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Wengle L, White LM, Naraghi A, Kamali M, Betsch M, Veillette C, Leroux T. Imaging in an academic orthopedic shoulder service: a report on incidental lung pathology findings. Skeletal Radiol 2024; 53:339-344. [PMID: 37481479 DOI: 10.1007/s00256-023-04406-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
INTRODUCTION Computed tomography (CT) is often utilized for both diagnostic and pre-operative planning purposes in shoulder arthroplasty. Our study reports on the incidence of pulmonary findings in our pre-operative shoulder arthroplasty population over 14 years at our institution. METHODS We conducted a retrospective review of all "shoulder CT" exams ordered by two orthopedic upper extremity surgeons between the years of 2008 and 2021. These exams were then further analyzed to include only those ordered for the purpose of pre-operative "shoulder arthroplasty" planning. All incidental findings were documented and those with pulmonary findings were then further analyzed. A detailed chart review was then performed on these patients to determine the impact on their planned shoulder arthroplasty. RESULTS A total of 363 shoulder pre-operative CTs were ordered by our two upper extremity orthopedic surgeons at our institution between the years of 2008 and 2021. Primary lung cancer in the form of adenocarcinoma (n = 3) had an incidence of 0.8% of all CT scans and 1.4% of all pulmonary incidental findings. Fifteen patients (4% of all CT scans and 7% of all pulmonary incidental findings) had no concern for malignancy and were appropriately evaluated with further imaging based on their initial shoulder CT. CONCLUSION While shoulder arthroplasty and pre-operative planning with CT imaging continue to become more common, so too is the incidence of reported pulmonary findings. From a patient care standpoint, it is important that these findings are accurately identified, appropriately triaged, and communicated clearly to our patients.
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Affiliation(s)
- Lawrence Wengle
- Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Room 508-A, Toronto, Ontario, M5T 1P5, Canada.
| | - Lawrence M White
- Joint Department of Medical Imaging (JDMI), Mount Sinai Hospital, University Health Network, Women's College Hospital, ON, Toronto, Canada
| | - Ali Naraghi
- Joint Department of Medical Imaging (JDMI), Mount Sinai Hospital, University Health Network, Women's College Hospital, ON, Toronto, Canada
| | - Mahsa Kamali
- Joint Department of Medical Imaging (JDMI), Mount Sinai Hospital, University Health Network, Women's College Hospital, ON, Toronto, Canada
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Christian Veillette
- Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Room 508-A, Toronto, Ontario, M5T 1P5, Canada
- The Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Timothy Leroux
- Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Room 508-A, Toronto, Ontario, M5T 1P5, Canada
- The Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
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2
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Sabiq S, Alzauir A, Alenizi SA. Incidental Computed Tomography Findings Among Traumatized Adults: A One-Year Analysis at a Trauma Center. Cureus 2024; 16:e51904. [PMID: 38333492 PMCID: PMC10851046 DOI: 10.7759/cureus.51904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/10/2024] Open
Abstract
Background Computed tomography (CT) for patients with trauma represents a widely accepted diagnostic method. Non-trauma-related incidentalomas or incidental findings are commonly depicted based on CT examination. Our study aimed to assess the frequency of incidental findings on CT scans among traumatized adult patients during one year at a trauma center. Methods We performed a retrospective case review of all adult patients triaged at the King Abdullah Medical Complex trauma service in Jeddah, Saudi Arabia, between 31 May 2022 and 30 May 2023. Patients under the age of 18 were excluded from the study. Patients who could not complete radiographic studies due to deterioration in condition, patients with missing CT scan reports, and transfer patients who had CT scans done at outside facilities were excluded. Demographic data, including age, sex, type of trauma, and type of CT, were recorded. All CT studies were reviewed for incidental findings. Results A total of 106 incidental findings were discovered in 99 patients. The rate of incidental findings for one year was 1.87%. The average age was 41.19 ± 17.90 years, with 73 (73.7%) male and 26 (26.3%) female patients. In trauma classifications, road traffic accidents were the most common (59.60%), followed by falls (33.33%), penetrating trauma (3.03%), and others. A high number of scans for the whole body (56.57%); face, brain, and cervix (13.13%); chest and abdomen/pelvis (11%); and spine (5.05%) had incidental findings. Genitourinary-related incidental findings were observed in 27.36% of patients, followed by craniospinal (16.98%), pulmonary (12.26%), hepatobiliary (9.43%), endocrine (9.43%), and musculoskeletal (5.66%). Conclusion In trauma centers, incidental findings are frequently discovered during CT imaging. In contrast, our center has a lower incidental finding rate. A whole-body CT scan yielded more incident findings than a selective one. The incidental findings are prevalent in the genitourinary system and higher in young male patients. It is important to properly document, communicate, and follow up on these incidental discoveries.
