Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports?

Financial Impact of a Radiology Safety Net Program for Resolution of Clinically Necessary Follow-up Imaging Recommendations

OBJECTIVE

Health care safety net (SN) programs can potentially improve patient safety and decrease risk associated with missed or delayed follow-up care, although they require financial resources. This study aimed to assess whether the revenue generated from completion of clinically necessary recommendations for additional imaging (RAI) made possible by an IT-enabled SN program could fund the required additional labor resources.

METHODS

Clinically necessary RAI generated October 21, 2019, to September 24, 2021, were tracked to resolution as of April 13, 2023. A new radiology SN team worked with existing schedulers and care coordinators, performing chart review and patient and provider outreach to ensure RAI resolution. We applied relevant Current Procedural Terminology, version 4 codes of the completed imaging examinations to estimate total revenue. Coprimary outcomes included revenue generated by total performed examinations and estimated revenue attributed to SN involvement. We used Student's t test to compare the secondary outcome, RAI time interval, for higher versus lower revenue-generating modalities.

RESULTS

In all, 24% (3,243) of eligible follow-up recommendations (13,670) required SN involvement. Total estimated revenue generated by performed recommended examinations was $6,116,871, with $980,628 attributed to SN. Net SN-generated revenue per 1.0 full-time equivalent was an estimated $349,768. Greatest proportion of performed examinations were cross-sectional modalities (CT, MRI, PET/CT), which were higher revenue-generating than non-cross-sectional modalities (x-ray, ultrasound, mammography), and had shorter recommendation time frames (153 versus 180 days, P < .001).

DISCUSSION

The revenue generated from completion of RAI facilitated by an IT-enabled quality and safety program supplemented by an SN team can fund the required additional labor resources to improve patient safety. Realizing early revenue may require 5 to 6 months postimplementation.

Incidental pulmonary nodules - current guidelines and management

BACKGROUND

 Due to the greater use of high-resolution cross-sectional imaging, the number of incidental pulmonary nodules detected each year is increasing. Although the vast majority of incidental pulmonary nodules are benign, many early lung carcinomas could be diagnosed with consistent follow-up. However, for a variety of reasons, the existing recommendations are often not implemented correctly. Therefore, potential for improvement with respect to competence, communication, structure, and process is described.

METHODS

 This article presents the recommendations for incidental pulmonary nodules from the current S3 guideline for lung cancer (July 2023). The internationally established recommendations (BTS guidelines and Fleischner criteria) are compared and further studies on optimized management were included after a systematic literature search in PubMed.

RESULTS AND CONCLUSION

 In particular, AI-based software solutions are promising, as they can be used in a support capacity on several levels at once and can lead to simpler and more automated management. However, to be applicable in routine clinical practice, software must fit well into the radiology workflow and be integrated. In addition, "Lung Nodule Management" programs or clinics that follow a high-quality procedure for patients with incidental lung nodules or nodules detected by screening have been established in the USA. Similar structures might also be implemented in Germany in a future screening program in which patients with incidental pulmonary nodules could be included.

KEY POINTS

  · Incidental pulmonary nodules are common but are often not adequately managed. · The updated S3 guideline for lung cancer now includes recommendations for incidental pulmonary nodules. · Competence, communication, structure, and process levels offer significant potential for improvement.

CITATION FORMAT

· Glandorf J, Vogel-Claussen J, . Incidental pulmonary nodules - current guidelines and management. Fortschr Röntgenstr 2024; 196: 582 - 590.

Introduction of the Danish Lung Nodule Registry: A part of the Danish Lung Cancer Registry

BACKGROUND

The majority of lung cancer cases are diagnosed late, resulting in poor prognosis and high mortality rates. Early detection and management of lung cancer can improve patient outcomes and reduce mortality rates. Pulmonary nodules are key factors in the early detection of lung cancer, they are common in high-risk populations and require correct classification to determine whether they are benign or malignant. Over the last decade a steep increase in the number of thoracic CT scans has been seen in Denmark, resulting in substantial resources allocated to CT follow-up of incidentally detected pulmonary nodules. The implementation of a nationwide Danish prospective pulmonary nodule registry is to methodically record pulmonary nodules and thereby evaluate the scope of pulmonary nodule follow-up, the nature of the nodules, and the clinical progression of patients with pulmonary nodules.

