No one has quantified just how much of a risk these unacknowledged recommendations are to patient health, said presenter Dr. Alexander Norbash of the University of California, San Diego. So he and colleagues conducted a study that explored how many radiologist recommendations were not followed during one month at Boston Medical Center.
"We wanted to find out how many radiology results do not reach our patients, and how many of these missed recommendations could result in harm," he said. "And we wondered whether our data would support investing in tools that close communication gaps between radiologists, referring providers, and patients."
In September 2015, the Institute of Medicine released a report on diagnostic errors in healthcare, specifically mentioning the issue of diagnoses from specialties such as radiology not being incorporated into a patient's medical management.
To investigate the problem specifically at Boston Medical Center, Norbash's team conducted a retrospective review of the center's radiology reports from January 2014. The group flagged any report that included a recommendation, categorized those recommendations, and reviewed patient charts to determine whether a recommendation had been recognized, followed, or not followed. Finally, the group assessed the potential for harm represented by those recommendations that were not followed or acknowledged.
The study included 6,861 reports, with 982 recommendations. In all, 13% of the reports had at least one follow-up recommendation, including the following:
- Additional imaging (63%)
- Clinical correlation (24%)
- Nonimaging procedures (7%)
- Laboratory studies (4%)
- Consultation with a specialist (2%)
The good news? The majority (67%) of the recommendations were followed and noted, Norbash and colleagues found. But of those recommendations that were not followed, 40% were never acknowledged, 35% were acknowledged but the patient was lost to follow-up, 19% became unnecessary, and 6% were decided against by the physician.
How harmful to patient health were the unacknowledged recommendations? Of these, 44% had significant potential for harm, with 75% indicating possible cancer (primarily lung) and 25% indicating findings that could lead to patient morbidity, the group found.
"There's significant risk to patients of cancer or other morbidity related to radiology recommendations," Norbash said. "The main concern is radiology recommendations that are not acknowledged by clinicians."
Investing in information technology tools and radiology staff dedicated to communicating and tracking radiology recommendations could minimize the risks posed by the ones that aren't followed, according to Norbash and colleagues. But hospital administrators may be reluctant to commit to these investments if the risks aren't clear -- which is why the researchers hope that their peers will investigate the rate of recommendation follow-through at their own institutions.
"Our data have prompted an extensive evaluation of software and staffing solutions for radiology at Boston Medical Center that may also apply to other diagnostic specialties, like laboratory medicine," Norbash said. "We hope our findings serve as a point of reference for others who are embarking on similar efforts."
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