Brett Starr, MD, Chair, Department of Cardiovascular Sciences & Chief of Cardiovascular and Thoracic Surgery, Frye Regional Medical Center
Forty percent of imaging studies turn up an incidental finding. Sixty-five percent of those findings never get a follow-up. Run that math on your own volume and the pattern shows up fast: roughly one in four scans quietly flags a problem that then goes nowhere.
I've spent the vast majority of my career in the OR, and I've stopped thinking about this as a documentation problem. Every patient lost to follow-up is a patient who was already engaged in our system, already scanned, already partway to a diagnosis that may be life-saving. That patient can lose years of life to a ruptured aneurysm, a missed coronary stenosis, a new lung nodule. The only thing worse than a bad outcome is one that is based on a finding sitting silently, but recognized, in their chart.
The stakes are highest in rural communities, where people are 40% more likely to develop heart disease than their urban counterparts. More concerning, 86% percent of rural counties have no practicing cardiologist, and specialized cardiac surgical care is unavailable in nearly all of them. The result is a 50% higher mortality risk for rural cardiovascular patients.
Urban and suburban patients face a different challenge. Specialists are everywhere, spread across departments that each assume someone else is following these patients. An aortic aneurysm found incidentally on an ER CT scan may pass through radiology, primary care, cardiology, and vascular surgery before anyone takes the next step in implementing a plan. If no one owns that finding or makes the handoff, the finding ends up no different than a rural community with no specialists at all.
Distance and access cause the gap in one setting, while fragmentation and tunnel vision specialization cause it in the other. Regardless, the patient ends up in the same place: without the potentially life-saving follow-up care they need.
In today’s world, that gap not only doesn’t have to exist, it’s almost unacceptable to allow it to persist. Working for a health care enterprise that serves primarily rural markets, we saw the need to change the equation in the communities we serve. Across my health system's early detection program, rural patients returned for their follow-up care at a 73% rate, compared to 75% for non-rural patients.
This parity isn’t by chance… Once a system exists that actively tracks patients and creates accountability, the bar is raised and expectations are met. These patients should not be left behind because of where they live.
Finding the problem is the easy part. An incidental finding usually turns up on imaging ordered for a different reason entirely — a fall, abdominal pain, an unrelated ER visit — so the patient isn't primed to chase down a cardiovascular or lung diagnosis on their own.
Cardiovascular disease by nature is a chronic disease, and while often there is acute recognition, true longitudinal care often requires an ongoing surveillance plan that follows patients months to years into the future. Timing is key, and guidelines help drive patients to get the right studies and interventions at the right time, not at random chance for the next unrelated scan, or even worse at a catastrophic emergency.
In our system, several examples exist but notably a 58-year-old man came into the ER for a worsening cough and a CT scan showed not only pneumonia, but also an ascending aortic aneurysm measuring 4.7 centimeters. The radiologist's report called it “mild,” but the measurement was clear.
In the typical workflow, the ER would treat the patient’s pneumonia and a PCP would often get the report with an impression of a “mild” aneurysm. This gets read, acknowledged, and filed away with the patient assuming everything is fine. A year or two later, the patient is back in the same ER with an aneurysm dissection or rupture— this time for high-risk, emergency surgery, if he makes it that far.
In our case, an automated, guideline-driven tracking system caught the 4.7-centimeter measurement and triggered a surveillance pathway on its own, regardless of the “mild” grading by the radiologist. Our navigators worked with the PCP to contact the patient, explain the finding, and set the follow-up date for additional imaging.
Two years later, after ongoing serial imaging, the aneurysm had continued to grow and repair was indicated. In this scenario, the system worked to prevent the catastrophe, and they had a planned, elective repair on a date we chose, before the aneurysm could rupture.
What brought this so keenly into focus for me was watching this work alongside my rapidly growing service line.
To be the physician reporting the benefits and our success is truly full of irony. I was initially vocally skeptical of automated tracking when we first adopted it. Most surgeons are. Alert fatigue is real, and none of us want to hand clinical judgment to a piece of software. Perhaps that’s where the perception is truly quite removed from reality.
What brought this so keenly into focus for me was watching this work alongside my rapidly growing service line. This tool was not replacing my judgment, but was carrying out what I knew to be the best practice in the background. Despite significant resources we attempted to dedicate to this sort of tracking and navigating, we were still having gaps.
Reading volumes are heavy, and report language isn't consistent from one radiologist to the next. A step beyond natural language processing, the specialized system flags key components such as discrete measurements, even when the wording downplays the findings. That's a backstop for radiology and labor-intensive scrubbing and navigating efforts. While it's augmentation, it’s not a replacement for active physician involvement and clinical judgement.
From a community perspective, I want patients to trust that we are not only providing the highest level of care for things we know about today, I want them to trust us to provide that care well into the future. Patients already trusted us enough to walk through the door. But enduring trust is built when the system doesn't lose track of them once the visit that brought them in is over.
Learn more about Eon’s Cardiovascular solutions.
________________________________________________________________________________________________
Common Questions
A clinically meaningful finding, like an aortic aneurysm, that turns up on imaging ordered for an unrelated reason. About 40% of imaging studies produce one.
About 65% of them never get follow-up care, which works out to roughly one in four scans overall. The patient wasn't scanned for a cardiovascular reason, so they often have no idea a finding needs attention.
Rural residents are 40% more likely to develop heart disease compared to urban residents, yet 86% of rural counties have no practicing cardiologist and almost none have cardiac surgical care. That gap between increased risk and drastically lower access drives a 50% higher mortality rate for rural cardiovascular patients.
No. Urban and suburban systems lose the same patients to fragmentation and tunnel vision specialization instead of distance and access. A finding can pass through multiple service lines without one owning the finding and setting the plan to proceed forward. Different cause, same missed diagnosis, same potential for bad outcomes.
As opposed to using labor-intensive manual scrubbing which is also prone to human error, automatic tracking validates the measurement itself against clinical criteria, which gives the care team a safety net. Additionally, report language varies by radiologist, so a measurement that meets guideline criteria can still get called "mild" and filed away.
No. Physicians still make every clinical call on diagnosis, timing, and intervention. Longitudinal surveillance keeps patients visible to the care team so they surface for the right conversation at the right time.