METHODS

A prospective pulmonary nodule registry (Danish Lung Nodule Registry) will be a natural appendix to the Danish Lung Cancer Registry. Three new ICD-10 classification codes will be introduced, defining the type of nodule: /DR91.1/ Solid nodule /DR91.2/ Part-solid nodule; /DR91.3/ Non-solid nodule. Furthermore, an additional letter will describe whether the imaging exam is performed on suspicion of lung cancer (A), or the finding is incidental (B). Registration of the nodules will be performed by the departments of respiratory medicine who manage follow-up of pulmonary nodules. It is estimated that around 7000 nodules will be registered annually.

DISCUSSION

The registration of patients in the lung nodule registry complies with current Danish legislation. The registry will be seamlessly integrated with other nationwide Danish registries, including the Danish Lung Cancer Registry, to collect additional patient data and improve the quality and scope of the data acquired. The results from these comprehensive epidemiological studies will be of significant interest and offer valuable research opportunities.

Predictors of Completion of Clinically Necessary Radiologist-Recommended Follow-Up Imaging: Assessment Using an Automated Closed-Loop Communication and Tracking Tool

BACKGROUND. Patients with adverse social determinants of health may be at increased risk of not completing clinically necessary follow-up imaging. OBJECTIVE. The purpose of this study was to use an automated closed-loop communication and tracking tool to identify patient-, referrer-, and imaging-related factors associated with lack of completion of radiologist-recommended follow-up imaging. METHODS. This retrospective study was performed at a single academic health system. A tool for automated communication and tracking of radiologist-recommended follow-up imaging was embedded in the PACS and electronic health record. The tool prompted referrers to record whether they deemed recommendations to be clinically necessary and assessed whether clinically necessary follow-up imaging was pursued. If imaging was not performed within 1 month after the intended completion date, the tool prompted a safety net team to conduct further patient and referrer follow-up. The study included patients for whom a follow-up imaging recommendation deemed clinically necessary by the referrer was entered with the tool from October 21, 2019, through June 30, 2021. The electronic health record was reviewed for documentation of eventual completion of the recommended imaging at the study institution or an outside institution. Multivariable logistic regression analysis was performed to identify factors associated with completion of follow-up imaging. RESULTS. Of 5856 recommendations entered during the study period, the referrer agreed with 4881 recommendations in 4599 patients (2929 women, 1670 men; mean age, 61.3 ± 15.6 years), who formed the study sample. Follow-up was completed for 74.8% (3651/4881) of recommendations. Independent predictors of lower likelihood of completing follow-up imaging included living in a socioeconomically disadvantaged neighborhood according to the area deprivation index (odds ratio [OR], 0.67 [95% CI, 0.54-0.84]), inpatient (OR, 0.25 [95% CI, 0.20-0.32]) or emergency department (OR, 0.09 [95% CI, 0.05-0.15]) care setting, and referrer surgical specialty (OR, 0.70 [95% CI, 0.58-0.84]). Patient age, race and ethnicity, primary language, and insurance status were not independent predictors of completing follow-up (p > .05). CONCLUSION. Socioeconomically disadvantaged patients are at increased risk of not completing recommended follow-up imaging that referrers deem clinically necessary. CLINICAL IMPACT. Initiatives for ensuring completion of follow-up imaging should be aimed at the identified patient groups to reduce disparities in missed and delayed diagnoses.

Incidental Pulmonary Nodules - What Do We Know in 2022

Lung cancer (LC) is the leading cause of cancer-related mortality worldwide, and early LC diagnosis can significantly improve outcomes and survival rates in affected patients. Implementation of LC screening programs using low-dose computed tomography CT in high-risk subjects aims to detect LC as early as possible, but so far, adoption of screening programs into routine clinical care has been very slow. In recent years, the use of CT has significantly increased the rate of incidentally detected pulmonary nodules. Although most of those incidental pulmonary nodules (IPNs) are benign, some of them represent early-stage LC. Given the large number of IPNs detected in the range of several millions each year, this represents an additional, maybe even larger, opportunity to drive stage shift in LC diagnosis, next to LC screening programs. Comprehensive evaluation and targeted work-up of IPNs are mandatory to identify the malignant nodules from the crowd, and several guidelines provide radiologists and physicians' guidance on IPN assessment and management. However, IPNs still seem to be inadequately processed due to various reasons including insufficient reporting in the radiological report, missing communication between stakeholders, absence of patient tracking systems, and uncertainty regarding responsibilities for the IPN management. In recent years, several approaches such as lung nodule programs, patient tracking software, artificial intelligence, and communication software were introduced into clinical practice to address those shortcomings. This review evaluates the current situation of IPN management and highlights recent developments in process improvement to achieve first steps toward stage shift in LC diagnosis.

