Point-of-Care Reference Materials Increase Practice Compliance With Societal Guidelines for Incidental Findings in Emergency Imaging

Incidental Renal Cysts Found by Point-of-Care Ultrasound: A Retrospective Chart Review

BACKGROUND

Incidental findings are unrelated to a patient's complaint, found on diagnostic imaging, such as point-of-care ultrasound (POCUS). Incidental findings represent potential harms to patients and may lead to increased patient anxiety and health care costs related to downstream testing and surveillance.

STUDY OBJECTIVES

In this study, we aimed to calculate the rate of incidental renal cysts found by POCUS. Further, we hoped to describe how emergency physicians relay the findings to patients. Lastly, we hoped to examine if patients suffered harms in the 12 months following identification of an incidental renal cyst.

METHODS

From our single-center, academic emergency department (ED), we reviewed renal POCUS images from 1000 consecutive adult ED patients to determine if there was a renal cyst. Next, we performed manual chart review to determine if patients were informed of the incidental renal cyst or suffered any patient harms.

RESULTS

We found the prevalence of renal cysts to be 6.5% (95% confidence interval: 4.9%-8.4%). Those with cysts were more likely to be older compared to those without (63 ± 14 vs. 49 ± 15 years of age). Only 8% of patients had evidence that they were informed of their incidental renal cyst. No patients received a biopsy or were diagnosed with renal cell carcinoma or polycystic kidney disease.

CONCLUSION

Incidental renal cysts are common and are more likely to be found in older adults. In our study, physicians infrequently informed patients of their incidental finding.

Natural Language Processing for the Identification of Incidental Lung Nodules in Computed Tomography Reports: A Quality Control Tool

PURPOSE

To evaluate the diagnostic performance of a natural language processing (NLP) model in detecting incidental lung nodules (ILNs) in unstructured chest computed tomography (CT) reports.

METHODS

All unstructured consecutive reports of chest CT scans performed at a tertiary hospital between 2020 and 2021 were retrospectively reviewed (n = 21,542) to train the NLP tool. Internal validation was performed using reference readings by two radiologists of both CT scans and reports, using a different external cohort of 300 chest CT scans. Second, external validation was performed in a cohort of all random unstructured chest CT reports from 57 different hospitals conducted in May 2022. A review by the same thoracic radiologists was used as the gold standard. The sensitivity, specificity, and accuracy were calculated.

RESULTS

Of 21,542 CT reports, 484 mentioned at least one ILN (mean age, 71 ± 17.6 [standard deviation] years; women, 52%) and were included in the training set. In the internal validation (n = 300), the NLP tool detected ILN with a sensitivity of 100.0% (95% CI, 97.6 to 100.0), a specificity of 95.9% (95% CI, 91.3 to 98.5), and an accuracy of 98.0% (95% CI, 95.7 to 99.3). In the external validation (n = 977), the NLP tool yielded a sensitivity of 98.4% (95% CI, 94.5 to 99.8), a specificity of 98.6% (95% CI, 97.5 to 99.3), and an accuracy of 98.6% (95% CI, 97.6 to 99.2). Twelve months after the initial reports, 8 (8.60%) patients had a final diagnosis of lung cancer, among which 2 (2.15%) would have been lost to follow-up without the NLP tool.

CONCLUSION

NLP can be used to identify ILNs in unstructured reports with high accuracy, allowing a timely recall of patients and a potential diagnosis of early-stage lung cancer that might have been lost to follow-up.

Evaluating the Patient With a Pulmonary Nodule: A Review

IMPORTANCE

Pulmonary nodules are identified in approximately 1.6 million patients per year in the US and are detected on approximately 30% of computed tomographic (CT) images of the chest. Optimal treatment of an individual with a pulmonary nodule can lead to early detection of cancer while minimizing testing for a benign nodule.

OBSERVATIONS

At least 95% of all pulmonary nodules identified are benign, most often granulomas or intrapulmonary lymph nodes. Smaller nodules are more likely to be benign. Pulmonary nodules are categorized as small solid (<8 mm), larger solid (≥8 mm), and subsolid. Subsolid nodules are divided into ground-glass nodules (no solid component) and part-solid (both ground-glass and solid components). The probability of malignancy is less than 1% for all nodules smaller than 6 mm and 1% to 2% for nodules 6 mm to 8 mm. Nodules that are 6 mm to 8 mm can be followed with a repeat chest CT in 6 to 12 months, depending on the presence of patient risk factors and imaging characteristics associated with lung malignancy, clinical judgment about the probability of malignancy, and patient preferences. The treatment of an individual with a solid pulmonary nodule 8 mm or larger is based on the estimated probability of malignancy; the presence of patient comorbidities, such as chronic obstructive pulmonary disease and coronary artery disease; and patient preferences. Management options include surveillance imaging, defined as monitoring for nodule growth with chest CT imaging, positron emission tomography-CT imaging, nonsurgical biopsy with bronchoscopy or transthoracic needle biopsy, and surgical resection. Part-solid pulmonary nodules are managed according to the size of the solid component. Larger solid components are associated with a higher risk of malignancy. Ground-glass pulmonary nodules have a probability of malignancy of 10% to 50% when they persist beyond 3 months and are larger than 10 mm in diameter. A malignant nodule that is entirely ground glass in appearance is typically slow growing. Current bronchoscopy and transthoracic needle biopsy methods yield a sensitivity of 70% to 90% for a diagnosis of lung cancer.