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Affiliation(s)
- Sawsan Sabiq
- Department of Nuclear Medicine, King Abdullah Medical City, Jeddah, SAU
| | - Abdulaziz Alzauir
- Department of Radiology, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Sarah A Alenizi
- Department of Radiology, King Fahad Armed Forces Hospital, Jeddah, SAU
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Blodgett M, Fradinho J, Gurley K, Burke R, Grossman S. The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis. J Emerg Med 2023; 65:e568-e579. [PMID: 37879972 DOI: 10.1016/j.jemermed.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/06/2023] [Accepted: 08/10/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Incidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non-electronic health record (EHR)-specific solutions that can be used across different types of IFs and EHRs. OBJECTIVE The objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine-based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results. METHODS A QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation. RESULTS Of 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention. CONCLUSIONS Although abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients' subsequent clinical course, potentially increasing patient safety.
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Affiliation(s)
- Maxwell Blodgett
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jorge Fradinho
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Kiersten Gurley
- Department of Emergency Medicine, Anna Jaques Hospital, Newburyport, Massachusetts
| | - Ryan Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Shamai Grossman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Evans CS, Dorris HD, Kane MT, Mervak B, Brice JH, Gray B, Moore C. A Natural Language Processing and Machine Learning Approach to Identification of Incidental Radiology Findings in Trauma Patients Discharged from the Emergency Department. Ann Emerg Med 2023; 81:262-269. [PMID: 36328850 DOI: 10.1016/j.annemergmed.2022.08.450] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Patients undergoing diagnostic imaging studies in the emergency department (ED) commonly have incidental findings, which may represent unrecognized serious medical conditions, including cancer. Recognition of incidental findings frequently relies on manual review of textual radiology reports and can be overlooked in a busy clinical environment. Our study aimed to develop and validate a supervised machine learning model using natural language processing to automate the recognition of incidental findings in radiology reports of patients discharged from the ED. METHODS We performed a retrospective analysis of computed tomography (CT) reports from trauma patients discharged home across an integrated health system in 2019. Two independent annotators manually labeled CT reports for the presence of an incidental finding as a reference standard. We used regular expressions to derive and validate a random forest model using open-source and machine learning software. Final model performance was assessed across different ED types. RESULTS The study CT reports were divided into derivation (690 reports) and validation (282 reports) sets, with a prevalence of incidental findings of 22.3%, and 22.7%, respectively. The random forest model had an area under the curve of 0.88 (95% confidence interval [CI], 0.84 to 0.92) on the derivation set and 0.92 (95% CI, 0.88 to 0.96) on the validation set. The final model was found to have a sensitivity of 92.2%, a specificity of 79.4%, and a negative predictive value of 97.2%. Similarly, strong model performance was found when stratified to a dedicated trauma center, high-volume, and low-volume community EDs. CONCLUSION Machine learning and natural language processing can classify incidental findings in CT reports of ED patients with high sensitivity and high negative predictive value across a broad range of ED settings. These findings suggest the utility of natural language processing in automating the review of free-text reports to identify incidental findings and may facilitate interventions to improve timely follow-up.
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Affiliation(s)
- Christopher S Evans
- Information Services, ECU Health, Greenville, NC; Department of Emergency Medicine, Brody School of Medicine, East Carolina University, Greenville, NC.
