Prospective Study of a Systemwide Adrenal Incidentaloma Quality Improvement Initiative

Abstract

Background: Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs. Study Design: This systemwide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018 to December 31, 2019 were prospectively included (the “QI cohort”) and compared to a historical, pre-intervention cohort diagnosed with IAMs in 2016. The primary outcome was the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral. Results: The QI cohort included 437 patients, versus 210 in the historical cohort. All patients had ≥12 months of follow-up. In the QI cohort, 35.5% (155/437) met the primary endpoint for PCP-initiated evaluation, compared to 27.6% (58/210) in the historical cohort (p=0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74/160) met the primary endpoint in the QI cohort versus 33.3% (38/114) in the historical cohort (p=0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95%CI 1.16-2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9/437) of QI cohort patients and 0.95% (2/210) of historical cohort patients (p=0.517). Conclusions: This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.