Bates Ruth, Plooster Corbin, Croghan Ivana, Schroeder Darrell, McCoy Christopher
Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Clinical Research Office, Clinical Trials Unit, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
J Hosp Med. 2017 Jun;12(6):454-457. doi: 10.12788/jhm.2757.
Incidental imaging findings require an assessment of risk and clinical relevance, as well as consideration of further evaluation. Incidental findings are common on imaging obtained in the hospital, with pulmonary nodules being among the most frequent findings that may require additional evaluation. We conducted a retrospective study to determine the factors associated with documentation of incidental findings in the hospital discharge summary, using pulmonary nodules reported on abdominal computed tomography (CT) as an example of incidental findings with well-defined follow-up guidelines. Between January 1, 2012 and December 31, 2014, 7173 patients underwent in-patient abdominal CT without concurrent chest CT; of these patients, 62.2% were ≥60 years old, 50.6% were men, and 45.5% were current or former smokers. Incidental pulmonary nodules were reported in 402 patients (5.6%; 95% confidence interval [CI], 5.1%-6.2%). Based on nodule size, reported size stability, and patients' smoking status, 208 patients (2.9%; 95% CI, 2.5%-3.3%) required follow-up surveillance, per the 2005 Fleischner Society guidelines. Of these 208 patients, 48 (23%) received discharge summaries that included documentation of the incidental findings, with 34 summaries including a recommendation for nodule follow-up and 19 summaries including a time frame for repeat CT. Three factors were positively associated with the inclusion of the pulmonary nodule in the discharge summary: mention of the pulmonary nodule in the summary headings of the radiology report (P ≤ 0.001), radiologist recommendations for further surveillance (P ≤ 0.001), and medical discharging service (P = 0.016). These findings highlight the need for a multidisciplinary systems-based approach to incidental pulmonary nodule documentation and surveillance. Journal of Hospital Medicine 2017;12:454-457.
偶然发现的影像学结果需要对风险和临床相关性进行评估，并考虑进一步评估。偶然发现的情况在医院进行的影像学检查中很常见，肺结节是最常见的可能需要进一步评估的发现之一。我们进行了一项回顾性研究，以确定与医院出院小结中偶然发现的记录相关的因素，以腹部计算机断层扫描（CT）报告的肺结节为例，其具有明确的随访指南。在2012年1月1日至2014年12月31日期间，7173例患者接受了住院腹部CT检查，未同时进行胸部CT检查；在这些患者中，62.2%年龄≥60岁，50.6%为男性，45.5%为当前或既往吸烟者。402例患者（5.6%；95%置信区间[CI]，5.1%-6.2%）报告有偶然发现的肺结节。根据结节大小、报告的大小稳定性和患者的吸烟状况，按照2005年弗莱施纳学会指南，208例患者（2.9%；95%CI，2.5%-3.3%）需要进行随访监测。在这208例患者中，48例（23%）的出院小结中包含了偶然发现的记录，其中34份小结包括了结节随访的建议，19份小结包括了重复CT检查的时间框架。有三个因素与出院小结中包含肺结节呈正相关：放射学报告小结标题中提及肺结节（P≤0.001）、放射科医生建议进一步监测（P≤0.001）和医疗出院服务（P = 0.016）。这些发现强调了需要一种基于多学科系统的方法来记录和监测偶然发现的肺结节。《医院医学杂志》2017年；12:454-457。
