The Challenges of Communicating Incidental Findings

“Incidental finding” is an imaging finding that was discovered by chance on an imaging exam that was performed for another reason. The rates of discovering an incidental finding are on the rise as more and more patients undergo imaging exams and as the technology of diagnostic imaging advances.

A part of their standard practice, radiologists include incidental findings in their radiology reports for the referring physicians to review and discuss with the patient. However, the next step for patients varies greatly.

“The follow-up plan depends on the finding,” said Natasha Larocque, MD, a radiologist at the Timmins and District Hospital in Ontario, Canada. “Lung nodules, ovarian cysts and adrenal nodules have numerous different imaging follow-up pathways depending on many factors.”

There is, however, a growing discussion on the best practices on how to communicate incidental findings to patients and how to ensure these patients are not lost to follow-up.

Follow-Up Occurs Less Often In Emergency Department Patients

The emergency department (ED) represents a challenging clinical environment for follow-up of incidental findings as both the patients and physicians are focused on treating what brought the patient acutely to the ED in the first place.

“Most incidental findings are potentially concerning for an early malignancy,” said Christopher Moore, MD, professor and chief of the Section of Emergency Ultrasound in the Department of Emergency Medicine at the Yale School of Medicine in New Haven, CT. “The initial follow-up is typically additional or repeat imaging to see if a lesion is progressing.”

Further complicating matters is that the emergency physicians who are ordering these imaging tests don’t have the same relationship with the patient as a primary care physician and will most likely not be involved in any follow-up care.

In the U.S., medical imaging occurs in over half of the ED visits with patients undergoing multiple imaging procedures. Roughly one-third of CT exams in the ED result in incidental findings, although fewer likely require follow-up.

“Unfortunately, many incidental findings in emergency department patients may not receive the follow-up that they should,” Dr. Moore said. “Because the patient often came in for a different complaint, and care may occur at any time of the day or week, it can make it difficult to ensure that incidental findings are reliably communicated and followed.”

Some current data suggests that follow- up only occurs in 17% of patients in whom incidental findings were found as the result of ED imaging. Dr. Moore co-authored a Journal of the American College of Radiology article that included a 15-member panel comprised of radiologists, emergency physicians, patients and those involved in health care systems and quality who all identified best practices for the reporting, communication and follow-up of incidental findings from ED imaging. One area of consensus was the inclusion of patient-friendly explanations in the radiology report. This is especially relevant as more patients have direct access to their medical documentation through electronic health records systems. Additionally, the panel emphasized that communication and follow-up of incidental findings should be a systemwide issue. The report found that it is not feasible for an emergency clinician who ordered an imaging test, or a radiologist who documented an incidental finding, to be held fully responsible for the long-term follow-up of incidental findings.

Institutions that establish follow-up systems that assign a dedicated individual to contact patients and track their follow-up could greatly increase the number of patients who end up receiving potentially life-saving care.