Lack of timely follow-up of abnormal imaging results and radiologists' recommendations

Revenue and Cost Analysis of a System Utilizing Natural Language Processing and a Nurse Coordinator for Radiology Follow-up Recommendations

Radiology reports often contain recommendations for follow-up imaging, Provider adherence to these radiology recommendations can be incomplete, which may result in patient harm, lost revenue, or litigation. This study sought to perform a revenue assessment of a hybrid natural language processing (NLP) and human follow-up system. Reports generated from January 2020 to April 2021 that were indexed as overdue from follow-up recommendations by mPower Follow-Up Recommendation Algorithm (Nuance Communications Inc., Burlington, MA), were assessed for follow up and revenue. Follow-up exams completed because of the hybrid system were tabulated and given revenue amounts based on Medicare national reimbursement rates. These rates were then summated. A total of n =3011 patients were flagged via the mPower algorithm as having not received a timely follow-up indicated for procedure. Of these, n = 427 required the quality nurse to contact their healthcare provider to place orders. The follow-up imaging of these patients accounted for $62,937.66 of revenue. This revenue was calculated as higher than personnel cost (based on national average quality and safety nurse salary and time allotted on follow-ups). Our results indicate that a hybrid human-artificial intelligence follow-up system can be profitable, while potentially adding to patient safety. Our revenue figure likely significantly underestimates the true revenue obtained at our institution. This was due to the use of Medicare national reimbursement rates to calculate revenue, for the purposes of generalizability.

Applying Implementation Science Principles to Systematize High-Quality Care for Potentially Significant Imaging Findings

OBJECTIVE

Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings.

METHODS

Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool.

RESULTS

In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year.

DISCUSSION

Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain.

Managing Critical Patient-Reported Outcome Measures in Oncology Settings: System Development and Retrospective Study

BACKGROUND

Remote monitoring programs based on the collection of patient-reported outcome (PRO) data are being increasingly adopted in oncology practices. Although PROs are a great source of patient data, the management of critical PRO data is not discussed in detail in the literature.

OBJECTIVE

This first-of-its-kind study aimed to design, describe, and evaluate a closed-loop alerting and communication system focused on managing PRO-related alerts in cancer care.

METHODS

We designed and developed a novel solution using an agile software development methodology by incrementally building new capabilities. We evaluated these new features using participatory design and the Fit between Individuals, Task, and Technology framework.

RESULTS

A total of 8 questionnaires were implemented using alerting features, resulting in an alert rate of 7.82% (36,838/470,841) with 13.28% (10,965/82,544) of the patients triggering at least one alert. Alerts were reviewed by 501 staff members spanning across 191 care teams. All the alerts were reviewed with a median response time of 1 hour (SD 185 hours) during standard business hours. The most severe (red) alerts were documented 56.83% (2592/4561) of the time, whereas unlabeled alerts were documented 27.68% (1298/4689) of the time, signaling clinician concordance with the alert thresholds.

CONCLUSIONS

A PRO-based alert and communication system has some initial benefits in reviewing clinically meaningful PRO data in a reasonable amount of time. We have discussed key system design considerations, workflow integration, and the mitigation of potential impact on the burden of care teams. The introduction of a PRO-based alert and communication system provides a reliable mechanism for care teams to review and respond to patient symptoms quickly. The system was standardized across many different oncology settings, demonstrating system flexibility. Future studies should focus on formally evaluating system usability through qualitative methods.

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

PURPOSE

Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge.

METHODS

Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression.

RESULTS

In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI.

CONCLUSIONS

Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.

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.

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.

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.

Opportunistic Screening of Patients for Hepatic Steatosis: Clinical Follow-Up and Diagnostic Yield

PURPOSE

Hepatic steatosis is a common incidental finding on abdominal imaging that is not always reported or recognized as having clinical significance. Because of its association with liver disease, cirrhosis, and diabetes, the aim of this study was to bring attention to this finding and provide clinical guidance to referring clinicians by inserting standardized text into radiology reports of patients with incidentally detected hepatic steatosis.

METHODS

Patients with incidentally discovered hepatic steatosis on abdominal ultrasound or CT had standard text inserted into the impression sections of their diagnostic imaging reports. A total of 1,256 patients whose reports were tagged between April 2016 and September 2017 were retrospectively identified and their electronic medical records reviewed to determine subsequent acknowledgment in the medical record or clinical action in response to the tagged report. Information regarding patient demographics, the type of provider who ordered the examination, and the acuity of the examination results was also recorded.

