System-driven longitudinal follow-up of incidental imaging findings

Abstract

Increasing utilization of cross-sectional imaging has resulted in more clinically significant incidental findings being discovered. However, the current approach for handling these findings is commonly inconsistent, and relies greatly on the efforts of individual clinicians. Making sure every actionable incidental finding is handled in a consistent and reliable manner can be difficult, especially for a large health system. We propose an approach to handling incidental findings aimed at improving patient follow up rates, which involves implementing system level processes that standardize the reporting of incidental findings, notification of clinicians and the patient, and centralized monitoring of longitudinal patient follow up. We will lay out a general framework for standardized reporting of incidental findings by the radiologist using software integrated into the daily workflow. This should enable simultaneous notification of the ordering clinician, the patient’s primary care provider, and an incidental findings navigator. The navigator will “close the loop” by working with clinicians to notify the patient of the finding, coordinate patient follow up, and document the finding and long term follow up. We hope this can serve as a basic framework to help large health systems design an incidental findings workflow to improve follow up rates and reduce patient harm.

First do no harm in responding to incidental imaging findings

“…The proportion of incidentalomas that prove malignant also varies widely, due to variation in duration and type of follow-up and the extent of histological confirmation driven by investigative bias. 18 Less than 5% of lesions involving brain, parotid and adrenal gland prove malignant, whereas renal, thyroid, ovarian, pancreatic and breast incidentalomas are classified as malignant in 25-40% of cases. 1,2,19 However, cancers range from indolent or in situ to rapidly growing tumours, so the binary cancer/non-cancer categorisation is prognostically misleading and promotes overtreatment of non-progressive cancers.…”

“…This may reflect different incidentaloma prevalence in different patient populations (eg, ethnicity and age), or differences in how radiologists take images of, classify and report incidentalomas. The proportion of incidentalomas that prove malignant also varies widely, due to variation in duration and type of follow‐up and the extent of histological confirmation driven by investigative bias 18 . Less than 5% of lesions involving brain, parotid and adrenal gland prove malignant, whereas renal, thyroid, ovarian, pancreatic and breast incidentalomas are classified as malignant in 25–40% of cases 1,2,19 .…”