CONCLUSIONS AND RELEVANCE

Pulmonary nodules are identified in approximately 1.6 million people per year in the US and approximately 30% of chest CT images. The treatment of an individual with a pulmonary nodule should be guided by the probability that the nodule is malignant, safety of testing, the likelihood that additional testing will be informative, and patient preferences.

Data Sharing of Imaging in an Evolving Health Care World: Report of the ACR Data Sharing Workgroup Part 2: Annotation, Curation, and Contracting

A core principle of ethical data sharing is maintaining the security and anonymity of the data, and care must be taken to ensure medical records and images cannot be reidentified to be traced back to patients or misconstrued as a breach in the trust between health care providers and patients. Once those principles have been observed, those seeking to share data must take the appropriate steps to curate the data in a way that organizes the clinically relevant information so as to be useful to the data sharing party, assesses the ensuing value of the data set and its annotations, and informs the data sharing contracts that will govern use of the data. Embarking on a data sharing partnership engenders a host of ethical, practical, technical, legal, and commercial challenges that require a thoughtful, considered approach. In 2019 the ACR convened a Data Sharing Workgroup to develop philosophies around best practices in the sharing of health information. This is Part 2 of a Report on the workgroup's efforts in exploring these issues.

Incidental Adrenal Masses: Adherence to Guidelines and Methods to Improve Initial Follow-Up, A Systematic Review

OBJECTIVE

Incidental adrenal masses (IAMs) are detected in approximately 1%-2% of abdominal computed tomography (CT) scans. Recent estimates suggest that more than 70-million relevant CT scans are performed annually in the United States; thus, IAMs represent a significant clinical entity. Most clinical guidelines recommend an initial follow-up evaluation that includes imaging and biochemical testing after index IAM detection.

METHODS

Systematic review of literature in the PubMed, EMBASE and Web of Science databases to determine whether guidelines regarding IAM evaluation are followed and to identify effective management strategies. Our initial search was in January 2018 and updated in November, 2019.

RESULTS

31 studies met inclusion criteria. In most institutions, only a minority of patients with IAMs undergo initial follow-up imaging (median 34%, IQR 20%-50%) or biochemical testing (median 18%, IQR 15%-28%). 2 interventions shown to improve IAM evaluation are IAM-specific recommendations in radiology reports and dedicated multi-disciplinary teams. Interventions focused solely on alerting the ordering clinician or primary care provider to the presence of an IAM have not demonstrated effectiveness. Patients who are referred to an endocrinologist are more likely to have a complete IAM evaluation, but few are referred.

DISCUSSION

Most patients with an IAM do not have an initial evaluation. The radiology report has been identified as a key component in determining whether IAMs are evaluated appropriately. Care teams dedicated to management of incidental radiographic findings also improve IAM follow-up. Although the evidence base is sparse, these interventions may be a starting point for further inquiry into optimizing care in this common clinical scenario.

Incidental Ovarian and Uterine Findings on Cross-sectional Imaging

Incidental adnexal masses and uterine findings occur with a high frequency on cross-sectional imaging examinations, particularly in postmenopausal women in whom imaging is performed for a different reason. These incidentalomas encompass a gamut of potential pelvic gynecologic disorders. Most are benign ovarian cysts; however, other less commonly encountered disorders and improperly positioned gynecologic devices may be seen. A knowledge of the management recommendations for such pelvic incidental findings is critical to avoid unnecessary imaging and surgical interventions, as well as to avoid failure in diagnosis and management of some of these conditions.

Incidental findings on emergency CT scans: Predictive factors and medico-economic impact

PURPOSE

The main objective was to evaluate types and predictive factors of incidental findings (IFs) on multidetector computed tomographies (MDCTs) performed for an emergency department (ED). The secondary aim was to analyze additional investigations, their benefits, side effects, costs and the final diagnoses.

METHOD

One thousand consecutive patients over 18 years old who underwent an MDCT in the ED of our institution from January 2011 to November 2011 were retrospectively included, accounting for 300 head MDCTs and 700 other MDCTs. The following criteria were collected in patient electronic medical records: IFs (divided into low and high clinical significance), body areas covered, availability of a prior imaging, radiologist's experience and subspecialty, additional investigations, their outcomes and costs.

RESULTS

Among the 1000 included patients, 232 had at least one IF and 122 had at least one IF of high clinical significance (IFCS). There were 340 IFs and 150 IFCSs. A significant association with the presence of at least one IF was noted for older patients, less-experienced radiologists, no subspecialty of the radiologist, the abdominopelvic area, and the absence of prior imaging. Eighteen IFs generated additional investigations in our institution, including five invasive samplings and three surgical operations, with two diagnoses of malignancy (a gastrointestinal stromal tumor and a Bosniak IV cystic renal lesion). One benign iatrogenic complication occurred. Total cost of these investigations was €41,247 (with an average of €2292 per IF investigated).