| | - Hugh D Dorris
- Department of Medicine, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Michael T Kane
- UNC Hospitals Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Psychiatry, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Benjamin Mervak
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Jane H Brice
- Department of Emergency Medicine, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Benjamin Gray
- School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carlton Moore
- Department of Medicine, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; UNC Hospitals Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC
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Martin S, LoPolito A, Whitney LD, Fenninger A, Bonneville K, Ward R, Graeff S, Saint Fort L, Brown CT, Miller V, Perea LL. Incidental Findings Protocol Implementation at a Level-I Trauma Center: A Review of Patient Follow-Up. Am Surg 2023:31348231157822. [PMID: 36792996 DOI: 10.1177/00031348231157822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Pan scanning in trauma patients has become routine, resulting in increased identification of incidental findings (IF), findings unrelated to the reason for the scan. This has posed a conundrum of ensuring patients have appropriate follow-up for these findings. We sought to evaluate our compliance and follow-up for patients after implementation of an IF protocol at our level-I trauma center. METHODS We performed a retrospective review from 9/2020 to 4/2021, to encompass before and after protocol implementation. Patients were separated into PRE and POST groups. Charts were reviewed evaluating several factors including three- and six-month follow-ups on IF. Data were analyzed comparing PRE and POST groups. RESULTS A total of 1989 patients were identified, 31.22% (n = 621) with an IF. 612 patients were included in our study. Compared to PRE, POST showed a significant increase in PCP notification (35% vs 22%, P < .001) and patient notification (82% vs 65%, P < .001). As a result, patient follow-up regarding IF at six months was significantly higher in POST (44%) v. PRE (29%), (P < .001). There was no difference in follow-up based on insurance carrier. There was no difference in patient age for PRE (63 y) and POST (66 y) overall, (P = .089); nor in age of patients who followed up; 68.8 PRE vs 68.2 years POST (P = .819). CONCLUSION Implementation of an IF protocol with patient and PCP notification was significantly improved in overall patient follow-up for category one and two IF. Utilizing the results of this study, the protocol will be further revised to improve patient follow-up.
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Affiliation(s)
- Sarah Martin
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Andrew LoPolito
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Larissa D Whitney
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Ashley Fenninger
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Kelly Bonneville
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Ryan Ward
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Shelby Graeff
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Launick Saint Fort
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Catherine T Brown
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Virginia Miller
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Lindsey L Perea
- Department of Surgery, Division of Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
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Evans CS, Arthur R, Kane M, Omofoye F, Chung AE, Moreton E, Moore C. Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis. Ann Emerg Med 2022; 80:243-256. [PMID: 35717273 DOI: 10.1016/j.annemergmed.2022.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings. METHODS On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis. RESULTS A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED. CONCLUSION In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.
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Affiliation(s)
- Christopher S Evans
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Rodney Arthur
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael Kane
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Fola Omofoye
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Arlene E Chung
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Biostatistics & Bioinformatics, Duke School of Medicine, Durham, NC
| | - Elizabeth Moreton
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carlton Moore
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Talutis SD, Childs E, Goldman AL, Knapp PE, Gupta A, Ferrao C, Feeney T, McAneny D, Thurston Drake F. Strategies to optimize management of incidental radiographic findings in the primary care setting: A mixed methods study. Am J Surg 2021; 223:297-302. [PMID: 33810834 DOI: 10.1016/j.amjsurg.2021.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Incidental adrenal masses (IAMs) are common. Primary care providers (PCPs) are frequently responsible for incidentaloma evaluations. We evaluated whether PCPs view this paradigm effective, barriers faced, and strategies to optimize care delivery. METHODS This is a sequential explanatory study, comprised of surveys followed by focus groups of PCPs. Because lung nodules are another type of common incidental finding, we compared PCP views on management of lung nodules to their views on IAMs. RESULTS For IAMs, 22.3% of PCPs "always refer" to specialists, but for lung nodules this was 11.5% (p = 0.026). For lung nodules, the most significant barrier was insufficient time/support to longitudinally follow results (69%), but for IAMs it was uncertainty about which tests to order (68%). Fear of litigation was equal (lung = 22.5%, IAMs = 21.3%). Consistent themes regarding the "ideal" system included specific recommendations in radiology reports; automation of orders for follow-up tests; longitudinal tracking tools; streamlined consultations; and decision guides embedded within the electronic health record. CONCLUSIONS Respondents are more comfortable with lung nodules than IAMs. Management of "incidentalomas" is within their scope of practice, but the current system can be optimized.
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Affiliation(s)
- Stephanie D Talutis
- Boston University School of Medicine, Department of Surgery. Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | - Ellen Childs
- Boston University School of Public Health, Boston, MA, USA; Abt Associates, Rockville, MD, USA
| | - Anna L Goldman
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Department of Medicine. Boston, MA, USA
| | - Philip E Knapp
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Department of Medicine. Boston, MA, USA
| | - Avneesh Gupta
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Department of Radiology. Boston, MA, USA
| | - Cleopatra Ferrao
- Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Department of Medicine. Boston, MA, USA
| | - Timothy Feeney
- Boston University School of Medicine, Department of Surgery. Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | - David McAneny
- Boston University School of Medicine, Department of Surgery. Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | - Frederick Thurston Drake
- Boston University School of Medicine, Department of Surgery. Boston, MA, USA; Boston Medical Center, Boston, MA, USA.
