Optimizing Follow-up of Incidental Findings: A Structured Survey of Primary Care Providers
*Stephanie D Talutis1, *Ellen Childs2, *Philip E Knapp1, *Avneesh Gupta1, *Cleopatra Ferrao1, David McAneny1, *F. Thurston Drake1
1Boston University, Boston, MA;2Boston University School of Public Health, Boston, MA
Objective
Understand management strategies among PCPs for incidental pulmonary nodules (PNs) and adrenal nodules (ANs).
Design
Surveys of practice patterns for incidental PNs/ANs.
Setting
Emailed surveys.
Participants
PCPs.
Interventions
Participants were randomly assigned to a survey +/- guidelines for management of incidentalomas.
Main Outcome Measures
Participants were asked about management strategies and barriers faced, then asked to consider clinical vignettes. Responses were compared between those with/without guidelines.
Results
On average, PCPs encounter 4(SD=6) incidentalomas/month, half from studies ordered by another provider. The most important resources to guide follow-up are radiology report recommendations(PN=80%, AN=74%) and Up-To-Date(PN=59%, AN=65%). While 48% of PCPs had encountered an incidental PN diagnosed as lung cancer, substantially fewer(<10%) had encountered adrenal pathologies among incidental ANs. For PNs, the most significant barrier was insufficient time/support to follow results longitudinally(69%). For ANs, it was uncertainty about tests to order(68%). Themes regarding the "ideal" system: automated report-delivery and follow-up tests, longitudinal tracking tools, "virtual consultations," and decision guides within EMR. Differences between groups with and without guidelines were observed. Access to guidelines was significantly associated with a correct choice among lower-risk AN scenarios; there was little impact for higher-risk scenarios (Table).
Conclusions
PCP input is necessary to design an effective system. Easy access to straightforward clinical guidelines may improve decision-making, especially for lower-risk lesions that still require action. The radiology report is the most utilized source of information guiding next steps. Strategies to improve follow-up must focus beyond simply alerting PCPs and should include decision guides, tracking capabilities, and EMR-integration. 
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