"When radiologists make follow-up recommendation and somehow communication about these recommendations fall through the cracks and the follow-up does not happen — it is rightfully most concerning," says Nadja Kadom, MD, director of pediatric neuroradiology at Emory University and at Children's Healthcare of Atlanta.
“For example, if there’s a small lung nodule that we pick up incidentally on a study, we might recommend follow-up,” Kadom says. “If the follow-up is not done, the lesion may grow. Now instead of an early-stage cancer, we may discover a cancer at a later stage. This, of course, may change how well we can treat the cancer and patient outcomes may be much worse.”
An Eye on Recommendations
In 2019, the ACR was awarded a grant from the Gordon and Betty Moore Foundation under its Diagnostic Excellence Initiative. The grant funded the development of a clinical quality measure set to increase the number of patients who appropriately receive radiologist-recommended follow-up care for actionable incidental findings (AIFs). A 12-member technical-expert panel representing a wide range of stakeholders contributed many hours of reflection, deliberation, and input to develop the quality measures to improve patient care and outcomes.
A recent paper published in the JACR® focuses on how care gaps occur when radiology follow-up recommendations are poorly communicated or not completed — resulting in a missed or delayed diagnosis that can potentially lead to worse patient outcomes.1 The key takeaway here is that there needs to be a process in place, says Kadom, lead author of the paper. “This won’t happen on its own,” she notes. “Somebody has to keep an eye on these recommendations and make sure they are addressed.”
FOLLOW-UP MEASURES
To bridge this gap, a suite of nine measures were developed — three of which are designed as use cases focused on closing the follow-up loop on non-emergent AIFs to include addressing pulmonary nodule AIFs, abdominal aortic aneurysm, and a general measure for closing the loop on any AIF. The other six measures address communication, recommendation specificity and appropriateness, and AIF tracking systems.
“This ACR measure set identifies specific components of an AIF tracking program that are likely to lead to success in increasing patients receiving recommended follow-up,” says Judy Burleson, MHSA, vice president of quality management programs for ACR. “The measure set encourages monitoring of recommendation follow-up completion, implementation of tracking systems to support the completion, effective communication practices to referring physicians and patients, and outcome data collection.”
Some measures in their current form may seem cumbersome — such as the inclusion in the radiology report of an evidence-based source for the recommendation — but the technical expert panel agreed such measures are important to enable best practices, says Burleson. “Next steps will focus on increasing awareness in the radiology community about the importance of the measure set for patients and practices,” she says.
Measures for Prime Time
Initial measure testing was a critical next step prior to deployment for use in routine quality improvement work. A handful of forward-thinking radiology practices participated in the recently completed proof-of-concept testing for the Closing the Recommendations Follow-Up Loop measure set. The next phase in measure refinement is for early adopters to begin using measures and submitting data to the ACR quality registry. Active recruitment for approximately 20 early-adopter practices (with at least five radiologists) is underway. The early-adopter sites will be awarded a nominal financial incentive (on a first-come, first-served basis), and ACR staff will engage participants in an educational web meeting to learn about the data collection process, feasibility, and, importantly, the validity for measuring the quality of patient care. Practices that sign on as early measure adopters will receive ACR staff support regarding data collection or submission issues. Training for the first group of early-adopter practices will occur in the early fall; however, practices can sign up on a rolling basis.
Based upon the results and experiences of the early adopters, the measures may be revised before they are rolled out for use more broadly (for example, for instituting a tracking program and use in local improvement efforts).
“We now need practices to use the measures for specification refinement,” says Samantha Shugarman, director of quality programs for the ACR. “We strongly encourage radiology practices interested in using the measures to participate as an early adopter to contact us. Specifically, this next phase will inform us about whether the measures must be revised to better integrate into the clinical workflow. We want to confirm the measure’s scalability, and in the end, we want the larger radiology community to use these measures so that patients receive needed follow-up care.”
