Radiology Intelligence Routinely Not Followed in Practice

Damian McNamara

April 21, 2016

LOS ANGELES — Approximately one in three radiology recommendations that call for additional clinical action are not abided by, according to a large retrospective study. And nearly half of those directives are not even acknowledged.

The findings suggest the need for better communication and technology to protect patients from possible harm.

"We were concerned because we had a number of cases in which we made a recommendation that was not followed, and it turned into a problem," study investigator Alexander Norbash, MD, from the University of San Diego, said here at the American Roentgen Ray Society 2016 Annual Meeting.

The study comes in the wake of a major report from the Institute of Medicine, released in September 2015, which calls for reforms related to diagnostic errors. The definition of a diagnostic error used in the report includes "the failure to (a) establish an accurate and timely explanation of the patient's health problem or (b) communicate that explanation to the patient."

Dr Norbash and his colleagues reviewed 6851 patient reports generated at Boston Medical Center in January 2014, and identified 857 (13%) with one or more radiology recommendations. The 972 recommendations included calls for additional imaging (63%), clinical correlation (24%), a nonimaging procedure (7%), a laboratory study (4%), and consultation with a specialist (2%).

The team then reviewed patient charts to identify subsequent changes in patient management. They found that 650 (67%) of the radiology recommendations were followed.

But "fully one-third of the time, the recommendations were not followed," Dr Norbash reported.

Of the recommendations not adhered to, 127 (39%) were not even acknowledged in the referring physician's notes. And although 195 (61%) recommendations were documented, patients were either lost to follow-up, the physician did not accept the recommendation, or the recommendation was no longer clinically relevant.

Of the 127 recommendations not acknowledged, 55 (43%) were significant. Forty-two were related to a cancer concern, 20 of which involved lung nodules requiring follow-up on the basis of Fleischner criteria, and 13 were related to another concern, such as a new brain abscess.

"There is a significant risk to patients of cancer or another morbidity related to radiology recommendations," said Dr Norbash. "We found 55 patients in 1 month; that adds up over a year."

We're in the diagnosis business. What good is it if no one knows what we're recommending?

"We cannot assume that information about patients' health sent by radiologists will always be received by referring providers," said study investigator Nadja Kadom, MD, from Emory University in Atlanta.

Information can get lost when electronic messages are not noticed or received, when fax machines malfunction, or when communication goes to a physician other than the patient's primary care doctor, she told Medscape Medical News. And in some cases, the information is transmitted but the patient has moved, does not return for further workup, or is lost to follow-up for another reason.

"We need to fix the system," Dr Kadom said, who offered some solutions.

Dedicated radiology staff, patient navigators, and modern information technology systems could facilitate and track communication about results between radiologists and referring physicians and could document delivery. And recommendations to patients delivered through a portal could increase the chances of follow through, she explained.

"These solutions may seem costly, but health enterprises need to weigh the cost of medicolegal actions from missed cancers or other adverse outcomes against the cost of investing in preventive measures," Dr Kadom said.

This was "an excellent talk," said Ian Amber, MD, from the Hospital for Special Surgery in New York City. "It's important and something we need to discuss as radiologists."

"We're in the diagnosis business," Dr Amber told Medscape Medical News. "What good is it if no one knows what we're recommending? It's the worst thing in the world if we diagnose a cancer and nothing is done about it."

Dr Norbash, Dr Kadom, and Dr Amber have disclosed no relevant financial relationships.

American Roentgen Ray Society (ARRS) 2016 Annual Meeting: Abstract 3003. Presented April 20, 2016.

Follow Damian McNamara on Twitter: @MedReporter


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