By William Boonn, MD
“Patients are falling through the cracks,” says Dr. Ben Wandtke, Chief of Radiology at the University of Rochester (NY) Health System’s Thompson Hospital, which initiated one of the first tracking programs in the country aimed at reducing the occurrence of failed follow-ups. “This is leading to delayed diagnosis and treatment. Cancers that could have been treated early with good outcomes are progressing to advanced disease and poorer prognosis.”
Failed follow-up is a nationwide problem with profoundly negative consequences in patient outcomes, malpractice claims, and healthcare costs. These concerns have led both doctors and legislators to develop programs to ensure that patients receive needed exam. Doctors at the University of Rochester and at the Penn State Hershey Medical Center have independently launched follow-up tracking programs which use sophisticated software tools to identify follow-up recommendations in radiology reports to alert patients and their physicians when exams are overdue. A new Pennsylvania law – the first such measure in the United States — requires hospitals and imaging providers to notify patients directly when radiology findings warrant follow-up exams.
Incidental Findings Are Common
Radiologists often detect previously undiagnosed cancers and other abnormalities during X-ray, CT, MRI, or ultrasound examinations originally ordered for other reasons. They report these “incidental findings” in about 5% to 30% of cases depending on the type of exam. A common incidental finding is the presence of one or more lung nodules, small round masses seen on chest X-rays and CT scans. These usually are non-cancerous, but some have characteristics indicating that they may progress to lung cancer, the leading cause of cancer deaths in the United States. The radiologist will recommend follow-up chest imaging to monitor those nodules, often in 6 months or a year. If the nodule is unchanged in size it’s likely benign. If it has grown, there is increased likelihood of cancer which warrants additional follow-up.
Failed follow-up is not limited to lung nodules. In a March 2019 study at the Hospital of the University of Pennsylvania, researchers found that up to 60% of emergency department (ED) patients whose abdominal CT scans had incidental findings of possible cancer did not receive follow-up exams within one year.
There are multiple reasons for the disconnect. For example, a patient seen in the ED after an automobile accident may have a chest CT to detect a possible rib fracture or other injury. If the radiologist reports a lung nodule and recommends a follow-up exam in a year, that would typically be ordered and managed by the patient’s primary care physician (PCP). However, there may be gaps in communication between the ED and the PCP, particularly if they are in different health networks or geographical areas. Unfortunately, many patients also do not have PCPs to reach with the results.
Data Analytics Drive Follow-up Tracking
In Rochester, Dr. Wandtke created the multi-phased “Backstop” program to identify and track follow-up recommendations automatically. Radiology staff contact PCPs’ care managers when one month has lapsed from the recommended exam date. The PCP is alerted if the exam is two months overdue, and the patient is contacted directly when it’s 90 days late. Since the program began, the follow-up completion rate for tracked patients rose by 52 percent, and the number of patients at risk for delayed diagnosis dropped by 74 percent.
Dr. Michael Bruno, a radiologist at the Hershey Medical Center, started the “Failsafe” program using software tools primarily for tracking ED patients. If a patient misses their follow-up exam, a member of his team contacts both the PCP and the patient directly. Recent data showed that up to 70% of patients contacted by the Failsafe team were unaware of their incidental findings and follow-up recommendations until they received either a letter or phone call.
Pennsylvania Act 112
Currently, few hospitals around the country have established programs like Backstop and Failsafe. In Pennsylvania, former State Representative Marguerite Quinn drafted legislation requiring all hospitals and imaging centers in the state to notify patients directly when an imaging study identifies significant abnormalities that may require follow-up. Named the “Patient Test Result Information Act” and commonly referred to as Act 112, Quinn’s bill passed nearly unanimously in the Pennsylvania House and Senate and was signed into law in October 2018 by Governor Tom Wolf. It went into effect in December 2018.
“Test results belong to patients and are provided upon request by law,” Quinn said in a statement at the signing. “However, patients should not have to ask for a summary of their results. “Sadly, I personally know two people who would likely be alive today if their results were communicated to them. Both died of cancer, which most likely would have been curable if it had been detected in early diagnostic testing. For whatever reason, these patients were not told of their results following the early testing. Communication of the diagnosis is as important as the diagnosis itself.”
The rapid implementation of Act 112 left hospitals and imaging centers scrambling for solutions to comply. The Pennsylvania Medical Society and the Hospital and Healthsystem Association of Pennsylvania successfully petitioned the state’s Department of Health to delay enforcement for one year to allow systems to be put in place.
Critics of the law believe that it doesn’t go far enough and cite its multiple inclusion and exclusion criteria. For example, it excludes patients examined in the ED. Chest X-rays are also exempted. Further, notifications are required only for follow-up recommendations of 3 months or less while clinical guidelines for lung nodule follow-up are often 6 to 12 months.
Even so, Pennsylvania hospital systems are moving intently to meet or exceed the law’s requirements by the end of 2019. Thomas Jefferson University Hospital was one of the first in the state to fully comply with the law, implementing an automated tracking and notification system in January 2019 . Dr. Adam Flanders, the radiologist who created the program noted, “Although there are flaws with PA Act 112, we are using it as a baseline and have expanded the notification program to include a broader spectrum of patients to ensure that they receive appropriate and timely care.”
Following the Money
Improved follow-up can increase patient safety and wellness while generating financial benefits for hospital systems and imaging centers. In fee-for-service models, improved follow-up rates can boost imaging revenues. At the University of Rochester, the Backstop program resulted in a 4.1x return on the costs of implementing the program. For Accountable Care Organizations or health systems with fixed reimbursements for services, better follow-up can lead to lower costs through earlier detection and treatment compared to the much higher costs for treating advanced stage disease.
Higher follow-up rates also have raised concerns about excessive imaging and increased costs and radiation exposure. The American College of Radiology addresses these concerns with its Appropriateness Criteria — evidence-based guidelines to ensure patients receive the correct imaging study based on their specific clinical scenario.
Sealing The Cracks
The benefits of follow-up tracking programs are evident. In one case in Rochester, an 80-year-old woman went to the ED with shortness of breath. The radiologist’s report on a chest X-ray noted a suspicious lung nodule and recommended a follow-up CT scan. That follow-up was not scheduled at the time. However, instead of the recommendation “slipping through the cracks,” the Backstop program automatically extracted it and alerted the woman’s PCP. Her doctor ordered the exam which detected early-stage lung cancer and resulted in the start of treatment.
Hospital quality improvement programs such as Failsafe and Backstop as well as the Pennsylvania law are helping to seal the cracks and ensure patients receive timely, effective and appropriate care.
William Boonn, MD is Chief Medical Information Officer at Nuance Communications Inc. and a practicing cardiovascular radiologist at the University of Pennsylvania.