Communication Critical to Providers Adhering to Follow-Up Recommendations

From the detection of a bulging blood vessel to a blocked artery to a suspicious mass, the advancements in modern medical imaging save lives. However, there are many times when medical imaging tests are being performed for one reason, and the radiologist detects an unexpected anomaly that is completely unrelated. In those cases, the radiologist usually recommends additional imaging.

Unfortunately, the number of the recommendations that actually translate into additional imaging (RAIs) tests being performed is low. This non-compliance can cause poor outcomes for patients, and it could have negative downstream effects for a practice, as well. In some cases, a patient could file a malpractice lawsuit, resulting in the radiology practice or department being found legally liable for some of a patient's damages.

New Research Indicates Adherence to Recommendations for Additional Imaging is Low

New research gathered during a six-month study shows that whether the follow-up exams a radiologist recommends are performed depends greatly on the type of provider who receives the recommendation and the care setting in which that provider treats the patient.

The Goal of This Study: Determining Why RAI Adherence is Low

The only way to increase the number of providers adhering to the recommendations for additional imaging is to discover the factors affecting adherence rates.

That was the goal of the study, Factors Affecting Adherence to Recommendations for Additional Imaging of Incidental Findings in Radiology Reports. Conducted by doctors at the University of California’s Davis Medical Center, this study focused on the reasons why providers disregard RAIs. To answer this question, researchers reviewed 539 reports of computed axial tomography scans that, due to incidental findings, had recommendations for additional imaging. Since these reports were studied retrospectively, the researchers used the patients’ medical charts to determine if providers adhered to the RAIs.

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Study Results

Study results indicate that outpatient sites and primary care providers (PCP) were most likely to follow additional imaging recommendations. However, according to study researcher Shan S. Hansra, M.D., from the Sacramento, California, institution, it is the referring physician who is usually responsible for managing radiology report recommendations.

Nevertheless, if the referring physician neglects to follow-up on the incidental findings, the consequences are likely to trickle down, detrimentally affecting the radiology practice or department.

Factors Affecting Recommendations for Additional Imaging Adherence Rates

Ascertaining adherence rates and, then, recognizing the factors that affect these rates can help determine the reasons that RAIs are not being addressed.

Comprehensive Adherence Rates for RAIs:

• Overall, the recommendations for additional imaging were performed in 39.1 percent of the 539 cases. However, when the patient’s primary care provider was at the institution where the CT scan was performed, the compliance rate increased substantially to 56.8 percent.

Adherence Rates Based on the Type of Patient Being Treated When the PCP is at the Same Location

The adherence rate when the patient is seen as:

• An outpatient, 66.7 percent.
• An inpatient, 36 percent.
• A patient in the emergency department, 46 percent.

Adherence rates based on the part of the body that requires additional imaging tests:

• At 3.5 percent, chest imaging had the highest rate of adherence. After chest imaging, providers adhered to 3.1 percent of the RAIs for the neck, abdomen and pelvis.
• The lowest adherence rates involved an extremity (0.3 percent), the spine (0.8 percent), the head (0.1 percent) and the face (0.1 percent).

For outpatients, the specialty of the provider ordering the CT scan made a difference in the percentage of providers following up, as well:

• PCPs adhered to the recommendations 67 percent of the time.
• Surgeons followed up 37.7 percent of the time.
• Internal medicine subspecialists adhered to the RAIs 50 percent of the time.

Noncompliance to RAIs is Mainly Due to a Lapse in Communication

According to the authors of this study, lapses in communication serve as the main reason for the failure to follow-up on RAIs. While documenting the need for follow-up imaging in the discharge summary does boost adherence rates, these details are often absent from the patient's discharge summary. In addition, many times, the patient only receives the test results once they are released.

Communication Gaps

There are numerous gaps that must be addressed to make sure that there is a good line of communication between the radiologist, the ordering physician, the PCP, and the patient.

Neglecting to follow-up on a recommendation for additional imaging can result in diagnosis and treatment delays, which may lead to poor patient outcomes. Poor patient outcomes due to this negligence can lead to a malpractice lawsuit, resulting in the practice’s or department’s legal liability. 

Risks of a Lapse in Communication

Numerous examples demonstrate where incidental findings go unnoticed due to a gap in communication and lack of patient tracking – these mishaps can lead to patient fatalities and lawsuits. A recent settlement in Illinois makes it clear how important good communication is.

The Case of Mark James:

In November 2017, Mark James had a CT scan for potential venous stenosis in one of his kidneys. This scan was performed on James' pelvis and abdomen. While the radiologist was reading the scan, he found a mass on James’ lung. The radiologist gave a recommendation for additional imaging; however, this information was not shared with James.

In May 2019, James began experiencing inflammation and pain in his chest and shoulder. He had another CT scan – it revealed that the mass found in 2017, which he was never informed about, had metastasized. James passed away in July of 2019.

Due to the delayed cancer diagnosis, James’ family received a $7.5 million settlement from the University of Illinois Hospital.

Methods of Improving Communication

Patients who miss their follow-up appointments or choose another provider for their care are vulnerable. Often, incidental findings and recommendations are altogether missed by the referring provider. It is essential that patient contact information and preferences on how to be contacted are captured accurately to ensure the continuity of care. Otherwise, the patient may never know there is a recommendation for additional imaging. Consider implementing the practice of informing the patient how important his or her follow-up visit is. Doing so may increase the likelihood that the patient keeps this appointment.

Texas Radiology Associates, a group of 150 radiologists based in Plano, Texas, also has a unique solution to combat the lack of follow-ups through technological advancements.

John Kim, M.D., managing partner of Texas Radiology Associates explains how technology has helped them better communicate.

“We have deployed technology that identifies studies that require follow-ups based on the patient’s case. This technology can also ensure the same information has been relayed and received by the referring physician, and creates an alerting mechanism to take action should the particular patient not have the recommended study, such as following up with the patient, or the referring physician to inform them of a recommendation not being adhered to,” he said. “This has resulted into a significant decrease in missed recommendations.” 

Texas Radiology Associates also allows patients to have access to their radiology reports, thereby allowing them to play a critical role in their continuity of care. In the healthcare space, innovative technology can address several gaps and is ever-growing and evolving.

The American College of Radiology is Addressing Gaps in Care

Currently, a consensus for guiding classification of the incidental findings discovered on imaging tests is nonexistent. However, the American College of Radiology (ACR) is in the process of creating a quality measure for addressing these potentially dangerous gaps in care.

Recently, the ACR received a grant in the amount of $341,000 for work that was previously done with a large group of radiologists. Now, the researchers are requesting that physicians give questionnaires to patients and their families with the goal of attaining additional information related to incidental findings. Furthermore, the American College of Emergency Physicians is working in conjunction with the ACR to create guidance related to following up on anomalies found during emergency situations.

Once a coordinated process is implemented to prevent gaps in care, patient morbidity and mortality rates should drop. Consequently, the likelihood of litigation due to poor communication related to CT scans and other imaging test results will drop.