ACR Members' Response to JACR White Paper on the Management of Incidental Abdominal CT Findings

doi:10.1016/j.jacr.2013.06.002

Journal of the American College of Radiology

Volume 11, Issue 1, January 2014, Pages 30-35

https://doi.org/10.1016/j.jacr.2013.06.002 Get rights and content

Purpose

In October 2010, a white paper was published in this journal that represented a consensus of the ACR Incidental Findings Committee, including guidance for characterizing, reporting, and managing incidental findings in the liver, kidneys, adrenal glands, and pancreas. A survey was conducted of the ACR membership to determine how widely this paper had been read, how the information is being used, and how management of incidental findings may be improved.

Methods

A survey consisting of 14 multiple-choice and 5 free-text responses was distributed by e-mail to 14,336 ACR physician members. The survey was open during June and July 2012 using SurveyMonkey. Topics included how the paper's recommendations had affected practice and the frequency of recommendations for additional imaging, how incidental findings are reported, the content and the form of the white paper, and the possible effects of tort reform.

Results

Of the 14,336 radiologists contacted, 2,892 (20%) returned the survey; of these, 1,099 (38%) indicated that they had read the paper. Of the 1,099 radiologists who read the paper, 978 (89%) responded that the content was used in clinical practice. The white paper led 560 radiologists (51%) to recommend additional imaging less often and 33 radiologists (3%) to recommend imaging more often. Tort reform was cited by 835 radiologists (76%) as a means to decrease the likelihood of their recommending additional imaging.

Conclusions

The 2010 JACR white paper on incidental abdominal CT findings has been read by a substantial number of radiologists, and among those who read it, the recommendations are being largely followed and are leading to a reduction in imaging recommendations. Future similar consensus-based white papers could lead to more consistent and effective management of incidental imaging findings and likely reduce the overall number of patients for whom additional imaging is recommended.

Introduction

The high frequency of incidental findings (IFs) has caused consternation among radiologists and referring clinicians [1, 2]. Practitioners are aware that important, treatable conditions may occasionally be discovered, but they also appreciate that most of these findings are unimportant and may lead to additional testing and procedures that carry some risk to patients and an increase in health care costs. One response to the challenge of IFs has been to develop consistent recommendations on how to manage such findings. A white paper on abdominal IFs was published in JACR^® in October 2010 [3]. The paper addressed IFs in the kidneys, liver, adrenal glands, and pancreas and offered a literature-derived, consensus-based set of management recommendations. These were intended to be medically appropriate, while acknowledging the desire to reduce testing for findings that have an extremely high likelihood of being unimportant. At the time of publication, this white paper was listed on JACR's website as the most read paper in the journal.

The chair and 3 of the subcommittee chairs of the ACR Incidental Findings Committee, which was responsible for the development of the white paper, thought that it would be useful to determine how the recommendations in the paper have been applied in clinical practice. With the assistance of ACR staff members, a survey of the ACR membership was performed to determine how widely this paper had been read, how the information is being used, and how the management of IFs may be improved.

Section snippets

Methods

A survey was composed by the authors and ACR staff members, then reviewed, revised, and approved for distribution by the ACR. An e-mail message sent on June 15 and 16, 2012, to 14,336 regular physician members of the ACR included a link to respond using SurveyMonkey (SurveyMonkey.com, Palo Alto, California). Two reminder e-mail notices were sent subsequently, and the survey was closed to further respondents on July 23, 2012. Respondents were asked to reply to up to 14 multiple-choice questions

Results

Of the 14,336 radiologists surveyed, 2,892 (20%) responded. Of those who responded, 526 (18%) had <10 years of experience after residency, 993 (34%) had 10 to 20 years, and 1,373 (48%) had >20 years. Among all respondents, 2,032 (70%) were in private practice, 705 (25%) in academic practice, and 155 (5%) in “other” types of practice or were not active. There were respondents from all 50 states, the District of Columbia, and other territories of the United States and 31 respondents from outside

Discussion

The burgeoning use of medical imaging coupled with the increased spatial and contrast resolution of imaging modalities has resulted in the detection of myriad findings in virtually every organ system that are both unrelated to patients' presenting symptoms and pose no harm. Although the incidentaloma conundrum has been known for many years [8, 9], there has been a paucity of studies on the subject. As a result, many radiologists have established their own independent, often subjective and

Take-Home Points

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A substantial number of radiologists who read the ACR Incidental Findings Committee white paper use it in clinical practice and apply its recommendations.
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Radiologists who read the white paper indicated that they recommend imaging for IFs less often than those who did not.
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Radiologists who read the white paper were more likely to report an IF that was highly likely to be benign as “likely benign,” whereas those who had not read the paper were more likely to recommend additional imaging.
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Most

Acknowledgment

We thank David Kurth of the ACR, who assisted in the development and distribution of this survey.

