1. Failing to Follow-Up: Poor adherence to radiology recommendations for follow-up imaging in head and neck cancer patients
Devin Piccott (MD), Matthew H. Rigby (MD), S Mark Taylor (MD), Jonathan Trites(MD), Jens Heidenreich (MD) & Robert Hart (MD)
Dalhousie University, Halifax, Nova Scotia - Department of Otolaryngology- Head and Neck Surgery
Introduction:
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.
Demographics:
Results:
Other Interesting findings
11 of 456 patients had suspicious apical chest findings found on their initial CT neck study
Average Age 65
Min Age 17
Max Age
Median Age 66
Mode Age
Females
157
Males
343
N = 456
456 Included Patients with CT Neck
356
Had CT Chest
122
Had Concerning Findings
109
Had recommendation for future imaging
52 (48%)
Patients got appropriate follow up
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%)
57 (52%)
Patients did not get follow up as recommended
14 (13%)
Received follow up but not within recommended time frame
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%)
43 (39%) Did not receive any
radiologic follow up
Unknown Outcome (88%)
Died (12%) 13
Had initial malignancy or no recommendation
Results:
Figure 5 - An coronal slice of a CT acquisition with contrast of the neck. The orange arrow indicates a solid pulmonary nodule.
Implications & Conclusions:
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.
Figure 1 - An axial slice of a thin-slice CT acquisition (low-dose). The orange arrow indicates a solid pulmonary nodule.
Clinical Question: 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?
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.
Limitations:
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
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
Future Directions:
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
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), doi: /s [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), doi: /archotol [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), doi: /j.clgc [doi]
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), doi: /hed [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, doi: /s [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), doi: /j.ajem [doi]
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), doi: / [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), doi: /ans [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: /j.amjmed [doi]
109 (of 356)
Had recommendation for future imaging
8 (7.3%)
Radiology booked imaging follow up
5 (62.5%)
Received appropriate follow up
3 (37.5%) Did not receive appropriate follow up
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.
Figure 2 – An example for the data analysis and formatting
Figure 4 – Rate at which appropriate follow up was attained when follow up was booked immediately by radiology