RESULTS

Acknowledgment and subsequent clinical action were more likely in patients whose examinations was ordered by primary care providers, whose examination results were not urgent, and who were in the ultrasound group. The overall diagnostic yield in patients who underwent clinical evaluation was nonalcoholic fatty liver disease in 70%, nonalcoholic steatohepatitis in 6%, and alcoholic hepatitis in 17%.

CONCLUSIONS

Opportunistic screening for incidental hepatic steatosis on abdominal CT and ultrasound is feasible, with substantial yield for patients with clinically important entities including nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Verbal Notification of Radiology Results: Are radiologists meeting expectations?

BACKGROUND

Delayed communication of radiographic findings is associated with poor patient outcomes and significant medicolegal risk. Radiologists verbally contact referring practitioners with urgent findings, though practitioner's expectations regarding notification has rarely been examined.

AIM

To assess differences in preferred practice between radiologists and referring practitioners in the verbal communication of urgent radiology findings.

METHODS

For 33 clinical stems, respondents were asked if they would issue (radiologists) or expect to receive (referring practitioners) verbal notification of results or routine written communication only. Surveys were emailed to radiologists and referring practitioners of varying experience at a tertiary referral hospital in Melbourne, Victoria.

RESULTS

A total of 97 survey responses were received. 80 responses were from referring practitioners and 17 from radiologists. Referring practitioners were seen to slightly prefer verbal notification more often than issued by radiologists overall (61%; 95CI 57-66% verbal notification expected versus 58%; 95CI 52-64% issued). More senior referring practitioners with greater than 10 years' experience expected verbal notification more often (67%; 95CI 59-75%), and more senior radiologists issued verbal reports less often (54%; 95CI 39-69%). More junior referring practitioners, for example registrars or fellows, expected notification less often overall (59%; 95CI 43-76%). Subgroup analysis demonstrated statistically significant differences in notification preferences for certain clinical scenarios.

CONCLUSIONS

Overall results show fair correlation between referrer's expectations of verbal notification and the provision of verbal notification by radiologists. However, there were discrepancies in the practice and preferences of more junior and senior practitioners, in addition to in certain clinical scenarios. This article is protected by copyright. All rights reserved.

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review

Background

Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.

Methods

A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.

Results

Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.

Conclusions

Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08100-3.

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.

Implementation and Impact of a Comprehensive Radiology Report Categorization System on Communication of Important Results

PURPOSE

Effective communication of important imaging results is critical to patient care but difficult to accomplish efficiently. To improve communication at their institution, the authors introduced a radiology report categorization system (RADCAT) that organizes diagnostic imaging reports and uses automated communication systems. The study objectives were to (1) describe RADCAT's design, (2) evaluate its implementation for appropriate imaging, and (3) evaluate the communication of important, nonurgent results with recommended follow-up.

METHODS

This retrospective study was performed in a multihospital adult and pediatric tertiary referral academic health system. The intervention, a radiology report categorization system with five levels of acuity and IT-supported communication workflows, was globally implemented in November 2017. The primary outcomes were the successful implementation of RADCAT to appropriate diagnostic imaging reports and the successful communication of important, nonurgent results with recommended follow-up to ordering providers and patients by the radiology quality assurance team.

RESULTS

Over 18 months after implementation, 740,625 radiology reports were categorized under the RADCAT system, with 42%, 28%, and 30% from the emergency department, inpatient, and outpatient settings, respectively. A random selection of 100 studies from the 23,718 total reports without RADCAT categorization identified 4 diagnostic radiology reports that erroneously lacked RADCAT grading. In 2019, of the 38,701 studies with nonurgent imaging follow-up recommendations, 38,692 (nearly 100.0%) were successfully communicated to providers or patients on the basis of quality assurance data.

CONCLUSIONS

A comprehensive radiology report categorization system was successfully implemented across a multihospital adult and pediatric health system, demonstrating reliable communication of imaging results with recommendations for nonacute imaging follow-up.

