Low Rate of Guideline Adherence for the Diagnosis and Management of Adrenal Incidentalomas in the Nova Scotia Health Authority Central Zone

Abstract Background: Adrenal incidentalomas are prevalent and clinically significant, yet are often overlooked by clinicians. The objective of this study was to retrospectively examine the adherence to American College of Radiology (2017) and European Endocrine Society (2016) guidelines for the diagnosis and management of adrenal incidentalomas within a centre servicing a population of over 400,000. Methods: Relevant computed tomography (CT) and magnetic resonance (MR) scans from February 17th, 2019 to December 18th, 2019 were consecutively reviewed for the presence of adrenal incidentalomas. Radiographic reports and original imaging were reviewed to evaluate the completeness of reporting. A chart review was conducted to determine if biochemical investigations for cases were undertaken and whether referral to Endocrinology was made. Reports were checked for the inclusion of an addendum recommending Endocrinology referral. Results: A convenience sample of 148 cases were included in the study, with 176 distinct adrenal incidentalomas identified. Where relevant, attenuation values were provided for 20% of cases, and follow-up imaging was recommended in 59% of cases. Of the 124 cases where biochemical investigation was deemed appropriate, a complete work-up was conducted in 4% of cases, and 11% were referred to Endocrinology. Follow-up imaging was ordered appropriately in 36% of cases, and no cases had inappropriate follow-up imaging. The addendum was included for 19% of cases, and it did not impact biochemical investigation rates but did improve Endocrinology referral rates. Conclusions: There is poor adherence to guidelines for the diagnosis and management of adrenal incidentalomas within our study population. This poor adherence would be an ideal target for quality improvement initiatives, in order to minimize missed functional and malignant adrenal masses.