When referring physicians agree with radiologists’ recommendations on the clinical necessity of follow-up imaging, three-quarters of patients go on to complete the additional exam.
Of the 25% who fail to follow through, most live in low-income neighborhoods. However, other significant predictors of patient non-completion include receiving the instructions while in the ED or upon hospital inpatient discharge and, curiously, having a surgical specialist as the referrer.
These are among the key findings to emerge from a study conducted by Harvard researchers at Brigham and Women’s Hospital. The American Journal of Roentgenology published the team’s report online Oct. 26.
Corresponding author Neena Kapoor, MD, and colleagues reviewed records from a closed-loop communications and tracking tool embedded in the PACS and EHR.
The tool included a communications component that asked referrers to indicate whether they agreed or disagreed on the clinical necessity of follow-up imaging as recommended by radiologists.
When radiologist/referrer agreement was present, the tracker alerted a “safety net” team if the patient had not been imaged within a month of a target period.
The digital monitoring system also included an EHR review to check on possible follow-through at or outside Brigham and Women’s after the 1-month window.
Way to Address Disparities, Reduce Missed and Delayed Diagnoses
Kapoor and co-authors report that, of 5,856 radiologist recommendations entered during the study period, 4,881 (around 80%) met with referrer agreement.
This dataset made up the study sample, as the researchers omitted cases in which referrers bypassed radiologist recommendations and unilaterally deemed follow-up imaging clinically unneeded.
Of the 4,881 agreed-upon sets of follow-up imaging instructions, 3,651 (74.8%) resulted in completed exams.
Further, the authors report, independent predictors of lower likelihood of follow-up imaging completion included
- living in a socioeconomically disadvantaged neighborhood (odds ratio 0.67),
- inpatient (odds ratio 0.25) or emergency department (odds ratio 0.09) care setting, and
- referrer surgical specialty (odds ratio 0.70).
Here Kapoor and colleagues write that quality-improvement initiatives should “target these identified factors to address disparities in receipt of clinically necessary follow-up testing and thereby reduce missed and delayed diagnoses.”
Interpreting Outliers
Commenting on the lower completion rates among inpatients and ED patients, the authors note the challenges inherent in coordinating follow-up care even for patients who have documented primary care providers.
As for the association between surgical referrers and suboptimal rates of follow-up imaging completion, Kapoor and co-authors surmised these referrers may be less likely to order follow-up testing for imaging findings that don’t pertain to the reason for the surgical consult.
Interestingly, failing to register as independent predictors of follow-up completion in the present study were patient age, race and ethnicity, primary language and insurance status.
Referrer Agreement—or Lack Thereof—a Source of Important Feedback
In their discussion, Kapoor et al. comment that failure to comply with physicians’ instructions for follow-up diagnostic testing can lead to patient harm—but that doesn’t mean referrers should rubber-stamp radiologists’ recommendations.
In the present study, referrers deemed just under 20% of radiologist recommendations unnecessary, which may reflect the role of “explicit referrer input” vis-à-vis radiologist recommendations, the authors write.
“Referrers have additional patient information that is not available to radiologists,” they point out.
Kapoor and colleagues acknowledge that the particular closed-loop tracking tool they used may not be adoptable in provider organizations with varying IT infrastructures.
“Nonetheless, based on the current observations, we suggest that comparable tracking systems at other institutions incorporate referrer feedback regarding the need for radiologist-recommended follow-up imaging to avoid contributing to obtaining follow-up imaging examinations that may in fact be unnecessary,” they write before adding:
[T]he referrer’s agreement or lack thereof could serve as important feedback for radiologists and may ultimately improve the quality of radiologists’ subsequent recommendations.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.