By Mark Watts
We should change the medical imaging conversation from reactive to proactive.
If lung cancer is detected and treated before it grows to more than one centimeter, it is 90 percent curable. If the tumor has grown to more that 2 cm, it is 10 percent curable.
If an abdominal aortic aneurysm is found early and referred for treatment, it is 90 percent survivable. If it ruptures without intervention, the patient survival rate drops to less than 4 percent.
If a radiologist sees something (incidental findings), they should say something and follow up.
Adhering to the radiologist follow-up recommendations is a long-standing problem that impacts outcomes, liabilities and revenue. Unfortunately, less than 40% of the referring providers adhere to the radiologist recommendations around incidental findings. Lapses in communication were cited as the primary factor causing low adherence rates.
Alert: Missed recommendations and follow-ups are responsible for one out of three malpractice claims. As well as billions in unnecessary services and substantial missed hospital revenue
There is clear evidence that by tracking, communicating and closing the loop on follow-ups, radiology departments can significantly improve outcomes, liability and revenue. In fact, several studies have been published regarding such follow-up tracking
A team at Penn State Milton Medical Center has developed a program that closes the gaps and follows up on incidental findings for emergency department patients. Participants in the program receive a letter and a phone call about their incidental findings and were encouraged to follow up with the primary care provider. This program not only improved intent to schedule follow-up visits with the PCPs by 21% but also improved patient satisfaction.
At the University of Rochester Medical Center, tracking and communicating follow-up improved completion rates by as much as 29% and increased the volume of high reimbursable exams (such as CT and MRI) by up to 15% in the first 13 months. They tracked 589 recommendations – 86% of which were satisfactorily closed – through the program. It reduced the risk of delayed diagnosis by 74% and early diagnosis leads to improved patient care and better outcomes. It can even result in lower cost of care.
Others have conducted a study on the impact of direct committee patient communication on the follow-up adherence of patients with unscheduled follow-ups. They were contacted as their follow-up care came due and we’re encouraged to speak to their referring physicians about the findings of the study showed. The follow-up compliance rate for patients that received a reminder message improved by 49% relative to the control group.
Given the lack of historical tracking of follow-ups and recent studies showing the positive benefits of follow-up tracking, the American College of Radiology has recently proposed nine new quality measures regarding follow-ups in radiology. These measures are still in the works as they undergo commenting, scrutiny and testing.
• A measure proposed by the ACR is to close the loop on the completion of follow-up recommendations with actionable incidental findings. This measure aims to increase the number of patients with actionable non-emergent findings receiving radiological recommendations for a follow up. It tracks the percentage of patients who receive follow-up imaging within the recommended time interval.
• Closing the loop on the completion of follow-up recommendations with actionable incidental findings for abdominal aortic aneurysm. This measure aims to increase the number of patients receiving a follow-up for abdominal aortic aneurysm imaging findings. Specifically, it intends to improve the odds of early detection.
• Closing the loop on the completion of a follow-up recommendation for actionable incidental findings on pulmonary nodules. The goal is to also increase the percentage of patients with a single 6-millimeter pulmonary nodule finding who received follow-up imaging within the recommended time interval.
• Specificity of the follow-up imaging recommendations for the actionable incidental findings. This measure aims to ensure that recommendations that are given contain key pieces of information such as the locations of the findings, modality and timeframe associated with the follow up. This measure tracks the percentage of reports with recommended follow-ups that contain these key pieces of information.
• Evidence documentation in follow-up imaging recommendations for actionable incidental finds. This measure aims to ensure that the radiologists include the source of evidence-based guidelines supporting the recommendations. It looks at the percentage of all final reports with a recommendation for follow-up imaging that include evidence-based guidelines in the interpretation or conclusion section.
• Communication to the practice managing ongoing care. This measure aims to ensure that there is communication between radiologists and physicians managing follow-up care. It tracks the percentage of reports containing recommendations that provide documentation of direct communication to the referring physician or the patient’s care team within five business days of the exam interpretation.
• Communication of the actionable incidental findings to the patient. This measure seeks to ensure that patients are made aware of incidental findings and documentation of the communication taking place within 30 days of the findings.
• Tracking and reminder systems for incidental findings. The goal is to ensure that a tracking system is in place to remind patients of incidental findings and track follow-up completion. It measures the number of reports that contain recommendations for which information was entered into a tracking system.
• Patient’s cancer detection rate with follow-up imaging (surveillance measure). The intent of this measure is to track and document cancer rates based on follow-up imaging recommendation. This tracks the percentage of patients with imaging recommendations that lead to a diagnosis of cancer.
The expectation of this new quality measure is to try better tracking of recommendations, follow-up completion rates, communication and, ultimately, outcomes. The next logical question is how these measures can be implemented into a practice. The ACR is currently seeking and working with alpha sites to test the proposed measures.
The major roadblocks for implementation are the additional time, resources, money and specialized digital health knowledge required to implement these measures. For these reasons, various practices (including academic, corporate, governmental and private practice) may have difficulty implementing some or all these measures.
We can transform the practice of radiology by changing the medical imaging conversation from reactive to proactive and communicating findings.
Mark Watts is the enterprise imaging director at Fountain Hills Medical Center.