Elaboration of a tool for an audit of radiology reports

PURPOSE: Elaboration of a tool for an Audit of radiology reports in a department of radiology. Materials and methods. We have made a grid and a guide to evaluate the relevance and the quality of the radiology reports. We have tested this tool on 120 reports from in-patients of the gastroenterology department. The test has been done by two radiologists (blinded test) to verify if the answers were identical. We have calculated for each item the Kappa coefficient (inter-observer agreement). RESULTS: This study has validated most of the items of our grid, some have been deleted, and others modified. CONCLUSION: Our study shows that our tool can evaluate the radiology reports of a radiology department, an audit can thus be conducted using that tool.     

Establishing an outpatient clinic for minimally invasive vein care

OBJECTIVE: Minimally invasive vein care procedures are less invasive than surgery and have a lower complication rate, are well tolerated by patients, and have good cosmetic results. Because radiologists have expertise in imaging-guided procedures, offering minimally invasive vein care is a logical step. CONCLUSION: Starting an effective outpatient vein care clinic involves decisions about space, equipment, and advertising. With proper staffing and rapport with patients and referring physicians, a varicose vein practice can be a profitable adjunct to any radiology practice.     

A detailed audit of reimbursement for abdominal CT in an academic practice

RATIONALE AND OBJECTIVES: Declining fee schedules, decreasing operating margins, and increasingly stringent compliance regulations create a need for intense scrutiny and optimization of a radiology organization's billing and collection procedures. The authors' goal was to analyze the effectiveness of departmental professional billing procedures, identify controllable factors, and intervene when they could be improved. MATERIALS AND METHODS: A detailed audit of professional claims and payments was performed for all patients who underwent abdominal-pelvic computed tomography (CT) during July 1999 (n = 717). The adequacy of indication for the CT examination as given by the referring physician and modified by the radiology staff, the time required for claim generation, and the status of reimbursement within 120 days were assessed by an interdisciplinary team. After an intervention was performed to improve adequacy of the available clinical indication, the audit was repeated in December 1999 (n = 710). RESULTS: Despite a significant (P < .05) improvement in wording of clinical indications for billing purposes between July (68%) and December (85%), there was no significant change in reimbursement against gross charges. The vast majority of claims (97% in July, 99% in December) were generated in less than 30 days. At 120 days after the date of service, payments had been received that amounted to only 66% and 54% of discounted professional fees for July and December, respectively. For examinations performed in December, payment was delayed beyond contracted time periods in 138 cases (19%). CONCLUSION: Optimum billing and collection for imaging studies is an increasingly complex task. Even when substantial efforts are devoted to eliciting the proper indication for the study, reimbursement remains low primarily because of payer delays.     

Establishing an endovascular carotid stent program

FDA approval of carotid stent and distal protection devices has transformed carotid artery stenting (CAS) from an investigational procedure to a practical application. Recent approval by the Center for Medicare Services (CMS) has ensured that CAS will be a part of everyday practice throughout the country. To establish a competitive endovascular carotid stent program, one needs to develop an effective strategy. The key to success is substance and service. A high-quality clinical program with excellent communication between the patient and referring physician is essential. You must first get access to the patient by establishing a clinical practice. As a radiologist, you have the advantage of gaining access by identifying appropriate patients through noninvasive vascular labs, CTA, and MRA. An algorithm-driven evaluation and treatment protocol with good pre- and postoperative care, along with a quality assurance program, will ensure that your carotid stent program has substance and delivers optimal service. With good planning, you will have a firm clinical foundation for treatment of carotid artery stenosis in your community. Putting all of the ingredients together will ensure a successful carotid endovascular program.     

Interdepartmental audit with an anatomically realistic lung phantom

The diagnostic proficiency of nuclear medicine professionals and the accuracy of equipment may be tested with phantoms. All phases of the imaging chain should be included in the external quality assurance of imaging. METHODS: The aim of this study was to evaluate and compare the quality of nuclear imaging of the lung in Finland. For this purpose, we developed a new anatomically realistic lung phantom. The phantom consisted of plastic containers filled with plastic pellets to imitate the 3-dimensional shape of the lungs. These containers were filled with radioactive liquid and placed inside an anatomically accurate phantom of the chest cavity. The attenuation properties of the phantom were close to those of a real human thorax. Perfusion and ventilation defects were positioned inside the phantom to mimic 2 clinical cases. The phantom was imaged and interpreted as a patient simulation study in 18 Finnish hospitals. Reconstruction, printout, and reporting were according to the clinical routine of each hospital. The quality of the image sets and reports was evaluated and scored from 0 to 10. Additionally, technical performance was evaluated by a nuclear medicine specialist and hospital physicians. RESULTS: The average score (+/-SD) for overall quality was 7.1+/-1.1 (range, 5.2-8.5). Reports received a score of 7.2+/-1.7 (4.7-10.0); image sets, 7.2+/-1.3 (4.8-9.7), technical evaluation by hospital readers, 6.5+/-2.3 (1.6-9.5); and technical evaluation by a specialist, 7.8+/-1.2 (5.7-10.0). CONCLUSION: Lung imaging routines and the results of this survey were diverse. None of the participating hospitals routinely used tomography. In planar imaging, the most valuable projections were oblique (left anterior oblique, right anterior oblique, left posterior oblique, and right posterior oblique) and straight sides (right and left). The phantom mimics variable clinical situations well and is suitable for testing of imaging protocols and for proficiency testing of nuclear medicine professionals and equipment. Clinical phantom studies are an effective way of assessing an imaging program.     

