Radiology report language positively influences adrenal incidentaloma guideline adherence

Prospective Study of a System-Wide Adrenal Incidentaloma Quality Improvement Initiative

BACKGROUND

Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs.

STUDY DESIGN

This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral.

RESULTS

The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517).

CONCLUSIONS

This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care

OBJECTIVE

Thyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy.

METHODS

We identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy.

RESULTS

A total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000.

CONCLUSIONS

Overall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

To report hounsfeld units or not: There is no question

INTRODUCTION

Most adrenal incidentalomas are not appropriately evaluated. Reporting the mass in the radiology report summary and providing recommendations in the report can positively impact evaluation. This study evaluated the effect of reporting Hounsfield units(HU) on adrenal incidentaloma follow-up.

METHODS

Patients with adrenal incidentalomas identified on noncontrast CT scan from 2015 to 2020 ​at a tertiary care institution were studied. Chart review was conducted. Patient and imaging characteristics were compared between patients who did and did not have HU reported. Outcomes of interest were 1)outpatient referral, 2)biochemical evaluation, and 3)dedicated imaging if appropriate. Multivariate analysis determined the impact of HU, reporting in the summary and provision of recommendations on the outcomes.

RESULTS

363 patients were studied, 36(9.9 ​%) had HU reported. When HU were used in addition to recommendations and reporting in the summary, the likelihood of outpatient referral increased from 10.1 to 32.6-fold (95%CI 7.7-138.1, p ​< ​0.001). Similarly, the likelihood of biochemical workup increased from 2.5 to 7.8-fold (95%CI 2.5-24.1, p ​< ​0.001).

CONCLUSION

Recording adrenal incidentaloma HU on non-contrast CT scans was associated with increased rates of outpatient referral and biochemical workup.

Diagnosing and managing adrenal incidentalomas

ABSTRACT

Adrenal incidentalomas are commonly encountered because of the widespread use of high-resolution cross-sectional imaging. Adrenal incidentalomas may be benign or malignant, and also may demonstrate hormonal hypersecretion, so all patients with adrenal masses should undergo further assessment. Clinicians should have a basic understanding of adrenal incidentalomas, their workup, and when follow-up and referral are warranted.

Association Between Surgical Indication and Outcomes for Outpatient Adrenalectomy

INTRODUCTION

Despite a favorable risk-benefit profile, inpatient admission postoperatively for minimally invasive adrenalectomy (MIA) has remained common. Prior studies have shown that outpatient MIA was not associated with an increased 30-day complications or readmission. However, this has not been explored in-depth by adrenalectomy indication. We aimed to examine whether the safety profile of outpatient MIA varies by adrenal indication.

MATERIALS AND METHODS

Clinicopathologic parameters were examined for all MIAs entered into an adrenal database at our institution from 2012 to 2021. Predictor variables included patient demographics, surgical indication, and operative time. Outcomes were 30-day emergency department visit, readmission, and complication rates between surgical indications, comparing outpatient and inpatient groups. Statistical analyses were performed using Kruskal-Wallis, Wilcoxon, Mann-Whitney, and Chi-squared tests, as appropriate.

RESULTS

A total of 185 MIA patients were included. Outpatient MIA was performed in 53 patients (28.6%). Outpatient discharge post-MIA was related to both surgical indication and operative time. Pheochromocytoma (PC) patients were less likely to be discharged as an outpatient postoperatively when compared to all other indications (13.0% versus 33.8%, P = 0.007). Among all patients with operations 2-3 h in length, PC patients were less likely to be discharged home as an outpatient (10% versus 33.3%, P = 0.040). No significant differences were identified between outpatient and inpatient MIA groups for complications, emergency department visits, or readmission (P > 0.05 for all). Only six outpatient MIA patients had any complication (11.3%) and six were readmitted (11.3%).

CONCLUSIONS

Outpatient MIA was demonstrated to be associated with similar, low complication and readmission rates compared to inpatient MIA, although it was used less often for patients with PC or prolonged operative times. Our study highlights potential evidence that outpatient MIA can be safely used in selected patients across all indications for adrenal surgery.

Automated extraction of incidental adrenal nodules from electronic health records

BACKGROUND

Many adrenal incidentalomas do not undergo appropriate biochemical testing and complete imaging characterization to assess for hormone hypersecretion and malignancy. With the growing availability of clinical narratives in the electronic medical record, automated surveillance using advanced data analytic techniques may represent a promising method to improve management.

METHODS

A data provisioning process using a series of structured query language scripts was used to abstract all chest and abdominal computed tomography and magnetic resonance imaging reports from an academic health care system in 2018. The narratives and impressions were queried for key text relating to the identification of adrenal incidentalomas. Patients with a history of extra-adrenal malignancy undergoing staging or surveillance imaging were excluded. The prevalence and radiographic characteristics were analyzed. Patients with adrenal incidentalomas newly identified in 2018 were assessed for biochemical testing and nodule stability through August 2021.

RESULTS

Of 36,618 patients queried, 8,557 were excluded owing to a history of extra-adrenal malignancy. Data from 447 patients were flagged by the structured query language scripts and electronically abstracted. On internal validation, 307/447 (69%) patients were correctly identified as having adrenal nodules (1.1% overall prevalence). The median patient age was 67 years, and 56% were female. The median nodule size was 1.7 (IQR 1.3-2.5) cm, 9% were bilateral, and 63% were low density (unenhanced Hounsfield units <10). Adrenal carcinoma was identified in 10 patients. In 2018, 121 patients were diagnosed with a new adrenal incidentaloma. Of 32 (27%) patients who had follow-up imaging at a median of 1.9 years, 97% of nodules were stable in size. Biochemical testing was performed in 53 patients (44%), of which 31 (26%) had complete hormonal assessment; 14 (26%) were functional nodules: 7 aldosterone-secreting, 4 cortisol-secreting, and 3 pheochromocytoma.

CONCLUSION

Only one-fourth of patients received appropriate biochemical testing after incidental diagnosis of an adrenal nodule, and most nodules with indeterminate imaging characteristics did not undergo follow-up imaging. Advanced data analytic techniques on electronic imaging reports may aid in the clinical identification and improved management of patients with adrenal incidentalomas.