Patient-level factors influencing adherence to follow-up imaging recommendations

PURPOSE

To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center.

METHODS

In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05.

RESULTS

A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06-0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion.

CONCLUSION

Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.

Informatics Solutions to Mitigate Legal Risk Associated With Communication Failures

Communication failures are a documented cause of malpractice litigation against radiologists. As imaging volumes have increased, and with them the number of findings requiring further workup, radiologists are increasingly expected to communicate with ordering clinicians. However, communication may be unsuccessful for a variety of reasons that expose radiologists to potential malpractice risk. Informatics solutions have the potential to improve communication and decrease this risk. We discuss human-powered, purely automated, and hybrid approaches to closing the communications loop. In addition, we describe the Patient Test Results Information Act (Pennsylvania Act 112) and its implications for closing the loop on noncritical actionable findings.

Assessment of the Response to Abdominal and Pelvic Computed Tomography Report Recommendations: A Single-Center, Retrospective, Chart Review Study

Objectives

The radiology report is the primary form of communication between the radiologists and referring clinicians. It is a structured document containing several key components pertaining to the interpretation of radiological examinations and may require the addition of follow-up imaging recommendations to optimize patient outcomes. This study aims to determine whether follow-up imaging recommendations are being acknowledged and acted upon by referrers.

Methods

This retrospective study was conducted at a single tertiary hospital. Prerecorded BESTCare data of patients who underwent abdominal and pelvic computed tomography (CT) scans between October 1, 2017, and December 31, 2017, and received recommendations for further evaluation were collected after obtaining ethical approval from the local authority. Data of patients younger than 14 years old, patients who did not receive a recommendation, and patients who had CT scans that were uploaded to the BESTCare system but were performed outside the institution were excluded. The collected data were recorded in a password-protected Microsoft Excel file for further analysis.

Results

A total of 523 report recommendations from 422 abdominal and pelvic CT reports were analyzed. The most common organs indicated for CT scan evaluation were the breast (N = 54, 10.33%), kidney (N = 46, 8.80%), lymph node (N = 36, 6.88%), and colon (N = 33, 6.31%). The most common type of further evaluation recommended was further imaging (N = 410, 78.39%). A total of 278 (53.15%) recommendations were not performed, with 199 (71.58%) not having a documented rationale for noncompliance.

Conclusion

The majority of the follow-up imaging recommendations to ordering physicians were not carried out. This study highlights the need for notification and audit systems to monitor compliance with follow-up recommendations. Improving the communication between radiologists and referring physicians is key to optimizing patient healthcare.

Automatic detection of actionable radiology reports using bidirectional encoder representations from transformers

Background

It is essential for radiologists to communicate actionable findings to the referring clinicians reliably. Natural language processing (NLP) has been shown to help identify free-text radiology reports including actionable findings. However, the application of recent deep learning techniques to radiology reports, which can improve the detection performance, has not been thoroughly examined. Moreover, free-text that clinicians input in the ordering form (order information) has seldom been used to identify actionable reports. This study aims to evaluate the benefits of two new approaches: (1) bidirectional encoder representations from transformers (BERT), a recent deep learning architecture in NLP, and (2) using order information in addition to radiology reports.

Methods

We performed a binary classification to distinguish actionable reports (i.e., radiology reports tagged as actionable in actual radiological practice) from non-actionable ones (those without an actionable tag). 90,923 Japanese radiology reports in our hospital were used, of which 788 (0.87%) were actionable. We evaluated four methods, statistical machine learning with logistic regression (LR) and with gradient boosting decision tree (GBDT), and deep learning with a bidirectional long short-term memory (LSTM) model and a publicly available Japanese BERT model. Each method was used with two different inputs, radiology reports alone and pairs of order information and radiology reports. Thus, eight experiments were conducted to examine the performance.

