Healthcare reform is forcing ongoing risk vs. reward debates that seek consensus on the ideal balance of cost expenditure and patient care quality. As a prime example: the issue of if and how to best handle patients with incidental imaging findings receives continued scrutiny. This Reuters article summarizing a recent study in the British Medical Journal (BMJ) highlights the complexities inherent to developing standards of care for the major types of incidentalomas. It also reveals key insights that can be used for the benefit of radiology practices and patients alike.
Fundamentally, this issue is about information overload. Improving imaging technology and increasing procedures performed produce more incidental findings – and more data in need of interpretation. Fortunately, radiologists at the center of this debate now have the opportunity to step forward and lead it in a more positive direction. How? By putting their existing practice data into action, and putting the focus back on appropriate, coordinated patient care via clinical analytics.
Since the majority of incidentaloma are benign, the medical community is currently concerned about the cost of unnecessary follow-up testing from both a financial and patient-impact perspective. This focus is worthwhile, but shortsighted. What about the minority of findings that will become malignant? Standards of care are in-place that dictate when monitoring via follow-up imaging is warranted. But rarely are communication processes actually executed to help ensure that the appropriate care happens. As reviewed in our blog article, a JACR study indicated that 71% of patients with incidental lung nodules detected during chest imaging did not return for the recommended follow-up testing. Those are real people, and that’s a real problem we’re helping radiologists solve right now.
Diagnosing the real problem with incidental findings
The BMJ study, designed as an “umbrella review of systematic reviews”, included 20 prior studies and 627,073 patients. Its authors concluded that “There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs.” The study supports the need to address the issues of cost and patient risk in determining standards for incidentaloma follow-up. With good software, a practice can identify processes to help mitigate associated overutilization issues in the patient population.
But that’s not the end of the story, nor is it the end of the responsibility of healthcare providers. We have an obligation to our patients to notify them, and their PCPs, of such incidental findings and enable the providers to make informed clinical decisions about the need for follow-up based on patient risk factors. The BMJ study states that, “Data will aid clinicians and patients to weigh up the pros and cons of requesting imaging scans and assist with management decisions after an incidentaloma diagnosis. These results can underpin the creation of guidelines to assist these decisions.”
At HAP, we’ve already enabled our hospital-based radiology practice billing clients to empower such decisions and address the more urgent problem with incidentalomas. Case in point: patients who come to the hospital ED, have an incidental lung nodule detected during chest imaging, and are discharged none-the-wiser. In these instances, it is rare that communication with the patient continues regarding the presence of the nodule, and highly doubtful that their PCPs are made aware of such findings.
Our existing solution identifies incidental lung nodules and sends notification letters to PCPs and patients when the latter have missed their recommended follow-up. That follow-up due date is calculated using Fleischner Guidelines, Lung-Rads categories, or the follow-up dictated on the radiologists’ original report. These variables are all appropriate criteria for determining a patient in need of follow-up monitoring, and we can further customize the logic to address specific requirements of each practice.
To validate program efficacy, our team went back and queried the data for patients who came in with a reason for study indicated as “trauma” or “injury”, were sent the notification letters, and did return for follow-up after receiving the letters. Out of this cohort, 75% of the patients were stable or improved at follow-up. However, 25% of these patients had new nodules, or their nodules had grown. There have been more than a few cases where a chest x-ray is performed, shows a pneumonia, and then the patient returns for another issue a year later and a cancer is discovered.
Adapt and overcome the most concerning radiology patient leakage issues
Deploying an integrated clinical analytics and communication solution to address these alarming radiology patient leakage problems requires flexibility in programming logic. For example, the BMJ study not only identified the type of imaging procedures that returned the most incidentalomas, it also identified the organs most likely to contain a malignancy in such cases:
“The prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland…whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%).”
Earlier this year, we expanded our follow-up logic to include patients with incidental thyroid, renal, liver, pancreas, and adrenal lesions. After reading the BMJ study, we have begun to expand our logic again to cover the patient population who have ovarian and breast incidentalomas. New standards and studies will continue to be published on this issue, so it is important that any such clinical analytics solution be both locked-in on what is current and able to adapt to what is to come.
Start with these steps to solve the problem
If you intend to tackle the issue of incidental findings patient leakage at your radiology practice, here’s what we recommend based on our experience:
- Document the data. Radiologists need to continue to dictate follow-ups in studies where incidentalomas are identified utilizing guidelines derived from research like the BMJ study or other documented clinical guidelines. This basic step lays the crucial data foundation for the entire program.
- Engage hospital administration. Position your radiology practice as a partner in achieving patient quality outcomes. Meet with your key hospital executive stakeholders to present the concept. Come armed with your data exposing the patient leakage problem. Be prepared to work with them on procedural and legal issues required to obtain their financial support.
- Get PCPs onboard early. Identify the key practices in your area and network. Brief them on the program in advance. If possible, bring specific examples where radiology studies of their patients never made it to their desk.
- Don’t go it alone. Get your practice’s billing vendor or internal team involved in the discussions early. They are closest to the clinical data that needs to be mined to deploy such a solution and can identify potential issues in advance.
In the debate over appropriate standards of care for patients with incidental findings, radiologists are too often placed in the crosshairs. Instead, why not turn this situation into a crossroads? Position your radiology practice as a valued problem-solver by putting your clinical data into action. Seize this opportunity to benefit patients, PCPs, and your hospital partners with one integrated solution. The result can be a win for all of them, and a newfound appreciation of your radiology practice value.
Sharon Taylor is the Chief Clinical Informatics Officer at Healthcare Administrative Partners. Her areas of expertise include patient-centered clinical informatics, clinical systems, project management of clinical system implementations and integrations, EHR Adoption and speech recognition training.