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Our April 13, 2021 Patient
Safety Tip of the Week Incidental Findings Whats
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.
So, three of our recommendations are important:
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.
Thats 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:
References:
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
https://www.jacr.org/article/S1546-1440(21)00919-4/fulltext
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
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5788828/
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
https://www.jacr.org/article/S1546-1440(22)00011-4/fulltext
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