CONCLUSION

IFs on emergency MDCTs were frequent, rarely severe, rarely iatrogenic and relatively expensive.

Comparing Breast and Abdominal Subspecialists' Follow-Up Recommendations for Incidental Liver Lesions on Breast MRI

Purpose:

The aim of this study was to compare breast imaging subspecialists’ follow-up recommendations for incidental liver lesions (ILLs) on breast MRI with abdominal subspecialty radiologists’ opinions informed by best-practice recommendations.

Methods:

In this retrospective study at an academic medical center, natural language processing identified reports with ILLs among 2,181 breast MRI studies completed in 2015. Electronic health record and radiology report reviews abstracted malignancy presence or absence, prior imaging, and breast subspecialists’ recommendations regarding ILLs for random sets of 30 patients: ILLs with follow-up recommendations, ILLs without recommendations, and without ILLs. Two abdominal radiologists evaluated MRI liver findings and offered follow-up recommendations in consensus. The primary outcome was agreement between breast and abdominal subspecialists in patients with ILL follow-up recommendations compared with those without (χ² analysis). Secondary outcomes were agreement between subspecialists when ILLs were reported and referring clinicians’ adherence to follow-up recommendations.

Results:

ILLs were identified in 11.3% of breast MRI reports (247 of 2,181); breast subspecialists made follow-up recommendations in 12% of them (30 of 247). Abdominal subspecialists agreed with breast subspecialists when ILLs required no follow-up (29 of 30 cases) but disagreed with 28 of 30 breast subspecialists’ follow-up recommendations (agreement proportion 29 of 30 versus 2 of 30, P < .0001). Subspecialists agreed in 93% of cases (28 of 30) when breast imagers reported no ILLs. Overall, 16 of 30 breast subspecialists’ follow-up recommendations were performed; ILLs were benign in 15.

Conclusions:

Abdominal subspecialists disagreed frequently with breast subspecialists regarding follow-up recommendations for ILLs on breast MRI. Abdominal subspecialty consultation or embedding liver imaging decision support in breast imaging reporting workflow may reduce unnecessary imaging and improve care. Improvement opportunities may exist in other cross-subspecialty interpretation workflows.

National Survey of Hospitalists' Experiences with Incidental Pulmonary Nodules

Incidental pulmonary nodules (IPNs) are common and often require follow-up. The Fleischner Society guidelines were created to support IPN management. We developed a 14-item survey to examine hospitalists' exposure to and management of IPNs. The survey targeted attendees of the 2016 Society of Hospital Medicine (SHM) annual conference. We recruited 174 attendees. In total, 82% were identified as hospitalist physicians and 7% as advanced practice providers; 63% practiced for >5 years and 62% supervised trainees. All reported seeing ≥1 IPN case in the past six months, with 39% seeing three to five cases and 39% seeing six or more cases. Notwithstanding, 42% were unfamiliar with the Fleischner Society guidelines. When determining the IPN follow-up, 83% used radiology report recommendations, 64% consulted national or international guidelines, and 34% contacted radiologists; 34% agreed that determining the follow-up was challenging; only 15% reported availability of automated tracking systems. In conclusion, despite frequent IPN exposure, hospitalists are frequently unaware of the Fleischner Society guidelines and rely on radiologists' recommendations.

Natural Language Processing for Identification of Incidental Pulmonary Nodules in Radiology Reports

PURPOSE

To develop natural language processing (NLP) to identify incidental lung nodules (ILNs) in radiology reports for assessment of management recommendations.

METHODS AND MATERIALS

We searched the electronic health records for patients who underwent chest CT during 2014 and 2017, before and after implementation of a department-wide dictation macro of the Fleischner Society recommendations. We randomly selected 950 unstructured chest CT reports and reviewed manually for ILNs. An NLP tool was trained and validated against the manually reviewed set, for the task of automated detection of ILNs with exclusion of previously known or definitively benign nodules. For ILNs found in the training and validation sets, we assessed whether reported management recommendations agreed with Fleischner Society guidelines. The guideline concordance of management recommendations was compared between 2014 and 2017.

RESULTS

The NLP tool identified ILNs with sensitivity and specificity of 91.1% and 82.2%, respectively, in the validation set. Positive and negative predictive values were 59.7% and 97.0%. In reports of ILNs in the training and validation sets before versus after introduction of a Fleischner reporting macro, there was no difference in the proportion of reports with ILNs (108 of 500 [21.6%] versus 101 of 450 [22.4%]; P = .8), or in the proportion of reports with ILNs containing follow-up recommendations (75 of 108 [69.4%] versus 80 of 101 [79.2%]; P = .2]. Rates of recommendation guideline concordance were not significantly different before and after implementation of the standardized macro (52 of 75 [69.3%] versus 60 of 80 [75.0%]; P = .43).

CONCLUSION

NLP reliably automates identification of ILNs in unstructured reports, pertinent to quality improvement efforts for ILN management.