.2 ± 5.4 mm (median 4.5 mm; IQR 4.0 mm). The majority of patients were female (64.9%). Regarding racial/ethnic distribution, 40.1% identified as White, 17.2% as Black or African American, 9.8% as Asian, and 27.2% as Other/Hispanic or Latino; race/ethnicity was not reported for 5.7% of participants. Most patients were covered by insurance categorized as “Other” (93.4%), while 2.3% were covered by Medicaid and 4.3% were uninsured. Completion of follow-up differed significantly by race/ethnicity (overall p = 0.004), with Black patients less likely to complete follow-up compared to White patients (19.9% vs 30.3%; p = 0.01). No statistically significant difference in follow-up completion was observed by gender (p = 0.12). A significant association was identified between insurance type and follow-up completion (p = 0.042). Follow-up completion rates were comparable between patients with Medicaid and those with “Other” insurance (24.0% vs 25.0%; p = 1.00; odds ratio [OR] 0.95; 95% confidence interval [CI] 0.31-2.51). However, uninsured patients exhibited significantly lower follow-up completion compared to those with “Other” insurance (8.7% vs 25.0%; p = 0.013; OR 0.29; 95% CI 0.07-0.80). Conclusion Disparities in the management of ILNs among never-smokers indicate inequities in care that may contribute to delayed diagnosis and adversely affect clinical outcomes. Targeted interventions aimed at standardizing follow-up protocols and mitigating systemic bias may help address these disparities and improve patient outcomes.