Unnecessary adnexal lesion follow-ups eliminated

A quality improvement initiative reduced unnecessary imaging referrals for adnexal lesions by a team of researchers at the Virginia Mason Medical Center, according to a study published online Oct. 18 in the Journal of the American College of Radiology.

Pelvic ultrasonography is the imaging modality most often used for the evaluation of gynecologic symptoms and abnormalities. Adnexal cysts are common findings in pelvic ultrasound exams, leading to follow-ups that are generally unnecessary because many of these lesions are usually physiologic or benign.

“Overuse of medical imaging is a major component of increasing healthcare costs in the United States. An estimated 35 percent of all advanced imaging studies may be unnecessary causing potential harm to patients by leading to unnecessary treatment,” wrote Jamie S. Hui, MD, of the Virginia Mason Medical Center, and colleagues.

Lack of consistent management criteria caused a decline in the quality of imaging services, an increase in patient anxiety, unneeded additional imaging, unnecessary gynecologic referrals and unwarranted clinical or surgical management at the medical center. Recognizing the important quality concern that results from the variability in ultrasound reporting of adnexal cysts, Hui and colleagues designed a five-year prospective cohort study composed of two interventions and three data collection periods to spearhead a quality improvement initiative.

The first intervention was heavily academic, in which ultrasound radiologists and sonographers were educated about the unnecessary follow-ups for physiologic or benign adnexal lesions. A quiz with ultrasound adnexal cases also was distributed to the ultrasound radiologists.

The second intervention consisted of the implementation of a national consensus guideline on adnexal cysts known as the Society of Radiologists in Ultrasound (SRU) Consensus statement white paper.

All pelvic ultrasound radiology reports were retrospectively reviewed, examining each adnexal lesion’s sonographic characteristics, clinical impressions of etiology and imaging follow-up or recommendations over the data collection period.

After the first intervention, the proportion of exams with adnexal lesions had decreased but not by a statistically significant amount.

The second intervention demonstrated a statistically significant decrease in follow-up recommendations with an increase in the number of lesions described as physiologic or benign. Though overall the proportion of adnexal lesions remained stable over the three data collection periods, there was a 58 percent decline in the percentage of patients with unnecessary follow-up recommendations.

“This reduction implies that radiologists are able to confidently characterize more adnexal lesions as physiologic or benign,” wrote Hui and colleagues. “By accepting a standard sonographic imaging reporting process, we reduce variability and thereby improve the quality of our reports.”

The study’s combination of education with other types of intervention demonstrated a significant improvement in results. Three components contributed to the effectiveness of education, including the acceptance of the external expert consensus guideline by the radiologists, the distribution of image-rich charts that reinforced learning and active engagement of radiology attendings, residents and sonographers in daily discussions and conferences.

“We have demonstrated that elimination of some unnecessary imaging is under the control of the radiologist in the reporting of radiologic findings and the making of recommendations,” wrote Hui and colleagues. “By reducing unnecessary imaging at our institution, we have contributed to reducing unnecessary patient anxiety, additional medical intervention and cost.”