Association between radiologic incidental findings and resource utilization in patients admitted with chest pain in an urban medical center

Diagnostic imaging is an integral part of patient evaluation in acute care settings. The use of imaging for presenting complaints of chest pain, abdominal pain, and injuries has increased in emergency departments across the United States without an increase in detection of acute pathologic conditions.^1,2 An unintended consequence of this increase in diagnostic imaging is the discovery of incidental findings (IFs).

Incidental findings are unexpected findings (eg, nodules) noted on diagnostic imaging that are not related to the presenting complaint.³ The increasing use of diagnostic imaging and increased sensitivity of these tests have led to a higher burden of radiologic IFs.⁴ In a tertiary level hospital, Lumbreras et al.⁵ found that the overall incidence of IFs for all radiologic imaging for inpatients and outpatients was 15%, while Orme et al.⁶ found that the incidence in imaging research was 39.8%. The existing evidence base suggests that the identification of radiologic IFs has financial,^5,7 clinical,⁶ ethical, and legal implications.⁸ Also, IFs increase workload for healthcare professionals, including that related to follow-up and surveillance.⁹

In the field of radiology, the burden of radiologic IFs is a well-accepted fact and various white papers have been published by the American College of Radiology on how to address them.^4,7 Hospitalized patients are a population that undergoes a substantial number of diagnostic tests. In the era of accountable care organizations¹⁰ with an emphasis on population health and high-value care, radiologic IFs pose a particular challenge to healthcare providers.

Chest pain is one of the most common reasons for emergency department visits in the United States.¹¹ In this study, we report on radiologic IFs and factors associated with these among patients hospitalized for chest pain of suspected cardiac origin, and we evaluate the hypothesis that radiologic IFs are associated with an increase in LOS in this population.

We conducted a secondary analysis of data from the Chest Pain and Cocaine Study (CPAC). The CPAC study is a cross sectional study of all patients hospitalized with chest pain to our urban academic medical center. Medical records were reviewed to generate a database of all such patients during the study period. The main focus of CPAC was to look at healthcare disparities and resource utilization in patients with or without a concomitant diagnosis of cocaine use.¹²

Study Population

The Figure shows the selection of the study sample for this analysis. The CPaC Study identified 1811 consecutive admissions for chest pain/angina pectoris (based on admitting diagnosis ICD-9-CM codes: 411.x; 413.x, 414.x; and 786.5x) over 24 months. Per the CPaC Study protocol, patients older than 65 years were excluded (n=567 admissions). After chart review, all admissions diagnosed with acute myocardial infarction (n=97) or noncardiac chest pain (n=655) were excluded. For this analysis, we excluded 39 additional admissions of patients who had known prior radiologic IFs, leading to a sample size of 453 admissions. Three hundred and seventy six patients had accounted for 453 admissions during the study period, and we included1 of these admissions in the analysis using the following process: If a patient had a radiologic IF on any admission during the study period, that patient was included in the “IF” group for the analysis, and data from the first admission with an IF were used for the analysis. If a patient had no radiologic IFs on any admission during the study period, that patient was included in the “no IF” group, and the data from the first admission in the database were used for analysis.