Towards better metainterpretation: improving the clinician's interpretation of the radiology report

How the clinician interprets the radiology report has a major impact on the patient's care. It is a crucial cognitive task, and can also be a significant source of error. Because the clinician must secondarily interpret the radiologist's interpretation of the images, this step can be referred to as a "metainterpretation". Some considerations for that task are offered from the perspective of a radiologist. A revival of the tradition of discussing cases with the radiologist is encouraged.

Barriers and facilitators impacting reliability of the electronic health record-facilitated total testing process

OBJECTIVE

Despite ongoing efforts to improve reliability of the total testing process (TTP), breakdowns continue to occur resulting in diagnostic delays and suboptimal patient outcomes. We performed an exploratory study to identify factors that impact TTP reliability in electronic health record (EHR)-enabled care.

MATERIALS AND METHODS

We interviewed experts at three large EHR-enabled health care organizations and identified all TTP steps performed from clinician test ordering to result communication to patients. Findings from all sites were combined to develop a detailed process map of known TTP activities. We additionally asked experts about factors that positively or negatively impacted TTP reliability at each step. We describe the specific TTP steps identified and associated barriers and facilitators to TTP reliability.

RESULTS

We interviewed 39 experts involved in or overseeing the TTP. Most TTP activities identified were similar across sites, but we found significant differences with test order transmission to diagnostic services and relay of results back to clinicians and patients. Twenty-five unique barriers were identified related to technology and EHR usability issues, time and resource constraints, suboptimal clinic workflows, patient-related factors, information access limitations, and insufficient clinician training. Twenty-four unique facilitators were identified related to personnel training, workflow optimization and standardization, helpful EHR features, and improved electronic communication between clinics and diagnostic services.

DISCUSSION

Barriers related to EHR usability and with communication between clinicians and diagnostic services increase TTP vulnerability and should be targeted by future efforts to improve process reliability. Several facilitators identified in the study could inform future strategies and solutions to improve TTP reliability.

The fate of radiology report recommendations at a pediatric medical center

BACKGROUND

The American College of Radiology (ACR) practice parameters for communication dictate that follow-up recommendations be suggested when appropriate. Radiologists assume that referring physicians read their reports and heed their advice. In reality, recommendations might not be carried out or even acknowledged.

OBJECTIVE

We aimed to determine the proportion of imaging recommendations that are acknowledged and acted upon.

MATERIALS AND METHODS

We conducted a retrospective review of all consecutive radiology reports containing "recommend" in the impression at a single academic children's hospital over a 1-month period. We documented point of care (emergency department, inpatient, outpatient), study type, recommendation wording, and communication method (report only or direct verbal). We reviewed medical records to ascertain whether the recommendations were acknowledged or executed. We used chi-square tests to evaluate associations between variables. P<0.05 was considered significant.

RESULTS

We reviewed 526 reports and excluded 73. We included the remaining 453 reports, from 370 unique patients (201 male, 169 female). Inpatients comprised most reports (n=223), followed by emergency department (ED) patients (n=118) and outpatients (n=112). Among these reports, 69% (n=313) of recommendations were executed. Of the 140 recommendations not carried out, 14% were acknowledged in clinical notes. Compliance correlated with point of care (ED>inpatient>outpatient; P=0.001) but not with additional verbal communication (P=0.33), study type (radiograph vs. other; P=0.35) or type of follow-up recommendation (follow-up imaging vs. other; P=0.99).

CONCLUSION

Nearly one-third of radiology report follow-up recommendations are not executed. Recommendations are most commonly neglected for outpatient imaging reports. The radiology community should take steps to improve recommendation adherence.

Assigning responsibility to close the loop on radiology test results

Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.

Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism

BACKGROUND

Delays in following up abnormal test results are a common problem in outpatient settings. Surveillance systems that use trigger tools to identify delayed follow-up can help reduce missed opportunities in care.

OBJECTIVE

To develop and test an electronic health record (EHR)-based trigger algorithm to identify instances of delayed follow-up of abnormal thyroid-stimulating hormone (TSH) results in patients being treated for hypothyroidism.

DESIGN

We developed an algorithm using structured EHR data to identify patients with hypothyroidism who had delayed follow-up (>60 days) after an abnormal TSH. We then retrospectively applied the algorithm to a large EHR data warehouse within the Department of Veterans Affairs (VA), on patient records from two large VA networks for the period from January 1, 2011, to December 31, 2011. Identified records were reviewed to confirm the presence of delays in follow-up.

