Download Poor Adherence to Radiology Recommendations for Follow

FA IL IN G TO FO L LOW-UP:
P O O R A D H E R E N C E T O R A D I O L O G Y R E C O M M E N D AT I O N S F O R F O L L O W - U P I M A G I N G I N H E A D A N D N E C K C A N C E R
P
AVTI N
I EPNI CTCSO T T ( M D ) , M AT T H E W H . R I G B Y ( M D ) , S M A R K TAY L O R ( M D ) , J O N AT H A N T R I T E S ( M D ) , J E N S H E I D E N R E I C H ( M D ) & R O B E RT H A RT
DE
(MD)
D A L H O U S I E U N I V E R S I T Y, H A L I FA X , N O VA S C O T I A - D E PA RT M E N T O F O TO L A RY N G O L O G Y- H E A D A N D N E C K S U R G E RY
Introduction:
Results:
Demographics:
• Computed Tomography is regularly used in the staging and workup of
patients with suspected head and neck malignancy.
• Often incidental findings are discovered and recommendations are made
for future radiologic follow-up.
• There is no known evidence regarding adherence to follow-up of
radiologist-recommendations in head and neck cancer patients.
• Little is known regarding the impact/outcome of non-adherence to
radiologist recommendations for follow up imaging.
Other Interesting findings
• 11 of 456 patients had suspicious apical chest findings found on their
initial CT neck study
Sex
Average Age 65
Min Age
17
Max Age
103
Females
157
Males
343
Median Age 66
Mode Age
70
https://images.radiopaedia.org/images/1302158/
http://www.diagnijmegen.nl/index.php/Lung_Cancer
N = 456
Results:
456
Included Patients with CT
Neck
Figure 5 - An coronal slice of a CT acquisition with contrast of the neck.The
orange arrow indicates a solid pulmonary nodule.
356
Had CT Chest
Implications & Conclusions:
Figure 1 - An axial slice of a thin-slice CT acquisition (low-dose).The orange arrow
indicates a solid pulmonary nodule.
Clinical Question:
• There is a concern regarding lack of adherence to follow-up
recommendations in head and neck cancer patients.
• In our study, approximately half (52%) of all patients did not receive
appropriate follow-up.
• There is evidence that failing to appropriately follow-up on
recommendations may lead to poor patient outcomes.
• Better systems need to be in place for proper communication and
arrangement of follow up imaging.
122
Had Concerning Findings
When a recommendation is made for future follow-up imagining, how often
does the patient receive appropriate follow up?
• What are the patient outcomes when proper follow up is attained?
• What are the patient outcomes when we fail to follow-up?
13
109
Had recommendation for
future imaging
Had initial malignancy or
no recommendation
Primary outcome:
Adherence to radiologist recommendation within 60 days of the suggested
follow-up period.
Secondary outcome:
Consequences of adherence and non-adherence to follow-up
recommendations.
57 (52%)
Patients did not get follow
up as recommended
52 (48%)
Patients got appropriate
follow up
14 (13%)
Methods:
• A retrospective cohort study of 500 patients the with suspected head
and neck cancer was performed.
• Patients were taken from the Tumor Nova Scotia Board Database
• Patients included were investigated between 2013 and 2015 for
suspected head and neck cancer
• There were no exclusions based on diagnosis, geographic location, etc.
• Electronic medical records were minded for data (SharedPortal, HPF,
Xero, IMPAX and Clinical Portal)
• Radiology reports were reviewed for recommendations and electronic
medical records were analyzed for outcomes. Of the 500 patients
reviewed, 456 met inclusion criteria.
• Reasons for exclusion were incomplete medical records despite
searching all available online databases
• The 456 individuals went through full chart evaluation
Data Analysis:
• Analysis was completed in Microsoft Excel - Version 15.24
• Numerical categorization was completed
• Data could then be sorted for investigations, findings, outcomes, etc.