Results

Without order information, BERT achieved the highest area under the precision-recall curve (AUPRC) of 0.5138, which showed a statistically significant improvement over LR, GBDT, and LSTM, and the highest area under the receiver operating characteristic curve (AUROC) of 0.9516. Simply coupling the order information with the radiology reports slightly increased the AUPRC of BERT but did not lead to a statistically significant improvement. This may be due to the complexity of clinical decisions made by radiologists.

Conclusions

BERT was assumed to be useful to detect actionable reports. More sophisticated methods are required to use order information effectively.

Determining Follow-Up Imaging Study Using Radiology Reports

Radiology reports often contain follow-up imaging recommendations. Failure to comply with these recommendations in a timely manner can lead to delayed treatment, poor patient outcomes, complications, unnecessary testing, lost revenue, and legal liability. The objective of this study was to develop a scalable approach to automatically identify the completion of a follow-up imaging study recommended by a radiologist in a preceding report. We selected imaging-reports containing 559 follow-up imaging recommendations and all subsequent reports from a multi-hospital academic practice. Three radiologists identified appropriate follow-up examinations among the subsequent reports for the same patient, if any, to establish a ground-truth dataset. We then trained an Extremely Randomized Trees that uses recommendation attributes, study meta-data and text similarity of the radiology reports to determine the most likely follow-up examination for a preceding recommendation. Pairwise inter-annotator F-score ranged from 0.853 to 0.868; the corresponding F-score of the classifier in identifying follow-up exams was 0.807. Our study describes a methodology to automatically determine the most likely follow-up exam after a follow-up imaging recommendation. The accuracy of the algorithm suggests that automated methods can be integrated into a follow-up management application to improve adherence to follow-up imaging recommendations. Radiology administrators could use such a system to monitor follow-up compliance rates and proactively send reminders to primary care providers and/or patients to improve adherence.

Asymptomatic Abdominal Aortic Aneurysm: Standardizing Reporting Recommendations at a Large Multistate Radiology Practice

OBJECTIVE

Although often asymptomatic at initial diagnosis, abdominal aortic aneurysms (AAAs) require careful surveillance to prevent rupture, with rupture-associated mortality rates as high as 90%. The purpose of this study was to explore if a performance improvement initiative implemented across a large radiology practice successfully increased inclusion of best practice recommendations (BPRs) within the radiology report across the practice.

METHODS

After BPRs for asymptomatic AAA surveillance were developed, a structured reporting macro for follow-up recommendation was integrated into dictation software. Following a training period, inclusion of recommendations within the radiology report was monitored across 345 facilities within the practice. Performance was reported on scorecards distributed monthly. To measure practice improvement, inclusion of appropriate recommendation in radiology reports postimplementation was compared with pre-implementation data.

RESULTS

During the period before AAA BPRs implementation, from 64,090 consecutive cross-sectional radiology reports reviewed during a 6-month period, 855 incidental AAAs (1.3%) were identified, with 783 aneurysms measuring 2.6 to 5.4 cm requiring imaging surveillance; only 17 (2.1%) included follow-up recommendations within the radiology report. Postimplementation, 2,641 of 148,807 cross-sectional imaging studies were positive for 2.6- to 5.4-cm AAAs requiring further management; 1,533 (58.0%) of these radiology reports included follow-up imaging recommendations (97.0% of which followed our AAA BPRs).

DISCUSSION

Quality improvement initiatives to develop BPRs for AAA surveillance and include these recommendations within the radiology report can be successfully implemented across large practices and are imperative to ensure imaging surveillance and avert AAA rupture.

Referral for Imaging in Physical Therapist Practice: Key Recommendations for Successful Implementation

In recent years, the use of diagnostic imaging in physical therapist practice in the United States has gained considerable interest. In several countries around the world and in the US military, patient direct referral for diagnostic imaging has been considered normative practice for decades. US physical therapy program accreditation standards now stipulate that diagnostic imaging content must be included in physical therapist educational curricula. The American Physical Therapy Association has made efforts to pursue practice authority for imaging referral. A recent review of state practice acts and other statutory language concluded that many states have no prohibitions against physical therapists referring for imaging studies. Additionally, physical therapists can now pursue certification as musculoskeletal sonographers. In light of these advances, and with a growing number of physical therapists serving patients who have not yet seen another health care provider, it may be helpful for those who have been actively involved in the use of imaging in physical therapist practice to provide their collective recommendations to serve as a guideline to those interested in incorporating this practice privilege. The purpose of this perspective article is to provide an overview of the key elements necessary for effective implementation of referral for imaging in physical therapist practice while emphasizing the cornerstone of effective communication.

