Plugging holes in the Incidental Findings safety net (or is there even a net?): Part 1

October 18, 2021
Plugging holes in the Incidental Findings safety net (or is there even a net?): Part 1

After all this time, there's still a care gap

Your husband gets a CT scan. You look at the report on the patient portal and see the radiologist found something unexpected on the scan. Say, a small kidney lesion. When you look to see what she recommended be done, you might see no recommendation, which may be confusing (but may be correct). However, you might find that she did recommended a follow-up scan, but were disturbed that his doctor did not schedule one... What would you do?

Despite the installation of literally hundreds of different kinds of computer systems in healthcare over the past couple of decades, you might be surprised at this care gap. However, the way these issues are addressed is little different than 30 years ago (which I remember, as a university attending radiologist at that time).

The frequency of Incidental Findings (IFs) has multiplied several-fold over recent years

Studies vary, but most find that fewer than 50% of recommendations for additional imaging (RAI) are actually scheduled and performed. Healthcare systems have been getting away with haphazard practices of follow-up of IFs since incidental findings were recognized as a problem. 

Why are we doing so badly?

There is a potential cascade of reasons and excuses for lack of follow-up. There is an extraordinary amount of “noise” in medical care. This is confusing for patients and for physicians, who are both attempting to prioritize the important aspects of care. The quality of communication varies starkly and the knowledge bases of providers differ greatly. Are the recommendations wrong or unconvincing? Did the referring physician just not see them in the report, or was the report poorly worded, or was the physician just too busy to follow through and they prioritized their time elsewhere? Is the referring physician skeptical or just frankly disagrees that follow-up is worthwhile? 

With all of the obligations of radiologists, rapidly developing technology and increased work stress, why should we prioritize trying to solve this particular problem?

Most importantly, patients expect us to. Signs suggest that our hit-or-miss follow-up of IFs will soon no longer be tolerated by our patients and their families, by the institutions we serve, and by the overseers of our work (insurers, regulators, etc.). Portals are seeing rapidly increasing use from patients, as the breadth of content proliferates, and with reports now being distributed more quickly than ever. IFs are pervasive throughout radiology and have become central to patient care, despite our natural desire to focus on the patient’s central clinical presenting problem. 

Lesions not acted upon are often the cases that relentlessly haunt physicians and institutions, both materially and psychologically. They can be 1) catastrophic to the patient, such as missing asymptomatic cancers when they are still curable, 2) damaging to the physician’s reputation and creating malpractice liability for the physicians and legal liability for the institution and 3) costly to the institution from loss of revenue from indicated examinations that are never done. Although its effectiveness has been questioned, the state of Pennsylvania has even enacted a law requiring physicians to directly notify outpatients of incidental findings! 

How to disperse the fog of confusion about how to handle IF follow-up? What are the obstacles to improvement, and how can we jump over them? 

There is a growing number of papers describing possible solutions. Crable, et al [1], recently reviewed the literature on this topic and divided improvement strategies into four categories:

  1. training and distributing quick reference guides;
  2. guideline references placed online for easy access;
  3. structured reporting with enhanced radiology templates for improved documentation; and
  4. revised clinical and communication pathways.

Of course, effectively detecting incidental findings, accurately applying guidelines, and properly placing the recommendations in the report using efficient, consistent language, are important to starting the chain of follow-up. However, these are larger issues of the radiologists’ process that are not the subject of this discussion.

So far, we have covered why Incidental Findings are an ongoing issue in radiology and what solutions have been put forward to fix the problem. In Part 2, we focus on arguably the most effective solution - revised clinical and communication pathways - and where technology can assist.

About the author: Dr. Berland is retired, and Professor Emeritus from the University of Alabama at Birmingham. He founded the ACR Incidental Findings Committee in 2006, which has published about 15 white papers on this topic. He currently consults for Agamon Health.

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