As the quality of advanced diagnostic images studies, like MRI and CT, continue to improve, radiologists are increasingly perceiving findings such as masses or lesions that are "incidental" to the reason the studies were ordered in the first place. The growing number of imaging techniques being performed has dramatically increased the number of these incidental findings. Radiologists now regularly report their incidental findings, frequently conveyed along with recommendations for follow up diagnostic testing or other actions such as specialty referrals, invasive procedures or other actions . Too often, these findings and recommendations are overlooked, with no clinical follow up. Fortunately, as I describe below, technology is being harnessed to help close the follow up gap.
To assess the scope of this problem, researchers at Brigham and Women’s Hospital, Harvard Medical School's Center for Primary Care, conducted a retrospective evaluation of 598 radiology reports generated from imaging tests ordered by primary care physicians between January 1 and December 31, 2018, where the reports contained actionable recommendations. Their study, "Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance", was just published online on the JAMA Open Network.
The overall rate of completed actions (loop closure) was 87.4%. But they found 31 open cases to pose substantial clinical risks, as rated by quality expert reviewers who were part of the study. One in seven patients with major radiologic abnormalities where the radiologist's report recommended follow-up actions did not have any documented follow up.
The study researchers were particularly critical of radiology reporting containing what they viewed as contingency language such as "repeat computed tomography scan if the patient smokes" or other vague qualifying statements that the authors then tabulated and included as an eTable as a supplement to the article. They indicated their view that such statements contributed to lack of follow up.
Both referring physicians and radiologists have concerns about patient care - and malpractice exposure - caused by neglect of many important incidental findings that should require follow-up. So what is being done about this?
At the Radiology Business Management Association (RBMA) annual meeting, Paradigm, that I attended this year, I spoke to a vendor who is marketing a product designed specifically to close this loop. The company uses a natural language processing (NLP) software program to screen radiology reports to extract radiologists' recommendations and to deliver them to the referring physician's mobile device and dashboard. The mobile application allows the referring physician to review the report on the mobile device and to decide whether to accept, decline, modify, or defer the radiologist’s recommendation.
I hope we can all agree that incidental findings are a good thing, despite their increasing number. Here is hoping that awareness will improve action on radiologists' reporting and that technology will continue to advance to help identify and prevent failure to follow up on these important findings.