December 14, 2017

Incidental Findings: Q&A With Pari V. Pandharipande, MD, MPH

In this Spotlight, we talk with Pari V. Pandharipande, MD, MPH, Director of the Massachusetts General Hospital Institute for Technology Assessment, about how to improve quality of care with ACR incidental findings white papers.

What is the mission of the ACR Committee on Incidental Findings?
Our main goal is to improve the quality of care by giving radiologists guidance on how to manage incidentally detected findings. The core of our work is focused on different types of incidental findings that can be detected on imaging. Our deliverables are white papers that highlight various topics, such as incidental findings in the liver or kidneys, and provide radiologists with guidance about what to do when they see those findings. With these incidental findings reports, we can also encourage uniformity of action across the specialty.

There are four main objectives in each of the papers: 

  1. To develop consensus on patient characteristics and imaging features that are required to characterize incidental findings
  2. To provide guidance to manage such findings in ways that balance the risks and benefits to patients'
  3. To recommend reporting terms that reflect the level of confidence regarding a finding; and
  4. To focus future research by proposing a generalized management framework across practice settings.

What is the importance of uniformity in the response of radiologists to incidental findings?
Radiologists have to be as uniform and responsible as possible when they're recommending care in the setting of incidental findings. Uniformity increases confidence that careful thought has been given by a community of how to manage a finding that nobody was suspecting to begin with, not the physician who referred the patient, nor the patient themselves.

What makes incidental findings different from other findings in radiology?
The findings are solely imaging based — that's the main thing that distinguishes them from other types of findings in radiology. If a physician sends a patient to the emergency room for treatment of suspected appendicitis, a CT scan often confirms that the patient has appendicitis. Here, it's something that was completely unexpected and was found with imaging. Therefore, referring physicians and patients will look to radiologists for clear guidance on what to do, and we should really be ready to provide it.

How are the incidental findings white papers developed?
The white papers are developed by small groups of radiologists who are subspecialty experts in each area (for example, the liver, kidney, pancreas or adrenal gland). On many groups, there is also non-radiologist clinician who encounters these findings on a regular basis, such as a surgeon or a subspecialist physician. A lot of the work is focused around developing flowcharts or algorithms, based on both the evidence and on their clinical experience, which are then reviewed iteratively by multiple stakeholders. It is an incredibly rewarding experience for all. One thing that I find amazing is the amount of passion and genuine interest in helping people do the right thing that every member of every group has.

What’s the most challenging aspect of developing the white papers?
Getting the balance right. It is a balance between whether you're asking physicians and patients to do too much for something that's not going to be that important, or you're not asking physicians and patients to do enough, and leaving too much risk around something that's important and not followed up. The heart of all the decisions that are made in developing those algorithms really is centered in that balance. It's incredible to see how people approach that balance in different ways, but with an eye toward what's best for the patient.

What is the biggest benefit of the white papers in terms of patient care and quality and safety?
I hope that the work we do leads to care that is more data driven, more patient-centered, more transparent and more consistent than what we would do as radiologists if we did not have this type of guidance. I hope that my mom in Central Illinois will get the same kind of care as a patient in Boston, or in San Francisco, or rural Oregon — and that, collectively, our patient care will continue to get better and better across the country. As an imaging community, we still need to determine if that's what's actually happening. But the first step is to come together and get consensus on the right thing to do for these challenging findings. There's still much more work to do.

Why should radiologists participate in the process of developing incidental findings white papers?
I strongly encourage my colleagues to get involved for two reasons. First, it's a unique opportunity to work with people all around the country who are true experts in what they do. And everybody's focused around trying to do the best thing for the patient. It gets back to why we all went into medicine in the first place. It's tremendously rewarding and you learn a ton. It's an intense, singular experience. The second reason is that when you get involved in developing a recommendation or a consensus-based algorithm, you will inevitably sharpen your own clinical decision-making skills, and you will learn to think in this algorithmic way. As information gets more and more plentiful and complex, algorithms are going to become more and more important for the way that we practice medicine.

Meet the Physician

Pari V. Pandharipande, MD, MPH

Pari V. Pandharipande, MD, MPH, is an abdominal radiologist and health outcomes researcher at Massachusetts General Hospital (MGH), and is Director of the MGH Institute for Technology Assessment. She is a graduate of Cornell University, Cornell University Medical College and the Harvard School of Public Health. Her research is centered in imaging, decision science and cost-effectiveness analysis, with a focus in cancer outcomes.

She has a track record of extramural funding from the National Institutes of Health (NIH), the American Cancer Society, and the Medical Imaging and Technology Alliance. She has served on grant review committees of the NIH, American Cancer Society, and RSNA/AUR, holds editorial board positions at Radiology, AJR, and the Journal of the American College of Radiology, and serves on multiple national committees related to health policy and imaging. Among such roles, she serves as chair of the Incidental Findings Committee at the ACR.

Her career goal is to ensure that every patient’s encounter with imaging adds quality care value.