Massachusetts Chapter of the American College of Surgeons

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Point-of-care access to clinical guidelines may improve management of incidental findings in the primary care setting
Chandler A. Annesi, BS1, Stephanie D. Talutis, MD, MPH2, Anna L. Goldman, MD, MPA, MPH4,5, Ellen Childs, PhD6, Philip E. Knapp, MD, MS4,5, David McAneny, MD3,4, Frederick Thurston Drake, MD, MPH3,4
1Boston University School of Medicine, Boston, MA, USA; 2University of California Los Angeles, Department of Surgery, Division of Vascular Surgery, Los Angeles, CA, USA; 3Boston University School of Medicine, Department of Surgery, Division of Endocrine Surgery, Boston, MA, USA; 4Boston Medical Center, Boston, MA, USA; 5Boston University School of Medicine, Department of Medicine, Division of Endocrinology, Boston, MA, USA; 6Abt Associates, Rockville, MD, USA

Background: Incidental radiographic findings are common and evaluations are often initiated by primary care providers (PCPs). Clinical guidelines are available for management of common “incidentalomas,” but guideline-adherent evaluations are performed in <25% of patients with incidental adrenal masses(IAMs), an obvious quality and safety concern. Our objective was to examine whether point-of-care access to concise clinical guidelines promotes appropriate evaluations of two common incidentalomas: IAMs and lung nodules.
Methods: Survey-based, randomized experiment of PCP decision-making within clinical vignettes. Half of respondents were randomly assigned to surveys with concise clinical guidelines; the other half (controls) had surveys without guidelines. Scenarios involved patients with a variety of higher-risk and lower-risk IAMs and lung nodules. Our primary analysis examined safe versus inappropriate clinical decision-making.
Results: For both the higher-risk IAM and higher-risk lung nodule scenarios, safe answer choices were selected by respondents at a similar rate regardless of access to guidelines. For the lower-risk scenarios, inappropriate answer choices were chosen substantially more frequently by respondents who did not have access to guidelines compared to those with access (lung: 29.3 vs. 4.5%, P=0.003, adrenal: 31.6% vs. 7.0%, P=0.01 [Figure]).
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 a low-cost intervention that may reduce management errors and improve patient safety.


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