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8
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Smith LM, King SA, Shealy JA, Heidel RE, Morin-Ducote GI, Husband LD, Callison JC, Rosen BA, Savoy RA, Daley BJ. Incidental Findings in the Trauma Population: Interdisciplinary Approach and Electronic Medical Record Reminder Association with Pre-Discharge Reporting and Medicolegal Risk. J Am Coll Surg 2020; 232:380-385.e1. [PMID: 33385568 DOI: 10.1016/j.jamcollsurg.2020.11.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Incidental findings (IFs) are reported in 20% or more of trauma CT scans. In addition to the importance of patient disclosure, there is considerable legal pressure to avoid missed diagnoses. We reported previously that 63.5% of IFs were disclosed before discharge and with 20% were nondisclosed. We initiated a multidisciplinary systemic plan to effect predischarge disclosure by synoptic CT reports with American College of Radiology recommended follow-up, electronic medical records discharge prompts, and provider education. STUDY DESIGN Prospective observational series patients from November 2019 to February 2020 were included. Statistical analysis was performed with SPSS, version 21 (IBM Corp). RESULTS Eight hundred and seventy-seven patients underwent 1 or more CT scans for the evaluation of trauma (507 were male and 370 were female). Mean age of the patients was 57 years (range 14 to 99 years) and 96% had blunt injury. In 315 patients, there were 523 IFs (1.7 per patient); the most common were lung (17.5%), kidney (13%), and liver (11%). Radiology report compliance rate was 84% (210 of 249 patients). There were 66 studies from outside facilities. Sixteen IFs were suspicious for malignancy. A total of 151 patients needed no follow-up and 148 patients needed future follow-up evaluation. Predischarge IF disclosure compliance rate was 90.1% (286 patients); 25 were post discharge. Four patients remained undisclosed. Compared with our previous report, clearer reporting and electronic medical records prompts increased predischarge disclosure from 63.5% to 90.1% (p < 0.01, chi-square test) and decreased days to notification from 29.5 (range 0 to 277) to 5.2 (range 0 to 59) (p < 0.01, Mann-Whitney U test). CONCLUSIONS Timely, complete disclosure of IFs improves patient outcomes and reduces medicolegal risk. Collaboration among trauma, radiology, and information technology promotes improved disclosure in trauma populations.
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Affiliation(s)
- Lou M Smith
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Sarah A King
- East Tennessee State University College of Medicine, Mountain Home, TN
| | - Jordan A Shealy
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Robert E Heidel
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | | | - Leland D Husband
- Department of Radiology, University of Tennessee Medical Center, Knoxville, TN
| | - John C Callison
- Pulmonary and Critical Care, University of Tennessee Medical Center, Knoxville, TN
| | - Brenton A Rosen
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Rachel A Savoy
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | - Brian J Daley
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN.
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Sich N, Rogers A, Bertozzi D, Sabapathi P, Alswealmeen W, Lim P, Sternlieb J, Gartner L, Yuschak J, Kirton O, Shadis R. Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients. Surgery 2017; 163:657-660. [PMID: 29179912 DOI: 10.1016/j.surg.2017.09.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/17/2017] [Accepted: 09/13/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Incidental findings are prevalent in imaging but often go unreported to patients. Such unreported findings may present the potential for harm as well as medico-legal ramifications. METHODS A chart review of trauma patients was undertaken over a year. Systems-based changes were made utilizing our electronic medical record system and our staff protocols to improve the disclosure of clinically relevant incidental findings to patients. RESULTS During the preintervention period, 674 charts were reviewed. Trauma patients had a rate of incidental findings of 70%, and 36% of patients had clinically relevant incidentals. Rates of follow-up recommendation and disclosure to patients were 22% and 27%, respectively. In the postintervention period, of the 648 charts were reviewed, the rates of a clinically relevant incidental finding were 35%, but the rates of follow-up recommendation and disclosure to patients were 68% and 85%, respectively. CONCLUSION Incidental findings are more prevalent herein than previously reported. With simple changes and minimal resources, clinically relevant and important improvement in reporting incidental findings can be made to mitigate the harm and medico-legal impact of an incidental finding going unreported.
