Background: Around 1.6 million patients in the US annually have a pulmonary nodule (PN) found on imaging. Previous studies suggest 1-12% of PNs represent an underlying malignancy at a potentially curative stage. PNs ≥6mm are considered higher risk. Despite guideline availability, only about one-third of commercially insured patients with a PN receive recommended workup, which may include further investigation via imaging or surgery. In addition, patients and providers may delay workup of PNs identified during COVID-19. We aimed to describe variations in PN workup for different patient demographic and clinical characteristics at 7 healthcare institutions in New York (NY) state. Methods: We used a retrospective cross-sectional design in which structured demographic and unstructured clinical data were used to analyze patient documents from a NY state health information exchange from January 2018 to February 2022. Clinical features were abstracted using a clinical natural language processing platform, CLiX unlock. Results: 58 million documents from 5.5 million unique patients were analyzed. Of the overall 151,436 patients with PNs, workup was found in 47% (71,071). Across institutions, workup ranged between 24% and 52%; 40% (60,749) had evidence of a PN in the upper lung location. We found 52,789 patients (35%) had a maximum PN ≥6mm and of those, 55% (28,958) had a workup (Table). For patients with a PN ≥6mm, workup for non-English speaking patients was 9% lower than for English speaking patients (47% vs 56%), 17% lower for patients 18-44 years than patients 45-90 years (39% vs 56%), 47% lower for patients presenting with a chest injury rather than cancer screening (28% vs 75%), and 9% higher for patients with initial imaging via chest computed tomography (CT) rather than other CT (58% vs 49%). After the start of the COVID-19 pandemic (January 2020), overall workup decreased 3.8% and prevalence of symptoms such as dyspnea and chest pain increased. Conclusions: The descriptive findings of this analysis demonstrate gaps and variations in workup for patients with PNs across different demographics and clinical scenarios. A subsequent project is underway to explore strategies for improvement in adherence to guideline-recommended care to benefit patients by diagnosing lung cancer at an earlier, potentially curative stage.