A Quality Improvement Initiative to Reduce Unnecessary Follow-up Imaging for Adnexal Lesions

Our objective was to improve the quality of pelvic ultrasound reports and decrease the number of physiologic and benign adnexal lesions unnecessarily referred for follow-up. We performed a prospective cohort study of 2 quality improvement interventions: academic detailing with education for the ultrasound radiologists and sonographers, and implementation of a national consensus guideline on adnexal cysts. Our primary quality outcome measure was the proportion of pelvic ultrasound exams in which follow-up was recommended for an adnexal lesion. Baseline data collection in January 2006 identified 252 pelvic ultrasound exams, of which 58 (23%) reported an adnexal lesion and 31 (12%) recommended follow-up. Retrospective review revealed that 17 of 31 (55%) reported adnexal lesions with follow-up recommended were physiologic or benign. After intervention 1, 59 of 214 (28%) pelvic ultrasound exams from January 2008 reported an adnexal lesion, with 18 (8%) recommending follow-up. After intervention 2, 64 of 296 (22%) pelvic ultrasound exams from January 2011 reported an adnexal lesion, with 16 (5%) recommending follow-up. Follow-up recommendations decreased 58% (12% versus 5%, P = .004), with significant increase in the proportion characterized as physiologic or benign (P = .001). Through a quality initiative aimed at appropriate description and follow-up recommendations for adnexal cystic lesions identified at ultrasound, we effectively reduced unnecessary imaging referrals. We conclude that: (1) acceptance of an expert consensus guideline was important to add credibility, (2) accessible image-rich charts are invaluable tools at point of use, and (3) elimination of some unnecessary imaging is under the control of the radiologist.