Evaluation of Radiology Reports by the Emergency Department Clinical Providers: A Message to Radiologists

Objectives:

This study is an evaluation of the emergency department (ED) satisfaction with the current radiologic reporting system used at a major Northeastern academic medical center. The radiology reports are the main form of communication and usually the final product of any radiological investigation delivered to clinicians. The aim of this study was to improve current radiology reporting practices and to better tailor reports to match the needs and expectations of ED clinicians.

Methods:

A 9-question online survey was sent to ED residents, fellows, faculty, and nurse practitioners/advanced practice providers at a major Northeastern academic medical center in the United States. For the open-ended section, coding and emergent theme categorization was conducted for quantification of responses. The survey was designed to evaluate the attitudes toward the structure, style, form, and wording used in reports.

Results:

The response rate was 48.6% (68/140). The ED respondents were generally satisfied with radiology reports, their language, vocabulary, and clarity. They preferred the impression section to be before the findings in simple examinations and to stratify the reports according to emergency status for complex examinations. They did not like extended differential, hedge terms, and delayed reporting. Additionally, ED respondents recommended focused, fast reporting with considerable changes toward a more standardized report.

Conclusions:

This evaluation delivered a list of actionable recommendations. The top recommendation is to standardize reporting structure, style, and lexicon, in addition to being focused, timely, and brief.

Trends of Follow-Up Recommendations Made on Musculoskeletal MRI Reports

OBJECTIVE. The purpose of this article was to analyze trends in follow-up recommendations made on musculoskeletal MRI reports. MATERIALS AND METHODS. An IRB-approved retrospective study identified 790 musculoskeletal MRI reports from our database between January 1, 2016, and January 1, 2018, containing follow-up recommendations made by the interpreting radiologist. Metadata were automatically extracted and classification of the recommendations was performed by manual review. Clinical outcome data were collected from the electronic health record. After exclusion criteria were applied, 654 reports were included in the study. Descriptive statistics, Fisher exact tests, and chi-square tests were used for analysis. RESULTS. Clinicians acknowledged 83% and followed 73% of the recommendations. Follow-up compliance varied with the type of recommendation made: 98% for clinical intervention versus 67% for additional imaging (p < 0.001). Subspecialties acknowledged and followed recommendations at different rates: 92% and 85% for internists versus 76% and 64% for orthopedists (p < 0.001 and p < 0.001), respectively. Patient age, practice setting, radiologist experience, recommendation conditionality, and specified follow-up time intervals made no difference in compliance rate (all p > 0.05). There was no difference in compliance rate among various pathologic findings of concern (p = 0.995). Compliance rate increased significantly after direct communication between the radiologist and clinician compared with when there was no direct communication (93% vs 71%, p < 0.001). Concern for neoplasm comprised the greatest number of unacknowledged recommendations (73%). CONCLUSION. Musculoskeletal MRI recommendations are followed independent of the finding of concern and compliance is lowest for requests of additional imaging. Direct communication improves compliance and may be particularly helpful for orthopedic referrers.

Automated Tracking of Follow-Up Imaging Recommendations

OBJECTIVE. Radiology reports often contain follow-up imaging recommendations. Failure to comply with these recommendations in a timely manner can lead to poor patient outcomes, complications, and legal liability. As such, the primary objective of this research was to determine adherence rates to follow-up recommendations. MATERIALS AND METHODS. Radiology-related examination data, including report text, for examinations performed between June 1, 2015, and July 31, 2017, were extracted from the radiology departments at the University of Washington (UW) and Lahey Hospital and Medical Center (LHMC). The UW dataset contained 923,885 examinations, and the LHMC dataset contained 763,059 examinations. A 1-year period was used for detection of imaging recommendations and up to 14-months for the follow-up examination to be performed. RESULTS. On the basis of an algorithm with 97.9% detection accuracy, the follow-up imaging recommendation rate was 11.4% at UW and 20.9% at LHMC. Excluding mammography examinations, the overall follow-up imaging adherence rate was 51.9% at UW (range, 44.4% for nuclear medicine to 63.0% for MRI) and 52.0% at LHMC (range, 30.1% for fluoroscopy to 63.2% for ultrasound) using a matcher algorithm with 76.5% accuracy. CONCLUSION. This study suggests that follow-up imaging adherence rates vary by modality and between sites. Adherence rates can be influenced by various legitimate factors. Having the capability to identify patients who can benefit from patient engagement initiatives is important to improve overall adherence rates. Monitoring of follow-up adherence rates over time and critical evaluation of variation in recommendation patterns across the practice can inform measures to standardize and help mitigate risk.

Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules

OBJECTIVE. The purpose of this study is to assess radiologists' adoption of a closed-loop communication and tracking system, Result Alert and Development of Automated Resolution (RADAR), for incidental pulmonary nodules and to measure its effect on the completeness of radiologists' follow-up recommendations. MATERIALS AND METHODS. This retrospective study was performed at a tertiary academic center that performs more than 600,000 radiology examinations annually. Before RADAR, the institution's standard of care was for radiologists to generate alerts for newly discovered incidental pulmonary nodules using a previously described PACS-embedded software tool. RADAR is a new closed-loop communication tool embedded in the PACS and enterprise provider workflow that enables establishing a collaborative follow-up plan between a radiologist and referring provider and helps automate collaborative follow-up plan tracking and execution. We assessed RADAR adoption for incidental pulmonary nodules, the primary outcome, in our thoracic radiology division (study period March 9, 2018, through August 2, 2018). The secondary outcome was the completeness of follow-up recommendation for incidental pulmonary nodules, defined as explicit imaging modality and time frame for follow-up. RESULTS. After implementation, 106 of 183 (58%) incidental pulmonary nodules alerts were generated using RADAR. RADAR adoption increased by 75% during the study period (40% in the first 3 weeks vs 70% in the last 3 weeks; p < 0.001 test for trend). All RADAR alerts had explicit documentation of imaging modality and follow-up time frame, compared with 71% for non-RADAR alerts for incidental pulmonary nodules (p < 0.001). CONCLUSION. A closed-loop communication system that enables establishing and executing a collaborative follow-up plan for incidental pulmonary nodules can be adopted and improves the quality of radiologists' follow-up recommendations.

Reporting of Inferior Vena Cava Filter Complications on CT: Impact of Standardized Macros

OBJECTIVE

The objective of our study was to report the effect of implementing standardized inferior vena cava filter (IVCF) macros on the reporting of IVCFs and filter-related complications in abdominal CT reports.

MATERIALS AND METHODS

Retrospective analysis was performed of all abdominal CT reports performed between October 2014 and January 2015 before implementation of IVCF macros (n = 5143). Duplicated examinations and studies requested specifically to evaluate known IVCFs were excluded. In March 2016, normal and abnormal standardized IVCF macros were implemented. Two radiologists reviewed all CT abdominal reports using IVCF macros between March 2016 to July 2016 to assess for missed IVCF complications.

RESULTS

Before the implementation of the IVCF macros, 146 of 5143 (2.8%) abdominal CT studies (89 men and 57 women; mean age, 59 years) showed an IVCF. After implementation of IVCF macros, 105 abdominal CT studies using the IVCF macros were analyzed (48 men and 57 women; mean age, 58 years), including 73 normal macros and 32 abnormal macros). The rate of reported caval penetration and filter element-organ interaction improved from 12% (9/73) to 57% (28/49) (p < 0.001) and from 0% (0/53) to 36% (9/25) (p < 0.001) before and after macro implementation, respectively. However, one filter fracture and two filter-associated thrombi were missed when using the IVCF macros.

CONCLUSION

Implementation of standardized IVCF macros improves reporting of IVCFs and IVCF-associated complications in abdominal CT reports.

