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We’ve done many columns on “closing the loop”
and communicating significant results to ensure patients do not “fall through
the cracks”. One particular area that merits better communication relates to incidental
findings.
Incidental findings can occur on several
different types of diagnostic tests, but are most prevalent on imaging studies.
The most appropriate followup actions depend on the
specific nature of the incidental finding. There are numerous guidelines
regarding what to do for specific incidental findings. But there are 2 key
issues:
Who is responsible for such communication and
followup? We’ve stressed that multiple individuals or
entities share such responsibility:
A recent review (Crable 2021)
looked at management strategies used to promote guideline-concordant follow-up
for incidentalomas identified in diagnostic imaging studies. In all, 15 studies
met inclusion criteria. Four types of interventions designed to promote
guideline-concordant follow-up care for incidentalomas were identified:
Crable et al. note
that the ideal completed pathway would have the following steps or “phases”:
Of the strategies identified by Crable et al., enhanced radiology templates were
used to prompt actions in phase 2. These would Include standardized follow-up recommendations from
various sources.
Several of the reviewed studies utilized electronic
guideline references embedded within electronic radiology reporting and
communication systems. These provided radiologists easy access to guidelines
and follow-up recommendations as they were doing their reports (phase 2).
Electronic guideline references were also made available to clinicians when
reading radiologists’ reports (phase 3) in some studies.
Physical or verbal guideline reminders
and electronic guideline references were used to alter clinical processes in
both phases 2 and 3. Examples included incorporating guideline-recommended care
for pancreatic or ovarian incidentalomas. Those recommendations might be posted
in hard copies at every radiology workstation or provided as verbal reminders
at monthly case conferences.
Restructured clinical and communication
pathways impacted clinician tasks in phases 2 through 6. Task shifting
was an important strategy. For example, a staff person (such as a nurse
coordinator or nurse specialist) could be assigned to help manage the process.
In one system (Holden
2004), an electronic messaging system notified pulmonary
nurse specialists when incidental findings were identified. That nurse
specialist collected information about patients’ health and past imaging
studies. Then, a pulmonary service consultation team comprised of physicians
and a thoracic radiologist reviewed each incidental finding with relevant
patient history and created a management plan that was shared with PCP’s and stored
in the EHR. A member of the pulmonary service consultation team monitored the
EHR until the incidental finding was resolved.
We think having a field in your EHR
that can be flagged for “unresolved incidental finding” is a good idea.
Crable et al.
provide a long list of various metrics that can be applied to evaluate
the management of incidental findings. Of interest is that some monitored not
only rates of undermanagement, but also overmanagement
(eg. ordering follow-up imaging studies that were not
recommended in guidelines).
Crable et al., however, point out the paucity of metrics
of incidental finding diagnostic outcomes. And they note that few studies
address barriers to improving incidentaloma follow-up from interpretation to
patient education of findings and care delivery.
One scenario is worth
emphasizing – the incidental finding on an imaging study at the time of
hospital discharge. You know the picture: you and your team review the imaging
study in the morning and it allows you to discharge the patient. But the
official report of that study has not yet been dictated. When the radiologist
interprets the study, he/she notes an incidental finding. That report is often
not seen by someone in the position to follow up. The report may go to a
resident or hospitalist who has moved on to another rotation or other clinician
who will not see the patient after discharge. A copy of the report may not go
to the patient’s PCP (or other clinician who will be primarily responsible for
the patient after discharge). But, we’ve often lamented the unfortunate reality
that hospital IT systems often fail to accurately identify the patient’s PCP.
So this is your classic “falling through the cracks” scenario. We discussed this in detail in our September
8, 2020 “Follow
Up on Tests Pending at Discharge”.
That column also highlights similar problems that arise on studies done on
patients discharged from the emergency department. The ED physician who ordered
the study is no longer at the hospital (and, in some cases, may not return to
that hospital). The radiologist may, therefore, have difficulty identifying a
clinician who needs to be informed of that incidental finding.
