CT angio in an academic ED: So many incidental findings, too few follow-ups

Emergency physicians at one large teaching hospital performed 370 computed tomography angiography (CTA) exams for suspected aortic dissection in calendar year 2014. Almost 89 percent came back with at least one incidental finding. More than one-fourth were deemed clinically significant.

No major surprises there, but the ED docs recommended further imaging for 106 of the patients based on the CTA results—and of these only 28.3 percent, 30 patients, were followed by referring physicians.

The authors of the study that crunched the numbers point out that these percentages reinforce previous calls for EDs to develop and maintain follow-up mechanisms so that patients who come in for one serious problem don’t fall through the proverbial cracks with another.

Led by Anand Prabhakar, MD, a cardiovascular and emergency radiologist at Massachusetts General Hospital, the study’s authors found the most common incidental findings to be aspiration/pneumonia (9.7 percent), pleural effusion (7.6 percent) and pericardial effusion (4.3 percent).

None of these is as urgent as aortic dissection itself, but the findings are of concern because emergency physicians “are not typically able to follow up on these non-emergent incidental findings, as they do not have a longitudinal relationship with the patient being evaluated,” the study authors write.

“This emphasizes the importance of appropriate imaging in these patients,” they add, “and the availability of a system to ensure that appropriate follow-up imaging is arranged for patients initially imaged in the ED.”

Prabhakar and colleagues note that appropriate ordering of imaging has become a key part of the national conversation on priorities in medicine.

Suggesting that the momentum bodes well for improvement vis a vis incidental findings made with CTA in the ED, they cite the American Board of Internal Medicine’s Choosing Wisely campaign as well as the American College of Radiology Appropriateness Criteria.

Since the completion of the study, they write, the relevant clinical departments have worked to reinforce such sources of guidance on appropriateness of imaging while also implementing decision-support tools.

The study posted July 29 in the American Journal of Emergency Medicine. Click here to read it in full.