KEY RESULTS

During the study period, 645,555 patients were seen in the outpatient setting within the two networks. Of 293,554 patients with at least one TSH test result, the trigger identified 1250 patients on treatment for hypothyroidism with elevated TSH. Of these patients, 271 were flagged as potentially having delayed follow-up of their test result. Chart reviews confirmed delays in 163 of the 271 flagged patients (PPV = 60.1%).

CONCLUSIONS

An automated trigger algorithm applied to records in a large EHR data warehouse identified patients with hypothyroidism with potential delays in thyroid function test results follow-up. Future prospective application of the TSH trigger algorithm can be used by clinical teams as a surveillance and quality improvement technique to monitor and improve follow-up.

Incidental radiologic findings at breast cancer diagnosis and likelihood of disease recurrence

Despite guidelines recommending against its routine use, perioperative imaging for distant metastases is frequently performed in newly diagnosed breast cancer patients, uncovering incidental findings of uncertain significance. We assessed the clinical significance of incidental findings by determining if their presence is associated with disease recurrence. A retrospective review of staging imaging was performed in patients with stage II or III invasive breast cancer diagnosed during 2008-2009 at a large academic medical center. Data related to perioperative imaging and disease recurrence were abstracted from the medical record. Kaplan-Meier curves and Cox proportional hazards models were used to assess the association between incidental findings and time to disease recurrence. A total of 169 of 340 patients (49.7 %) underwent staging evaluation for distant metastases (CT chest, abdomen, pelvis, bone scan, and/or PET-CT). Of these, 146 (86.4 %) had at least one suspicious or indeterminate finding. Follow-up studies were performed in 73 (43.2 %) patients. Nineteen patients were diagnosed with metastatic disease at diagnosis, 18 of whom had stage III disease. In patients without metastatic disease at diagnosis, 32 later developed recurrence. Non-calcified pulmonary nodules were associated with shorter time to disease recurrence (hazard ratio 2.51, 95 % CI 1.13-5.57, p = 0.02). Imaging for distant metastases frequently reveals indeterminate findings, most of which are not associated with disease recurrence. The association between pulmonary nodules and recurrence warrants validation in an independent cohort. Overall, these findings support current guidelines recommending against routine extent of disease evaluation in patients with newly diagnosed stage II breast cancer.

Correlation of the Strength of Recommendations for Additional Imaging to Adherence Rate and Diagnostic Yield

PURPOSE

The aim of this study was to evaluate the association between the wording of radiologist recommendations for chest CT with the likelihood of recommendation adherence and the diagnostic yield of the recommended follow-up CT imaging.

METHODS

This HIPAA-compliant retrospective study had institutional review board approval, including waiver of the requirement for patient consent. All outpatient chest radiographic (CXR) studies performed at a tertiary care academic medical center in 2008 (n = 29,138) were searched to identify examinations with recommendations for chest CT. The wording of chest CT recommendations was classified as conditional or absolute, on the basis of whether the recommendation stood independent of the clinical judgment of the ordering clinician. Using the radiology information system, patients who underwent chest CT within 90 days of the index CXR study containing the recommendation were determined, and the CT studies were evaluated to determine if there were abnormalities corresponding to the CXR abnormalities that prompted the recommendations. Corresponding abnormalities were categorized as clinically relevant or not, on the basis of whether further workup or treatment was warranted. Groups were compared using t tests and Fisher exact tests.

RESULTS

Recommendations for chest CT appeared in 4.5% of outpatient CXR studies (1,316 of 29,138; 95% confidence interval [CI], 4.3%-4.8%); 39.4% (519 of 1,316; 95% CI, 36.8%-42.0%) were conditional and 60.6% (797 of 1,316; 95% CI, 58.0%-63.2%) were absolute. Patients with absolute recommendations were significantly more likely to undergo follow-up chest CT within 90 days than patients with conditional recommendations (67.8% vs 45.8%, respectively, P < .001). Despite this difference in provider adherence, there was no significant difference between the conditional and absolute recommendation groups with regard to the incidence of clinically relevant corresponding findings (P = .16) or malignancy (P = .08) on follow-up CT.

CONCLUSIONS

Conditional radiologist recommendations are associated with decreased provider adherence, though the likelihood of a clinically relevant finding on follow-up CT is no different than with absolute recommendations.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings

Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.