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Incidental findings on imaging studies may be benign and have no impact on patients. But they may also be important signs of serious conditions, such as cancer. Hence, it is important that incidental findings be managed appropriately. “Closing the loop” and communicating about incidental findings is critical to ensure patients do not “fall through the cracks”. Keep in mind that almost everything we say about incidental findings on imaging studies may also apply to incidental findings on other diagnostic studies, like lab and pathology studies.
Our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?” outlined many strategies for managing incidental findings. We stressed that 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:
Since that column we came across an excellent article on managing incidental findings (Makeeva 2021). Makeeva et al. note that approximately 65% of all incidental findings are “actionable” and that, among these, a diagnosis is confirmed in approximately 45% of patients. They also note the incidence of cancer among all incidental findings completing follow-up is 2.3-4.5%.
As we have pointed out, many medical societies and the American College of Radiology have published guidelines on how to approach various incidental findings. Makeela et al. point out that evidence-based documents guide radiologists in identifying findings that do or do not require follow-up and can help radiologists issue follow-up recommendations with regards to imaging modality and follow-up time intervals. Importantly, they note that evidence-based guidance can prevent unnecessary follow-up tests, thereby decreasing patient anxiety and financial burden on patients and society. Bt, unfortunately, there is not always a strong evidence base to provide guidance for some incidental findings.
How you communicate the findings and recommendations is important. Makeela et al. note that follow-up recommendation language should be clear and concise. They should not be so vague as to prevent the ordering clinician from understanding the necessity of follow-up. For example, they note that statements like, “If clinically indicated, follow-up CT could be performed in 4–6 weeks to document resolution,” limit clinicians’ ability to judge the necessity of follow-up and lead to low follow-up rates. Instead, they note that recommendations which precisely identify the lesion in question, the recommended modality, and time interval can result in higher completion rates. They recommend those detailed recommendations should be placed in the “Impression” section of the radiology report, where they can be easily seen and noted by clinicians. Links to the references for specific evidence-based guidelines can be included in the reports. Many radiologists have access to templates that can be used for specific incidental findings.
They also stress the importance of patient engagement in ensuring adequate follow-up.They note that in some venues, such as emergency departments and some radiology sites, the radiologist can speak directly to the patient. Ensuring patients fully understand the findings and their next steps. They also note that patients now have potential access to all their medical records, including reports of imaging studies. But the language in those reports may be too technical for patients to fully understand. But they note that “placing Info-RADS messages in radiology reports is an effective way to convey the nature of imaging results and whether any further steps are necessary. These messages indicate to patients either that the results are normal and no additional steps need to be taken, or that there was a non-emergent finding for which the patient should contact their provider to discuss next steps.”
They then discuss in detail our second key issue - having a system in place to find out that appropriate follow up, indeed, occurred. They note that tracking systems can considerably improve the chances that appropriate follow-up took place.
Hybrid tracking systems, using both staff and IT resources, may be effective. Including key words for phrases in imaging reports can flag those cases in which the tracking system should be activated. One example they provide is including the text “#follow” in the report. Newer tracking systems are also using natural language processing (NLP) capabilities to identify cases needing tracking.
They go on to describe what a fully automated tracking system would be able to do:
Of course, inadequate interoperability still presents challenges to any tracking system. We often see patients who get all their subsequent care in offices or health systems that do not communicate with the IT systems of the imaging department or practice. Sometimes, the patient is not even in the same geographic region after the initial imaging study. In our mind, that really increases the importance of that direct communication with the patient at the time of the study.
Overall, the Makeela paper has good recommendations. It is also well-referenced and has a couple nice workflow diagrams. We also refer you back to our many prior columns on communicating significant results and especially our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?”.
See also our other columns on communicating significant results:
Makeeva V, Schofield K, Davis M, Kadom N. Managing Incidental Findings. Appl Radiol. 2021; 50(6): 22-26
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