Knowing the guidelines or recommendations
regarding specific incidental findings is critical to avoid the “diagnostic
cascade” where one study leads to another study or intervention, often
resulting in unnecessary interventions or even patient harm. Many specialty
societies have issued such guidelines for common incidental findings. It would
be very difficult for a primary care physician to be knowledgeable about all
these guidelines. Therefore, we really like the idea of the radiology report
linking to the guideline specific to that incidental finding. Of course, that
puts the onus on the radiology department or practice to keep up to date on
those guidelines and links.
Then, there is the
problem of consistency and quality of guidelines. A recent study on radiologist
awareness of guidelines for pulmonary nodules is illustrative (Gould 2021). Gould et al. state that approximately 1.6
million patients annually are found to have incidental pulmonary nodules on
chest CT scans. They state that most have benign etiologies but about 5% are
malignant. They go on to state that, because of the low likelihood of
malignancy and the risks associated with biopsy, the preferred method for the
evaluation of most small nodules is longitudinal surveillance with serial CT
scans. There are existing guidelines from the Fleischner
Society and the American College of Radiology with recommended intervals for CT
surveillance. But these are based largely on indirect evidence and expert opinion,
because direct evidence from randomized trials of pulmonary nodule evaluation strategies
has not been available. They surveyed radiologists participating in the ongoing
Watch the Spot Trial, which is designed to provide higher quality evidence on
approach to small pulmonary nodules. They found that radiologists reported high
levels of familiarity and agreement with and adherence to guidelines for pulmonary
nodule evaluation, but many overestimated the quality of evidence in support of
the recommendations.
And, it is not just “incidental” findings
that need a system to ensure followup. A recent article
showed delays in followup of positive at-home tests
for colon cancer screening (Jaklevic 2021). Jaklevic et al. noted that, particularly since the COVID-19
pandemic began, more people are getting their colon cancer screening as fecal
immunochemical testing (FIT). The article notes that, depending on population
characteristics such as age and sex, 5% to 9% of patients have an abnormal
result, and about 1 in 3 of those have a large polyp or cancer.
A study of veterans age 50 to 75 years with
an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
between 1999 and 2010 showed increased time to colonoscopy is associated with
higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT
(Miguel
2021). The authors recommend interventions to improve
CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal
FIT/FOBT result.
So, just as we recommend having a field in
your EHR that can be flagged for “unresolved incidental finding”
it’s a good idea to have a field that can be flagged for “follow-up action
needed” for any significant finding.
There are many reasons, both system- and
patient-related, for failure of adequate follow up of incidental findings. And
even though many or even the majority of such findings have benign etiologies,
we’ve all seen cases where such failures have led to patients developing
untreatable cancers. Do you have any idea how often your patients do not get
appropriate follow up of such incidental findings? What is your system to
ensure adequate follow up?
See
also our other columns on communicating significant results:
References:
Crable EI, Feeney
T, Harvey J, et al. Management Strategies to Promote Follow-Up Care for
Incidental Findings: A Scoping Review. J Amer Coll Radiol
2021; 18(4): 566-579
https://www.jacr.org/article/S1546-1440(20)31225-4/fulltext
Holden WE, Lewinsohn
DM, Osborne ML, et al. Use of a clinical pathway to manage unsuspected
radiographic findings. Chest 2004; 125: 1753-1760
https://www.sciencedirect.com/science/article/abs/pii/S0012369215321723
Gould MK, Altman DE, Creekmur B, et al. Guidelines
for the Evaluation of Pulmonary Nodules Detected Incidentally or by Screening:
A Survey of Radiologist Awareness, Agreement, and Adherence From the Watch the
Spot Trial. J Amer Coll Radiol 2021; 18(4): 545-533
https://www.jacr.org/article/S1546-1440(20)31119-4/fulltext
Jaklevic MC. The Push
for Timely Follow-up After Abnormal At-home Colon Cancer Screening Results.
JAMA 2021; Published online March 31, 2021
https://jamanetwork.com/journals/jama/fullarticle/2778236
Miguel YS, Demb J,
Martinez ME, et al. Time to Colonoscopy After Abnormal Stool-Based Screening
and Risk for Colorectal Cancer Incidence and Mortality. Gastroenterology 2021;
Published online February 2, 2021
https://www.gastrojournal.org/article/S0016-5085(21)00325-5/fulltext
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