ACR Best Practices in the Communication and Management of Actionable Incidental Findings

April 20, 2023
ACR Best Practices in the Communication and Management of Actionable Incidental Findings

With millions of patients receiving imaging as part of an emergency department (ED) visit each year, it is essential to ensure that best practices are followed, especially under the intense, time-dependent conditions of the ED. Recent study Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging, published Journal of the American College of Radiology, April 2023, provides us with invaluable insights. 

High Number of AIFs Identified in the ED - Many Lacking Follow-Up

Each year millions of patients arrive in the Emergency Department and undergo an imaging examination. Between 5% and 30% of all imaging studies, as well as approximately one-third of CT examination reports, include an actionable incidental finding, or AIF. Defined as a “mass or lesion, detected by an imaging examination performed for an unrelated reason,” AIRs are important indicators of potential future health challenges.  

When one considers that in the United States, in 2019, there were over 150 million emergency department visits, over half of which required radiologic imaging and that in the ED more than 30 million CT scans are performed yearly, the sheer number of identified AIFs is astounding. However, these AIF findings and follow-up recommendations are difficult to track and outcomes are unclear. 

AIF Management is an Ongoing Challenge

Unfortunately, there is currently a wide disparity in how AIF reporting occurs, how they are communicated, and what follow-up is conducted. While the radiologist’s report is a record of findings, including any AIFs, there is a wide range of opinion regarding what exactly should be included. Additionally, there is no standard recommended follow-up interval or modality. 

The odds of receiving thorough followup on AIF’s is considerably more likely when conducted in other healthcare settings. Data suggests that of patients who have imaging performed in the ED, only 17% received follow-up treatment or testing, whereas 62% of patients whose imaging was performed in a non-ED outpatient setting, received follow-up. 

This can put some populations at a disadvantage. The numbers of underserved populations tend to be disproportionately higher in the ED. If these populations are relying on the ED to perform the bulk of their healthcare, then they are significantly less likely to receive follow-up for AIFs. 

ACR Engages Expert Panel to Address the Challenge 

To address this challenge, a panel of specialists was formed by the ACR and the ACEP, to conduct a survey into ED imaging follow-up.  The 15-member panel combined a cross-representation of practitioners diverse in geography, urban, suburban, or rural locations as well as academic and community practice.  All three stakeholder domains; radiology, emergency medicine, and non-medical personnel (IT/ systems/ patient representatives), were equally represented.

The aim of the survey was to explore what happens after AIFs are reported; how AIFs were communicated to the patient; what was the system for follow-up and tracking of AIFs; and what were the cost and economic considerations involved in the entire process. 

Identifying the Key Areas for Improvement  

It was decided that the survey would focus on 4 main pillars: 


Wide consensus on the Importance of Communicating and Tracking AIFs

87% of the clinicians responded that it is an imperative that responsibility is taken to ensure that an AIF is conveyed to the patient, to the primary care physician, and that a process will be set to monitor and ensure follow-up. 

AIF Communication is a Systems Responsibility

Given the potential healthcare implications of an AIF, the survey results recommended that reporting should include a summary, highlighting key elements of appropriate parts of the radiology report, including the presence of the AIF, as well as the evidence for supporting recommendations.

It is critical that there be standard practices for the communication between providers and for communication between providers and patients. 

"Perhaps the most important area in which agreement was strong was that the communication of incidental findings is ultimately a systems responsibility, as opposed to the responsibility of individual clinicians."

Follow-up Needs to be Tracked Systematically 

Agreement is rare in any survey. The overwhelming consensus found in this survey underline the importance of the findings. 

Survey respondents were in complete agreement of the importance of tracking actionable incidental findings, recommending thorough follow-up. Once reported by the radiologist, an alert or tracking system should be employed. The strength of this recommendation indicates the potential impact that thorough follow-up can have on patient outcomes,  strengthening ED departments nationwide.

Informatics-based Tracking is Recommended

The respondents had the same overwhelming agreement that AIFs should have an informatics-based tracking applied, enabling AIFs to be electronically flagged. Hospitals should have a tracking system in place, specifically enabling the tracking and follow-up of AIFs.

AIF Tracking Solutions are Worth the Investment 

There are currently systems available that enable a radiologist to flag AIFs, within a structured reporting system. Such systems require investment by the hospital or health care system. However, the study noted that this investment is justified when considering the cost of timely (early) identification of malignancies, the avoidance of morbidity and possibly mortality, and especially considering the financial and human cost of a delayed diagnosis, with inevitable resulting litigation. 

Additionally, when considering the total financial picture, the introduction of additional revenue that naturally accompanies the follow-up imaging and care, should be seen as a positive and additional financial incentive. 

Changing the Face of ED Imaging with Automated Follow-up Management 

The impact of thorough follow-up management has been the subject of various studies (1), in addition to the JACR article. A recent initiative, focused specifically on the implementation of an electronic follow-up system for ED patients with AIFs, saw a significant increase in the level of follow-up after the system was deployed with follow-up confirmed in more than 95% of cases (2). 

(1) Kang S.K. Doshi A.M. Recht M.P. Lover A.C. Kim D.C. Moore W. Process improvement for communication and follow-up of incidental lung nodules. J Am Coll Radiol. 2020; 17: 224-230
(2) Barrett T.W. Garland N.M. Freeman C.L. et al. Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. Ann Emerg Med. 2022; 80: 235-242

These results correlate with AGAMON Health data from leading imaging organizations in the US, who deployed the Agamon AI/NLP automated follow-up management system. Agamon analysis, based on over 20 million reports, shows that following deployment:

The impact is especially significant among low-income populations, where the deployment of the Agamon Automated follow-up system doubled patient adherence, closing the healthcare gap and advancing health equity for all.

Using Data to Fuel Innovation and Improvement 

Patients and healthcare providers alike can be grateful to the researchers who initiated this survey. It speaks volumes that there is an overwhelming consensus among such a diverse community of specialists of the need for an organized and efficient method to track, communicate and follow-up on AIFs. Armed with this hard data, healthcare administrators can now move forward to innovate change within their institutions. 

Agamon is proud to support this effort with an AI/NLP automated follow-up management platform that bridges this acute gap and provides a much needed solution for both patients and health care providers.

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