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Our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?” and our February 2022 What's New in the Patient Safety World column “Managing Incidental Findings” discussed several strategies used to promote adequate follow=up of incidental findings on imaging studies. But do they work? A recent study suggests that they are successful.
Bagga and colleagues (Bagga 2022) did a before and after comparison of an intervention to promote completion of recommended follow-up for incidental lung nodules. The intervention was use of structured recommendations for follow-up on imaging reports plus implementation of an electronic tracking system. They identified 255 patients before and 1,046 patients after structured recommendations or tracking.
40% of patients pre-intervention had no follow-up vs. 29.5% after the intervention. Of those who did get follow-up, 75.0% were followed up on time after the intervention, compared to 56.6% before the intervention. Looking at multiple factors, they found that younger age, White race, outpatient setting, and larger nodule size were significantly associated with appropriate follow-up completion, but use of structured recommendations was not an independent predictor. Similar results applied for loss to follow-up. In the post-intervention cohort, older age, history of smoking, categories with >6 month follow-up recommendations, and inpatient or ED setting were statistically more likely to have loss to follow-up.
Perhaps most importantly, they found that emergency department patients and inpatients are at high risk of missed or delayed follow-up despite structured recommendations. That comes as no surprise to us. Our numerous columns on “tests pending at discharge” apply equally to patients discharged from the ED or the inpatient service. Fragmentation of care is a problem there. Often, the imaging study is obtained and reviewed by the clinicians caring for the patient. But the official report may not arrive until after the patient has been discharged. The radiologist may attempt to reach the “ordering” physician, but that physician may no longer be available (hospitalists and ER physicians may have schedules that only place them in a hospital periodically) and is not likely the physician who would order any follow-up studies. And, in several columns, we’ve noted the difficulties often encountered in identifying in the EHR the primary care physician or other physician who will be following the patient after discharge.
1. “Test Results Pending” needs to be a specific field in the discharge summary to alert subsequent care providers that an official imaging report needs to be reviewed.
2. A designated ED clinician needs to review all imaging (and lab or other) reports that come back after patient discharge from the ED.
3. Radiology departments should have a system that records that a radiologist has, indeed, communicated with a responsible physician. And they should have staff that assist in identifying the responsible physician in those cases where contact has not been made.
Bagga et al. did note that, during the period of initiating structured recommendations at their institution, the ED began a coordinator service for communicating follow-up needs to patients for specific recommendations in imaging reports.
The authors conclude that appropriate follow-up completion and loss to follow-up improved when the structured recommendation system was in place, but further efforts to reach patients for missed follow-up may be best focused upon inpatient and ED discharge processes and care coordination.
Lacson et al. (Lacson 2018) reported on a health IT intervention that included discharge modules for both ED and inpatient settings, which allowed access to critical findings of pulmonary nodules and recommendations for follow-up management. These online modules enable physicians caring for patients in the ambulatory setting to access these recommendations after patients are discharged. The module for the ED was developed to replace a paper-based discharge instruction form. The implementation of a discharge module resulted in improved follow-up of patients with pulmonary nodules within 1 year after discharge (OR = 1.64). The ED implementation resulted in better follow-up compared to the inpatient module (OR = 2.24). Twenty-seven percent of patients with pulmonary nodules received follow-up management, which, although significantly improved from the 18% baseline, remains low.
In another study by Lacson et al. (Lacson 2022) on follow-up of patients with incidental pulmonary nodules, the only significant factor associated with follow-up completion was care setting. Imaging ordered in the ED had decreased odds of follow-up (odds ratio: 0.15). Those authors note that incidental findings in ED imaging are often not communicated to the responsible provider and, thus, stress the need for improved handoff processes. They suggest that specific interventions, like a closed-loop communication tool to establish a follow-up care plan, may be useful to further increase follow-up completion, especially in managing patients who span multiple care settings.
In our mind, structured imaging reports that include recommendations regarding follow-up for incidental findings are important. But, more importantly, having systems in place to ensure that the clinician most likely to be responsible for that follow-up is, in fact, made aware of the finding is critical. And having tracking systems in place to determine whether such follow-up was achieved is also important.
And, of course, the clinician with ultimate responsibility for follow-up must have in place his/her own “tickler” system to remind him/her to order recommended follow-up imaging after the number of months in any recommendation. That’s especially important since Bagga et al. noted higher failure to follow-up when the recommended time frame for action was 6 months or longer. Letting the patient know about the recommendation may also help alert the clinician that the follow-up is due. The patient also needs to be aware of the need to follow-up in the event he/she moves or switches to another clinician.
Again, we cannot overemphasize that “closing the loop” is the most important factor in preventing patients from “falling through the cracks”.
See also our other columns on communicating significant results:
Bagga B, Fansiwala K, Thomas S, et al. Outcomes of Incidental Lung Nodules With Structured Recommendations and Electronic Tracking. JACR 2022; 19(3); 407-414
Lacson R, Desai S, Landman A, et al. Impact of a health information technology intervention on the follow-up management of pulmonary nodules. J Digit Imaging 2018; 31: 19-25
Lacson R, Licaros A, Cochon L, et al. Factors Associated With Follow-up Testing Completion in Patients With Incidental Pulmonary Nodules Assessed to Require Follow-up. JACR 2022; 19(3); 433-436
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