Received follow up but not within
recommended time frame
• Patient choice is a possible confounder which was not noted to be
documented
• Consciousness decline of further imaging could be possible
• Outcomes cannot imply causation
• No survival data
Future Directions:
Required further follow up imaging (40%)
Concern for malignancy (17%)
Unchanged findings with no
need for future follow up (17%)
Resolution of concerning findings (15%)
Biopsy (10%)
Concern for malignancy (28%)
Required further follow up imaging (28%)
Unchanged findings with no
need for future follow up (21%)
Resolution of concerning findings (21%)
Unknown Outcome (88%)
Died (12%)
Second stage study
• Implementing a check sheet for all tumor board patients to prompt
further imaging requirements
• Determining efficacy and prompts at initiating follow up
• Determining similar outcomes including survival data
Figure 3 – Breakdown of imaging attained, radiologist recommendation and outcome of follow up or lack thereof
109 (of 356)
Had recommendation for
future imaging
References:
• Hanna, T. N., Shekhani, H., Zygmont, M. E., Kerchberger, J. M., & Johnson, J. O. (2016). Incidental findings in emergency imaging: Frequency,
recommendations, and compliance with consensus guidelines. Emergency Radiology, 23(2), 169-174. doi:10.1007/s10140-016-1378-1 [doi]
• Hsu,Y. B., Chu, P.Y., Liu, J. C., Lan, M. C., Chang, S.Y., Tsai, T. L., . . . Tai, S. K. (2008). Role of chest computed tomography in head and neck cancer. Archives
of Otolaryngology--Head & Neck Surgery, 134(10), 1050-1054. doi:10.1001/archotol.134.10.1050 [doi]
• Karl, A., Adejoro, O., Saigal, C., Konety, B., & Urologic Diseases in America Project. (2014). General adherence to guideline recommendations on initial
diagnosis of bladder cancer in the united states and influencing factors. Clinical Genitourinary Cancer, 12(4), 270-277. doi:10.1016/j.clgc.2013.11.003
[doi]
8 (7.3%)
Radiology booked imaging follow
up
• Loh, K. S., Brown, D. H., Baker, J. T., Gilbert, R. W., Gullane, P. J., & Irish, J. C. (2005). A rational approach to pulmonary screening in newly diagnosed head
and neck cancer. Head & Neck, 27(11), 990-994. doi:10.1002/hed.20261 [doi]
• Madana, J., Morand, G. B., Barona-Lleo, L., Black, M. J., Mlynarek, A. M., & Hier, M. P. (2015). A survey on pulmonary screening practices among
otolaryngology-head & neck surgeons across canada in the post treatment surveillance of head and neck squamous cell carcinoma. Journal of
Otolaryngology - Head & Neck Surgery = Le Journal d'Oto-Rhino-Laryngologie Et De Chirurgie Cervico-Faciale, 44, 5-015-0057-7. doi:10.1186/s40463-0150057-7 [doi]
• Prabhakar, A. M., Le, T. Q., Abujudeh, H. H., & Raja, A. S. (2015). Incidental findings and recommendations are common on ED CT angiography to
evaluate for aortic dissection. The American Journal of Emergency Medicine, 33(11), 1639-1641. doi:10.1016/j.ajem.2015.07.078 [doi]
3 (37.5%)
Did not receive appropriate
follow up
Figure 2 – An example for the data analysis and formatting
43 (39%)
Did not receive any
radiologic follow up
Limitations:
5 (62.5%)
Received appropriate follow
up
Figure 4 – Rate at which appropriate follow up was attained when follow up was booked immediately by radiology
• Rusner, C., Stang, A., Dieckmann, K. P., & Friedel, H. (2013). Frequency of computed tomography examinations in the follow-up care of testicular cancer
patients - an evaluation of patterns of care in germany. Onkologie, 36(4), 188-192. doi:10.1159/000349952 [doi]
• Wickramarachchi, B. N., Meyer-Rochow, G.Y., McAnulty, K., Conaglen, J. V., & Elston, M. S. (2016). Adherence to adrenal incidentaloma guidelines is
influenced by radiology report recommendations. ANZ Journal of Surgery, 86(6), 483-486. doi:10.1111/ans.12799 [doi]
• You, J. J., Laupacis, A., Newman, A., & Bell, C. M. (2010). Non-adherence to recommendations for further testing after outpatient CT and MRI. The
American Journal of Medicine, 123(6), 557.e1-557.e8. doi:10.1016/j.amjmed.2009.11.018 [doi]