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Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis
2022, Annals of Emergency Medicine
Citation Excerpt :
Notably, the American College of Radiology Incidental Findings Committee has published white papers with formal recommendations for reporting incidental findings across a broad spectrum of findings, which have often included detailed workflows for the timing and modalities of additional testing based on the radiographic features of a specific finding.81-83 However, these standards have not been uniformly adopted among radiologists, may include follow-up studies that are often not feasible in the ED setting, and have proven challenging to effectively communicate between radiologist and emergency physician workflows.84,85 Our review identified 5 studies that were performed in trauma centers and aimed at increasing the recognition of incidental findings in radiology reports and improving patient notification.
An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings.
On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis.
A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED.
In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.
Incidental liver lesions seen on Breast MRI: When is additional imaging warranted?
2017, European Journal of Radiology
Citation Excerpt :
However, no previous studies have correlated lesion characteristics with final lesion diagnosis. The American College of Radiology (ACR) has published guidelines for the management of incidental liver masses identified on CT and ultrasound [10–13]; however, no such guidelines exist for liver lesions identified on MRI. The analysis of incidental liver lesions detected during breast MR examinations can be complicated by the fact that lesions may not be identified on all sequences, rendering lesion characterization incomplete.
Incidental hepatic lesions identified on breast MR can be a diagnostic dilemma due to concern for liver metastases or other significant hepatic lesions. The purpose of this study was to identify the incidence and nature of liver lesions seen on breast MR, and determine if additional imaging is necessary.
Imaging reports of all breast MR examinations performed at our institution from January 1, 2010 to December 31, 2011 were reviewed to identify reports with hepatic abnormalities. Lesion characteristics, subsequent diagnosis, duration of follow up and additional imaging results (if performed) were all recorded.
Of 1664 breast MRs, incidental hepatic lesions were seen in 207 studies (12.4%) in 169 patients. In 154 of 169 patients (91.1%) the lesions were characterized as T2 hyperintense and clearly as bright as adjacent fat on T2-weighted or localizer sequences. 0 of these 154 lesions were clinically significant at clinical or radiological follow-up. In the remaining 8.9% (15 of 169), lesions were characterized as not as bright as adjacent fat on T2 weighted or localizer imaging. In two cases, lesions were confirmed as incidental hepatic metastatic disease.
91.1% of incidental hepatic lesions were circumscribed, T2 hyperintense lesions and characterised as clearly as bright as adjacent fat on T2 weighted imaging at additional review. None of which were clinically significant at clinical or radiological follow-up. We advocate that circumscribed T2 hyperintense lesions which are clearly as bright as adjacent fat on T2 weighted imaging are of unlikely clinical significance and follow-up imaging should not be recommended, reducing the rate of additional imaging from 37.3% to 5.3%.
Creation of an Open Framework for Point-of-Care Computer-Assisted Reporting and Decision Support Tools for Radiologists
2017, Journal of the American College of Radiology
Decreasing unnecessary variation in radiology reporting and producing guideline-concordant reports is fundamental to radiology’s success in value-based payment models and good for patient care. In this article, we present an open authoring system for point-of-care clinical decision support tools integrated into the radiologist reporting environment referred to as the computer-assisted reporting and decision support (CAR/DS) framework. The CAR/DS authoring system, described herein, includes: (1) a definition format for representing radiology clinical guidelines as structured, machine-readable Extensible Markup Language documents and (2) a user-friendly reference implementation to test the fidelity of the created definition files with the clinical guideline. The proposed definition format and reference implementation will enable content creators to develop CAR/DS tools that voice recognition software (VRS) vendors can use to extend the commercial tools currently in use. In making the definition format and reference implementation software freely available, we hope to empower individual radiologists, expert groups such as the ACR, and VRS vendors to develop a robust ecosystem of CAR/DS tools that can further improve the quality and efficiency of the patient care that our field provides. We hope that this initial effort can serve as the basis for a community-owned open standard for guideline definition that the imaging informatics and VRS vendor communities will embrace and strengthen. To this end, the ACR Assist™ initiative is intended to make the College's clinical content, including the Incidental Findings Committee White Papers, available for decision support tool creation based upon the herein described CAR/DS framework.
Focal Cystic Pancreatic Lesion Follow-up Recommendations After Publication of ACR White Paper on Managing Incidental Findings
2017, Journal of the American College of Radiology
Citation Excerpt :
