White Paper: Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging

Key Words Incidental findings; best practices; quality improvement Abstract Purpose Actionable incidental findings (AIFs) are common in radiologic imaging. Imaging is commonly performed in emergency department (ED) visits, and AIFs are frequently encountered, but the ED presents unique challenges for communication and follow-up of these findings. The authors formed a multidisciplinary panel to seek consensus regarding best practices in the reporting, communication, and follow-up of AIFs on ED imaging tests. Methods A 15-member panel was formed, nominated by the ACR and American College of Emergency Physicians, to represent radiologists, emergency physicians, patients, and those involved in health care systems and quality. A modified Delphi process was used to identify areas of best practice and seek consensus. The panel identified four areas: (1) report elements and structure, (2) communication of findings with patients, (3) communication of findings with clinicians, and (4) follow-up and tracking systems. A survey was constructed to seek consensus and was anonymously administered in two rounds, with a priori agreement requiring at least 80% consensus. Discussion occurred after the first round, with readministration of questions where consensus was not initially achieved. Results Consensus was reached in the four areas identified. There was particularly strong consensus that AIFs represent a system-level issue, with need for approaches that do not depend on individual clinicians or patients to ensure communication and completion of recommended follow-up. Conclusions This multidisciplinary collaboration represents consensus results on best practices regarding the reporting and communication of AIFs in the ED setting. Author Affiliation: (a) Section of Emergency Ultrasound, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut (b) Independent Consultant, Pheonixville, Pennsylvania (c) Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania (d) Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado (e) Vice Chair of Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut (f) Vice President, Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York; and Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York (g) University of Rochester Medical Center, Rochester, New York (h) Chair, ACR Incidental Findings Steering Committee; Chair, ACR Appropriateness Criteria Expert Panel on Obstetrical and Gynecological Imaging; Associate Chair of Population Health Imaging and Outcomes, Department of Radiology, Department of Population Health, Grossman School of Medicine, New York University, New York, New York (i) Department of Emergency Medicine, Ridgeview Medical Center, Waconia, Minnesota (j) Department of Diagnostic Radiology, Einstein Healthcare Network, Philadelphia Pennsylvania (k) Chief Medical Information Officer, Advent Health Central Florida Division, Orlando, Florida (l) Department of Emergency Medicine, College of Physicians and Surgeons, Columbia University, New York, New York (m) Hackensack Radiology Group, River Edge, New Jersey; Clinically Integrated Network Board and Finance Chair, Hackensack Meridian Health Partners; Chief Medical Officer, Neutigers; and Economics Chair, ACR Board of Chancellors (n) CEO, Triad Radiology Associates, Winston-Salem, North Carolina; ACR Board of Chancellors; Chair, ACR Reimbursement Committee; and Chair, ACR MACRA Committee * Corresponding author and reprints: Christopher L. Moore, MD, Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 273, New Haven, CT 06519. (footnote) This project was not directly funded but did receive support from the staff of the ACR in helping build, disseminate, and collate survey responses. Both the ACR and the ACEP supported the project through nomination of panel members. Dr Kang receives royalties from Wolters Kluwer, an honorarium from the ARRS for journal editorial work, and an honorarium for education from the RSNA. Dr Nicola is a shareholder in Neutigers and Voxelcloud and is a consultant for Guidepoint, and his practice is a shareholder in Sirona Medical. All other authors state that they have no conflict of interest related to the material discussed in this article. Drs Larson, Nicola, and Parks Nicola are partners; and the other authors are non-partner/non-partnership track/employees. Byline: Christopher L. Moore, MD [chris.moore@yale.edu] (a,*), Andrew Baskin, MD (b), Anna Marie Chang, MD, MSCE (c), Dickson Cheung, MD, MBA, MPH (d), Melissa A. Davis, MD, MBA (e), Baruch S. Fertel, MD, MPA (f), Kristen Hans, RN, MS (g), Stella K. Kang, MD, MSc (h), David M. Larson, MD (i), Ryan K. Lee, MD, MBA (j), Kristin B. McCabe-Kline, MD (k), Angela M. Mills, MD (l), Gregory N. Nicola, MD (m), Lauren P. Nicola, MD (n)