The Elusive Incidental Finding

This article is part one of a two-part series about incidental findings. Part two is available here.

When patients come to the emergency room with chest pain and leave with advice to follow up for an unrelated lung nodule, will they get the requested imaging? Will that primary care doctor (if there is one) receive a copy of the emergency department (ED) discharge or radiology report? And if so, is the physician likely to remember to send the patient for additional tests months later? If you ask hospital-based radiologists, the answer to these questions is often a resounding and frustrated “no!”

These are concerns that keep many diagnostic radiologists up at night. “This is a real problem,” said Paul Chang, MD, professor and vice chairman of radiology informatics at the University of Chicago Medical Center. “Most of the horror stories you hear (about incidental findings) are ER.” Why? In-patients already get regular follow-up. Out-patients sent for imaging tests by their treating physicians review the findings on scans they ordered, but typically don’t get proper follow-up.

But if a patient is seen in the emergency department, that’s supposed to be a one-shot deal for an urgent problem. Ideally, the radiologist communicates the incidental finding to the ED doctor before the patient leaves the hospital, and the patient is then told to follow-up accordingly. But patients might be sedated or in pain when hearing the news, or they may not understand the significance, have health insurance, or know how to seek the follow-up care.

And if their primary care physician isn’t in the hospital computer system, that doctor may not get the report. “So when the patient comes back with cancer, who is to blame?” Chang said.

While legal issues are a legitimate worry, doctors are also concerned that patients get the medical care needed in a timely manner, said Michael Bruno, MD, professor of radiology and medicine, and director of quality services and patient safety at Penn State’s Milton S. Hershey Medical Center.

Even putting incidental findings in writing for the patient to take home isn’t foolproof. “Theoretically, they should be put on the discharge instructions. I‘ve seen cases where that hasn’t happened for a variety of reasons,” said Ryan Thompson, MD, an emergency medicine fellow at the University of Wisconsin Hospital in Madison. Reasons might include not having the incidental information available when discharge instructions are given out, or some doctors just not documenting the incidental finding.

Studies confirm this. A 2013 Annals of Emergency Medicine study found that 4.5% of emergency department visits resulted in additional imaging recommendations, but that 51% of the discharge reports didn’t note the findings. A 2011 Emergency Medicine International study, which Thompson co-authored, showed that 33% of CT scans in the emergency room had incidental findings, but only 9.8% of those were reported in discharge papers.[[{"type":"media","view_mode":"media_crop","fid":"33757","attributes":{"alt":"head scan","class":"media-image media-image-right","id":"media_crop_4376074857431","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3572","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 133px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Andrey Burmakin/Shutterstock.com","typeof":"foaf:Image"}}]]

Who Tells The Patient About the Incidental Finding?
The best case scenario is: the radiologist tells the ED physician about the incidental finding while the patient is still in the hospital, said Mark Reiter, MD, president of the American Academy of Emergency Medicine and residency director and associate professor at Tennessee’s St. Thomas Rutherford Hospital at Murfreesboro.

Reiter said the standard of care should be contemporaneous final readings from radiology, with real-time, final interpretations, and no preliminary reads. “That allows us to have access to that final reading while the patient is still under our care. Then, it’s very easy to close the loop. If an incidental finding is noted, we make sure to inform the patient about the incidental finding.” It also allows them to give the patient a copy of the radiology report.

While contemporaneous final reads may be ideal, that’s not always possible. At the University of Wisconsin Hospital in Madison, residents read the overnight imaging studies, Thompson said. At night, “most of the time, incidental findings will be noticed, but they’re giving us an answer to the question we’re asking, like whether there’s a pulmonary embolus as opposed to a small granuloma that needs follow up.” Attendings do the final reads in the morning.

For standard of care in dealing with incidental findings, radiologists follow the ACR Practice Parameter for Communication of Diagnostic Imaging Findings, updated in 2014, according to Bruno. The practice parameters require that critical findings are reported in person or over the phone to the ordering physicians, with non-emergent findings included in the written report. The American Academy of Emergency Medicine doesn’t have a policy on how to handle incidental findings, said Reiter.

There’s also no coordinated national effort to determine who is responsible for sharing the incidental findings with the patient, said Thompson. “There’s not a whole lot of standardization of this process,” he said. Standardization is difficult because whenever you’re interfacing between two departments, you’re going to encounter political and liability issues, Thompson said. “It’s an individual hospital effort which is fraught with all sorts of complications when it changes from place to place.” He said that hospitals generally have a department policy on how to handle incidental findings and over reads, and a physician should ask about it when starting work at a new facility.

At the University of Wisconsin, if the patient has already left the hospital and the radiologist sees an incidental finding that isn’t viewed as clinically significant and won’t change the current treatment, radiology contacts the patient directly. If it’s significant or it will change the patient’s current management, the radiologist calls the emergency room attending physician. “In that case, the ED becomes responsible for making sure the patient is [informed].”

In contrast, Thompson also works at a small community emergency department in Beloit. There, it’s the emergency physician’s job to follow-up with all patients who have incidental findings noted on the radiology report.

It can get more complicated if a teleradiology group is used for nighttime readings, said the American Academy of Emergency Medicine’s Reiter. Sometimes the preliminary teleradiology reading disagrees with the in-house radiologist’s final reading, which he sees happening more than local radiology opinions disagreeing with each other. “In my opinion, incidental findings should be addressed by the radiology group in those situations,” he said.

The Problem with Contacting the Patient Later
Of course, it’s best to inform the patient about an incidental finding while they are still in the hospital, said Reiter. “If you rely on contacting the patient after they leave the ED, a lot of things could go wrong,” he said. “Easily 5% of all phone numbers supplied by patients are incorrect. That’s not a tiny number.” Even with the correct phone number, it can be difficult to reach the patient. Mailing letters has similar limitations. These patients tend to get lost to follow-up. “We’re not confident that we can close the loop.”

Patients with incorrect or missing phone numbers and addresses can be lost to follow-up “There’s a risk that some of those patients won’t ever find out about their incidental findings,” said Thompson.

How many times should a medical practitioner reach out to patients to inform them of incidental findings? “I don’t think there’s a true standard,” said Reiter. “A lot of places call the patient once or twice, and if they’re unable to reach them, they’ll send a certified letter to the patient address. Even with that, it’s not uncommon for someone to fall through the cracks.”

The next article in our series will look at two programs created by hospitals as solutions to this problem.