The objectives of the 2010 incidental findings White Paper included reducing unnecessary examinations and achieving greater consistency in recognizing, reporting, and managing incidental findings [12]. It was the most read article at the time on the JACR’s website [13], suggesting that its information was widely disseminated among the radiology community. The White Paper’s authors state that a substantial majority (89%) of their respondents report having used the recommendations.
To describe the variation in radiologists’ follow-up recommendations for focal cystic pancreatic lesions (FCPL) after publication of the 2010 ACR incidental findings White Paper and determine adherence to guidance of the ACR Incidental Findings Committee.
Institutional Review Board approval was obtained for this retrospective, HIPAA-compliant observational study. Patients with FCPL were identified from abdominal CT and MRI reports generated in 2013 using natural language processing software. Patient-, lesion-, and radiologist-specific variables were recorded. Primary outcome was whether a follow-up recommendation was made, and if it included a specific study or intervention and recommended time for follow-up. χ² and logistic regression models were used to identify predictors and controlled for recommendation. These data were compared with 2009 data obtained before the White Paper’s publication. Secondary outcome was adherence to the ACR’s guidance.
During calendar year 2013, 1,377 reports describing FCPLs were identified in 1,038 patients. After excluding examinations from low-volume readers (n = 80), radiologists recommended follow-up imaging in 13.5% (175/1,297) of cases, a decrease from 2009 when it was recommended in 23.7% (221/933) of cases (P < .001). Findings were consistent across radiologists after controlling for patient- and lesion-specific variables. Variability in follow-up recommendations persists between radiologists (2.4-fold difference in 2013 versus 2.8-fold difference in 2009). Radiologists adhered to ACR guidance principles 47.4% of the time.
Despite published guidance recommendations and reported awareness of them, fewer than half of follow-up recommendations for FCPL are consistent with the guidance and considerable variability persists among radiologists.
Editorial Comment
2017, Journal of Urology
Point-of-Care Reference Materials Increase Practice Compliance With Societal Guidelines for Incidental Findings in Emergency Imaging
2016, Journal of the American College of Radiology
Citation Excerpt :
However, some of the variability may be attributed to guideline ambiguity and calling for clinical judgement in certain cases. Berland et al [31] surveyed radiologists on their use of the ACR white paper for incidental abdominal findings and found that respondents prefer clearer definitions of certain diagnostic criteria, such as what determines limited life expectancy. Management of IFs may be of limited utility in the context of other clinical factors such as terminal illness, and appropriate follow-up may be difficult to determine without further history.
The aim of this study was to assess the efficacy of an educational framework encouraging the systematic application of national societal recommendations regarding the imaging evaluation and follow-up of incidental findings (IFs) in the emergency department.
After institutional review board approval was received, consecutive CT and ultrasonographic examinations from the emergency department over a 2-month period were collected. Examination reports were categorized by study type and evaluated individually for the presence of IFs that fit into the following core categories: solid or subsolid pulmonary nodules, liver lesions, splenic lesions, gallbladder polyps, pancreatic cystic lesions, adrenal nodules, adnexal cysts on CT or ultrasonography, thyroid nodules (CT), and abnormal lymph nodes. Subsequently, after an educational intervention consisting of printed and electronic references, e-mail, and verbal communication detailing societal guidelines and the introduction of voice recognition macros, data were recollected in the same fashion for an additional 2-month period.
A total of 3,131 imaging events occurred in the 2-month preintervention period, yielding 514 total incidental findings. Of these 514 findings, 67.5% were correctly managed and 32.5% were incorrectly managed according to societal recommendations. In the postintervention period, 3,793 imaging events yielded 499 total incidental findings. Of these 499 findings, 80.2% were correctly managed and 19.8% were incorrectly managed. The increased rate of reporting incidental findings in concordance with societal guidelines was statistically significant (P < .0001).
Point-of-care decision support reference materials increase radiologist compliance with societal guidelines for incidental findings. Compliance with societal guidelines improves patient care and has cost-saving implications.

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: Dr Berland is chair of the ACR Incidental Findings Committee and vice chair of the ACR Body Imaging Commission. Drs Silverman, Megibow, and Mayo-Smith are chairs of the renal, pancreatic, and adrenal subcommittees of the ACR Incidental Findings Committee, respectively.

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Original articleACR Members' Response to JACR White Paper on the Management of Incidental Abdominal CT Findings

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Take-Home Points

Acknowledgment

Radiol Clin North Am

J Am Coll Radiol

Endocr Pract

Endocr Pract

J Am Coll Radiol

J Am Coll Radiol

J Am Coll Radiol

Incidental findings in imaging diagnostic tests: a systematic review

Br J Radiol

Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?

Eur J Endocrinol

Original article
ACR Members' Response to JACR White Paper on the Management of Incidental Abdominal CT Findings