Improving Quality of Follow-Up Imaging Recommendations in Radiology

Failure of timely follow-up imaging recommendations can result in suboptimal patient care. Evidence suggests that the use of conditional language in follow-up recommendations is associated with changes to follow-up compliance. Assuming that referring physicians prefer explicit guidance for follow-up recommendations, we develop algorithms to extract recommended modality and interval from follow-up imaging recommendations related to lung, thyroid and adrenal findings. Using a production dataset of 417,451 radiology reports, we observed that on average, follow-up interval was not mentioned in 79.4% of reports, and modality was missing in 47.4% of reports (4,819 reports contained a follow-up imaging recommendation for one of the three findings). We also developed an interactive dashboard to be used to monitor compliance rates. Recognizing the importance of increasing precision of follow-up recommendations, a quality improvement pilot study is underway with the goal of achieving a target where follow-up modality and interval are both explicitly specified.

Time to Talk: Can Radiologists Improve Follow-Up of Abdominal Imaging Findings Indeterminate for Malignancy by Initiating Verbal Communication?

PURPOSE

The aims of this study were to examine the association between radiologist-initiated verbal communication for abdominal imaging findings indeterminate for malignancy and receipt of relevant outpatient follow-up imaging and to evaluate the proportion of findings that progress from indeterminate to suspicious for malignancy.

METHODS

Using a mandatory standardized assessment coding system, 727 eligible outpatient abdominal CT, MRI, and ultrasound studies performed between July 1, 2013, and January 31, 2014, were identified. Multivariate logistic regression was used to evaluate the association between radiologist-initiated verbal communication and receipt of relevant outpatient imaging follow-up, adjusted for patient, ordering physician, interpreting radiologist, and imaging variables.

RESULTS

Sixty-two percent of patients (451 of 727) with imaging findings indeterminate for malignancy received relevant outpatient imaging follow-up. Radiologist-initiated verbal communication occurred in 4.8% of cases (35 of 727). Radiologist-initiated verbal communication (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.02-5.87) and existing cancer diagnosis (OR, 3.00; 95% CI, 2.11-4.26) were associated with a higher likelihood of receiving relevant imaging follow-up. Compared with those whose imaging studies were ordered by clinicians in a medical specialty, patients with studies ordered by clinicians in surgical (OR, 0.70; 95% CI, 0.49-0.99) or other (OR, 0.44; 95% CI, 20.24-0.83) specialties were less likely to receive relevant imaging follow-up. Progression of findings from indeterminate to suspicious for malignancy occurred in 5.4% of cases and was not associated with radiologist-initiated verbal communication.

CONCLUSIONS

Radiologist-initiated verbal communication increases the likelihood that patients receive outpatient imaging follow-up for abdominal findings indeterminate for malignancy. Progression of these findings is relatively infrequent.

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up?

OBJECTIVE

To assess whether integrating critical result management software--Alert Notification of Critical Results (ANCR)--with an electronic health record (EHR)-based results management application impacts closed-loop communication and follow-up of nonurgent, clinically significant radiology results by primary care providers (PCPs).

MATERIALS AND METHODS

This institutional review board-approved study was conducted at a large academic medical center. Postintervention, PCPs could acknowledge nonurgent, clinically significant ANCR-generated alerts ("alerts") within ANCR or the EHR. Primary outcome was the proportion of alerts acknowledged via EHR over a 24-month postintervention. Chart abstractions for a random sample of alerts 12 months preintervention and 24 months postintervention were reviewed, and the follow-up rate of actionable alerts (eg, performing follow-up imaging, administering antibiotics) was estimated. Pre- and postintervention rates were compared using the Fisher exact test. Postintervention follow-up rate was compared for EHR-acknowledged alerts vs ANCR.

RESULTS

Five thousand nine hundred and thirty-one alerts were acknowledged by 171 PCPs, with 100% acknowledgement (consistent with expected ANCR functionality). PCPs acknowledged 16% (688 of 4428) of postintervention alerts in the EHR, with the remaining in ANCR. Follow-up was documented for 85 of 90 (94%; 95% CI, 88%-98%) preintervention and 79 of 84 (94%; 95% CI, 87%-97%) postintervention alerts (P > .99). Postintervention, 11 of 14 (79%; 95% CI, 52%-92%) alerts were acknowledged via EHR and 68 of 70 (97%; 95% CI, 90%-99%) in ANCR had follow-up (P = .03).

CONCLUSIONS

Integrating ANCR and EHR provides an additional workflow for acknowledging nonurgent, clinically significant results without significant change in rates of closed-loop communication or follow-up of alerts.