Point-of-care access to clinical guidelines may improve management of incidental findings in the primary care setting

Abstract

Rationale: Incidental radiographic findings are common, and primary care providers (PCPs) are often charged with the conducting or initiating an appropriate evaluation. Clinical guidelines are available for management of common 'incidentalomas' including lung and adrenal nodules, but guidelines-adherent evaluations are not always performed; for example, in the setting of incidental adrenal masses (IAMs), recent literature suggests that an evidence-based evaluation occurs in <25% of patients for whom it is warranted-a quality and safety concern.

Aims and objectives: The objective of this study was to examine whether point-of-care access to concise clinical guidelines would promote appropriate evaluations of two common incidentalomas: IAMs and lung nodules.

Method: This study was a survey-based, single-blinded, randomized experiment of decision-making within clinical vignettes. Respondents were PCPs in a variety of clinical practice settings, and half were randomly assigned to surveys that included concise clinical guidelines while the other half served as controls without access to guidelines. Scenarios involved patients with IAMs and lung nodules, and the scenarios included both higher-risk and lower-risk lesions. Our primary analysis examined safe versus inappropriate clinical decisions, while a secondary analysis compared guidelines-concordant versus guidelines-discordant responses.

Results: For both the higher-risk IAM and higher-risk lung nodule scenarios, safe answer choices were selected at a similar rate by respondents regardless of whether they had access to guidelines or not. However, for the lower risk scenarios, inappropriate answer choices were chosen substantially more frequently by respondents without access to guidelines compared to those with the guidelines (lung: 29.3% vs. 4.5%, p = 0.003, adrenal: 31.6% vs. 7.0%, p = 0.01). There was less variation in the secondary analysis.

Conclusion: Survey respondents were significantly more likely to make safe management decisions in lower-risk clinical scenarios when clinical guidelines were available. Point-of-care access to clinical guidelines for incidentalomas is an intervention that may reduce management errors and improve patient safety.

Keywords: adrenal incidentaloma; general surgery; incidental findings; solitary pulmonary nodule.