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Affiliation(s)
- Nicholas Sich
- Department of General Surgery, Abington-Jefferson Health, Abington, PA.
| | - Andrew Rogers
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Danelle Bertozzi
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Praveen Sabapathi
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Waed Alswealmeen
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Philip Lim
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | | | - Laura Gartner
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - James Yuschak
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Orlando Kirton
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
| | - Ryan Shadis
- Department of General Surgery, Abington-Jefferson Health, Abington, PA
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10
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Bates R, Plooster C, Croghan I, Schroeder D, McCoy C. Incidental Pulmonary Nodules Reported on CT Abdominal Imaging: Frequency and Factors Affecting Inclusion in the Hospital Discharge Summary. J Hosp Med 2017; 12:454-457. [PMID: 28574537 DOI: 10.12788/jhm.2757] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Incidental imaging findings require an assessment of risk and clinical relevance, as well as consideration of further evaluation. Incidental findings are common on imaging obtained in the hospital, with pulmonary nodules being among the most frequent findings that may require additional evaluation. We conducted a retrospective study to determine the factors associated with documentation of incidental findings in the hospital discharge summary, using pulmonary nodules reported on abdominal computed tomography (CT) as an example of incidental findings with well-defined follow-up guidelines. Between January 1, 2012 and December 31, 2014, 7173 patients underwent in-patient abdominal CT without concurrent chest CT; of these patients, 62.2% were ≥60 years old, 50.6% were men, and 45.5% were current or former smokers. Incidental pulmonary nodules were reported in 402 patients (5.6%; 95% confidence interval [CI], 5.1%-6.2%). Based on nodule size, reported size stability, and patients' smoking status, 208 patients (2.9%; 95% CI, 2.5%-3.3%) required follow-up surveillance, per the 2005 Fleischner Society guidelines. Of these 208 patients, 48 (23%) received discharge summaries that included documentation of the incidental findings, with 34 summaries including a recommendation for nodule follow-up and 19 summaries including a time frame for repeat CT. Three factors were positively associated with the inclusion of the pulmonary nodule in the discharge summary: mention of the pulmonary nodule in the summary headings of the radiology report (P ≤ 0.001), radiologist recommendations for further surveillance (P ≤ 0.001), and medical discharging service (P = 0.016). These findings highlight the need for a multidisciplinary systems-based approach to incidental pulmonary nodule documentation and surveillance. Journal of Hospital Medicine 2017;12:454-457.
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Affiliation(s)
- Ruth Bates
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Corbin Plooster
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ivana Croghan
- Clinical Research Office, Clinical Trials Unit, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell Schroeder
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Christopher McCoy
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Behbahani S, Mittal S, Patlas MN, Moshiri M, Menias CO, Katz DS. "Incidentalomas" on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations. Abdom Radiol (NY) 2017; 42:1046-1061. [PMID: 27695953 DOI: 10.1007/s00261-016-0914-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on "incidentalomas" discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.
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Affiliation(s)
- Siavash Behbahani
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA.
| | - Sameer Mittal
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA
| | - Michael N Patlas
- Department of Radiology, Hamilton General Hospital, McMaster University, 237 Barton St., East Hamilton, ON, L8L 2X2, Canada
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Christine O Menias
- Department of Radiology, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA
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12
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James MK, Francois MP, Yoeli G, Doughlin GK, Lee SW. Incidental findings in blunt trauma patients: prevalence, follow-up documentation, and risk factors. Emerg Radiol 2017; 24:347-353. [DOI: 10.1007/s10140-017-1479-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/13/2017] [Indexed: 12/21/2022]
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Abstract
Adrenal gland diagnostics can pose significant challenges. In most academic and community practice settings, adrenal gland resections are encountered less frequently than other endocrine or genitourinary specimens, leading to less familiarity with evolving classifications and criteria. The unique dichotomy between cortical and medullary lesions reflects the developmental evolution of these functionally independent components. Adrenal cortical lesions at resection include hyperplasia, adenoma, and carcinoma, with some cases straddling the boundary between these distinct clinical classifications. The lack of immunohistochemical or molecular markers to definitively categorize these intermediate lesions enhances the diagnostic challenge. In addition, modified terminology for oncocytic and myxoid cortical lesions has been proposed. Medullary lesions are somewhat easier to categorize; however, the prediction of aggressive behavior in pheochromocytomas remains a challenge due to a lack of reliable prognostic biomarkers. Recent work by the Cancer Genome Atlas Project and other research groups has identified a limited subset of molecular and signaling pathway alterations in these 2 major neoplastic categories. Ongoing research to better define prognostic and predictive biomarkers in cortical and medullary lesions has the potential to enhance both pathologic diagnosis and patient therapy.
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