Measure Set Takeaways
“There are a few messages I would like to get out there about the methods for measuring success in Closing the Recommendations Follow-Up Loop — the measures serve as a toolkit for measuring the success of individual steps in the process so that the processes can be improved,” says David J. Seidenwurm, MD, FACR, neuroradiologist at Sutter Medical Group, JACR paper coauthor, and chair of the measure technical expert panel. “The next point is that we hope these measures will help, obviously, to improve follow-up of incidental findings — providing a framework for engaging with hospital and practice administration to develop the resources and to actually make improvements. An additional goal would be to facilitate data gathering to determine the benefits and potential harms of incidental findings follow-up so that we can provide tools for refining the recommendations themselves.”
The measures serve as a toolkit for measuring the success of individual steps in the process so that the processes can be improved.
Control and Technology
“This is a big leap forward for radiologists to do their part in closing a complex loop of follow-up recommendations of incidental findings — specifically the reporting and being part of the process to ensure the patient receives recommended follow-up care. That’s in our control,” says Gregory N. Nicola, MD, FACR, chair of ACR’s Commission on Economics. “The name of the game is ensuring patients get appropriate follow-up in time so that the outcome is better for the patient.”
When paired with ongoing developments and improvements in health information technology, these measures may efficiently and effectively improve patient outcomes and provide additional evidence for the appropriate management of incidental findings, Nicola says.
Pride and Precision
“Why did we get involved in this initiative and decide to test the measures? We thought it was an important quality-improvement effort for the community,” says Richard J. Friedland, MD, FACR, president of Hudson Valley Radiologists, PC. His group has been an alpha tester and big proponent of the measures.
“We practice in relative isolation — an hour and a half from New York City and an hour and a half from Albany,” says Friedland. “Our medical center is the largest hospital in the area between those two points.”
“We get a lot of feedback from our patients,” Friedland says. “Even though we are radiologists, we know the community. A patient came into the ER, for instance, due to an obstructing kidney stone — but a pulmonary nodule was also mentioned in the report. Four years later, they returned with a pulmonary mass. You see their cancer. You go back to the original exam and look at the images and there it was, mentioned in the original report and you realize how horrible the situation has become.”
“Having that kind of feedback and seeing a chronic repetitious lack of follow-up on incidental findings was enough to make us realize that something has got to be done,” Friedland says. “When we started to look at the problem, we figured out that this was an important role for radiologists.”
“In many ways it took us down the proverbial radiologic rabbit hole,” Friedland says. “We even began to scrutinize our own reports and developed a report card for our radiologists based on level of adherence to guidelines. I thought that when we put that in place, it would be quite unpopular,” Friedland recalls. “Just the opposite. Nobody wanted to be the only doctor in the group that did not follow the guidelines.”
Process in Place
“I hope that people will realize that this is a problem worth addressing,” Kadom says. “The measure set we developed can serve as a framework for setting up an effective tracking program to ensure the closure of this follow-up loop.”
Kadom adds, “Often when we send reports to the person who ordered the study, she or he may not be the primary care physician (PCP), which means whoever gets the study back may not be equipped to follow up on incidental findings. This is particularly true for patients in the emergency department, but also for outpatients who are referred for imaging by a sub-specialist rather than directly by their PCP.”
There are various system gaps, Kadom says. “We need to define those gaps and intervene. For instance, healthcare inequity is a concerning barrier to closing the loop. Not all patients can access their reports electronically, for example, or understand the findings and implications. So those patients are uninformed,” she says. “I’ve also seen firsthand in my work at safety-net hospitals that many patients don’t have PCPs. For example, if a patient is homeless and doesn’t have a PCP, how would they know about an incidental finding that needed follow-up?” Other inequities we know about relate to where the patient lives, their insurance status, literacy level, race, age and many more.
“The concept of where the patient gets lost for follow-up is much more complex than a radiologist not putting a finding in a report,” Nicola says. “Sometimes a radiologist can put it in the report, but the note is not clear. And sometimes a radiologist can put it in the report, and it is clear, but the PCP chooses not to follow up on it — or misses it. Then there are the times that a patient just chooses not to follow up.”
“Still, someone has to take ownership,” Kadom says. “I believe radiologists can take that ownership. When we discover a cancer at a late stage, it may not be survivable. Treatment becomes more difficult, and outcomes are worse. Picking up on incidental findings means an early-stage cancer may be cured — or have a high percentage of long-term survival. There is a process now that can make this happen.”