How can radiologists ensure report recommendations are acted on?

2019 01 14 20 34 4092 Doctor Patient Consult 400

Recommendations in radiology reports for further imaging follow-up are not always acted on, and systemic improvements are needed to ensure these cases don't slip through the cracks, according to research published July 22 in JAMA Network Open.

After reviewing nearly 600 radiology reports and patient records at their institution, researchers led by Dr. Tiantian White of Harvard Medical School in Boston found that approximately one in seven recommendations for imaging follow-up was not completed. And a clinically significant lack of action was found in approximately 5% of the reports.

"Although multiple factors appeared to be associated with such unsuccessful follow-up, our findings suggest several potential areas for improvement, including dedicated radiology report recommendations fields; clearer, perhaps less conditional recommendations; better systems for scheduling patients for recommended follow-up examinations and referrals; more reliable systems for patient hand-off for [primary-care physicians] who leave practices; and follow-up of patients who do not schedule or present for scheduled activities," the authors wrote.

In an effort to document the types of recommendations in radiology reports and determine how often these recommended follow-up actions were carried out in the primary care setting, the researchers first developed a taxonomy of recommended actions, time frames, and contingencies. They then analyzed 598 radiology reports that contained structured recommendations for imaging follow-up.

Of the 598 reports, 462 recommendations were for additional or future radiologic studies and 196 were for nonradiologic actions such as specialty referrals, invasive procedures, or other actions. Overall, 518 (87.4%) of the recommendations were acted on within the recommended time frame.

After future review by quality expert reviewers, 31 of the "open loop" cases were deemed to pose substantial clinical risks.

"The findings of this study suggest that no follow-up on action-requiring abnormalities represents an important patient safety and malpractice risk; structured reports may help codify recommended actions and identify lack of follow-up," they wrote.

Delving further into the analysis, the researchers concluded that successful completion of the recommendations was associated with factors such as the following:

  • Absence of accompanying contingency language
  • Shorter recommended time frames
  • Evidence of direct radiologist communication with the ordering primary care physicians (PCPs)

"Although the bulk of published work on improving loop closure in radiology has focused on the neglect to pass information in a timely fashion from the radiologist to referring physician, our findings suggest additional failure modes and areas for improvement, such as including clearer, perhaps less conditional recommendations," the authors wrote.

It's suboptimal to rely on busy primary care physicians to manually track, order, and ensure the scheduling of a follow-up test, the researchers noted.

"Although the relatively high loop closure rate reported herein is a testament to the efforts by PCPs, future work applying a system engineering approach is needed to better understand workload and vulnerable steps in our current systems," the authors wrote.

In addition, more specificity in the recommendations may help close the loop in imaging follow-up recommendations, particularly for recommendations containing often vaguely worded contingencies, according to the authors.

"When faced with such conditional language, more failures occurred in developing a follow-up plan," they wrote. "More explicit recommendations minimizing the use of vague contingencies, such as 'if warranted depending on clinical correlation' as suggested by others, would also facilitate tracking because both existing manual and natural language processing tracking approaches tend to exclude conditional recommendations."

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