Sometimes in medicine we find things we were not necessarily looking for when we perform a test. We call these incidental findings. While many of these are benign they can potentially be problematic as they can change the workup of a patient including their disposition and management.
Incidental findings are frequently found on imaging but also with labs. Most of the research exists with imaging. How do incidental findings impact healthcare and what do we do when they occur?
In one study of incidental findings on CT scans in the ED in general, a third of scans had an incidental finding. Patients were less likely to have incidental findings when they were less than 60 years of age. The findings were less likely to be disclosed if only one was found versus multiple incidental findings. Less than 10% of the patients in total were notified of their incidental findings. Most of these findings were aortic dilations (33.3%), meningiomas (25%), pulmonary nodules (25%), bony changes (25%), and enlarged adnexa (21.4%). No hiatal hernias, renal lesions, diverticula, or cholelithiasis found during this study period were disclosed to the patients. Although many of the findings may be benign, these discussions and the appropriate follow-up can still be important later such as the aortic dilations and pulmonary nodules.
Another study of trauma patients found 42.5% of them had incidental findings. 62% of those patients had no further documentation but 5% received either specialty consult or additional studies related to their incidental findings with some others notified on dictated discharge summaries. A separate study in patients undergoing CT for possible pulmonary embolism (PE) found 59% of those who did not have a PE had incidental findings that often required intervention with some needed emergent treatment such as aortic dissection.
You may recall that our first review of a trial and the first podcast we did that covered clinical content was on the REACT-2 trial. Since that time there has been a follow-up study on those patients regarding the high rate of incidental findings in that trauma population. In those with whole body CT versus selected CTs and other imaging, there was a significant increase in the number of incidental findings overall as well as an increase rate in regards to their relevance from minor, moderate, and major. The major findings included (but not limited to) 4 brain masses, 6 pulmonary nodules, 6 adrenal masses, an aortic dissection, and an abdominal aneurysm >5.5cm in diameter. In regards to impact on hospital length of stay, one study demonstrated that of the 40% of patients with incidental findings they had a longer length of stay versus those who did not.
Point of care ultrasound (POCUS) can also have incidental findings. A study of resident-performed examinations had incidental findings with most being renal. 68.6% of those with incidental findings had additional imaging or workup. Most of these confirmed the incidental finding further supporting the importance of appropriate continued evaluation.
Incidental findings are a common issue in our investigations. Although most may be clinically insignificant, we must always consider the need for further evaluation and what to do with them. Just like ordering the imaging, we own the results of those images and need to know what to do with them.
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