Computed tomography in abdominal trauma: an audit of usage and image quality.

The use and quality of computed tomography (CT) in the evaluation of blunt abdominal trauma has been assessed by a retrospective review of 122 patients referred in the first 8 years following the installation of CT of the body. The referral patterns were analysed, and the quality of the images was assessed, with particular reference to unsatisfactory (unacceptable or poor) images. Referrals increased over the 8 years following installation. A large proportion of these examinations were performed outside normal working hours (58/122, 48%). In 64 out of 122 (52%) of examinations the images were considered of unsatisfactory quality with inadequate use of intravenous contrast medium cited as the most common cause for unsatisfactory examinations. Image quality did not improve with time. Image quality was unsatisfactory in a larger proportion of those examinations performed outside normal working hours (35/58, 60%) than those during the routine working day (29/64, 45%), although this difference did not reach statistical significance (0.1 greater than p greater than 0.05). Fewer unsatisfactory examinations were produced by a system dedicated to body CT (31/74, 42%) than by a neuroradiological system (33/48, 69%) (p less than 0.01). The proportion of unsatisfactory abdominal examinations was lower when the CT study concentrated on the abdomen (26/65, 40%) than when multiple regions (head, chest, abdomen, etc.) were examined (38/57, 67%) (p less than 0.01). This audit revealed many unsatisfactory examinations. In order to complete the audit loop we have addressed many of the contributory factors. A new CT system now provides images of high quality and is used for all abdominal work. Guidelines, which describe an optimized technique, have been issued to radiographers and radiologists. In particular, we have emphasized that there is no place for a poorly supervised "quick look" at the abdomen following a cranial or thoracic study.     

Establishing an optimized patient-specific verification program for volumetric modulated arc therapy

Quality assurance (QA) of volumetric modulated arc therapy (VMAT) increases the workload significantly. We compared the results from 4 verification methods to establish an efficient VMAT QA. Planning for VMAT treatments was carried out for 40 consecutive patients. Pretreatment verifications were carried out with ion chamber array Physikalish-Technische Werkstätten (PTW729), electronic portal dosimetry (EPID), ion chamber measurements, and independent dose calculation with Diamond program. 2D analyses were made using the gamma analysis (3 mm distance to agreement and 3% dose difference relative to maximum, 10% dose threshold). Average point dose difference calculated by Eclipse relative to ion chamber measurements and Diamond were 0.1%±0.9% and 0.6%±2.2%, respectively. Average pass rate for PTW729 was 99.2%±1.9% and 98.3%±1.3% for EPID. The total required time (linac occupancy time given in parentheses) for each QA method was: PTW729 43.5 minutes (26.5 minutes), EPID 14.5 minutes (2.5 minutes), ion chamber 34.5 minutes (26.5 minutes), and Diamond 12.0 minutes (0 minute). The results were consistent and allowed us to establish an optimized protocol, considering safety and accuracy as well as workload, consisting of 2 verification methods: EPID 2D analysis and independent dose calculation.     

Development of an online preparation system for multitracer solutions.

We have developed a new target-irradiation system for the online preparation of multitracer solutions, where the nuclear-reaction products recoiling out of the target are directly implanted in a solvent as a liquid catcher. A rapid online transportation of the solution has enabled highly efficient recovery of the multitracer solutions having even short-lived radioactive isotopes without any chemical treatments. It has been suggested that the collection efficiency depends on the chemical properties of the recoil elements.     

Errors of interpretation as elicited by a quality audit of an emergency radiology facility.

A process-oriented quality care audit was performed in a large metropolitan hospital emergency radiology facility with an annual volume of over 50,000 examinations. One aspect of the audit dealt with errors found among interpretations by radiology residents, the initial interpreters of x-ray studies. Misinterpretations were identified by staff radiologists, who checked all examinations and countersigned the reports. Error rates were correlated with duration of training and were separated as to significance and whether the errors were false-negative (omission) or false-positive (commission). The false-positive to false-negative ratio was 27:73% which is in agreement with previous studies. For all cases of errors, the significance of change in interpretation was high in 20%, moderate in 29% and low in 51%. The effect of inadequate clinical history on the rate and significance of interpretation errors was also determined. When clinical information was inadequate, the significance was high in 27%, moderate in 40% and low in 33%.     

Diagnosis and management of simple ovarian cysts: an audit

Simple ovarian cysts are common. The aim of clinical management is to optimize the treatment of malignant and premalignant cysts while minimizing intervention for cysts likely to resolve spontaneously. In this retrospective study, ovarian cysts over 30 mm in diameter were detected in 90 women. Of this population, 75 were premenopausal, 13 postmenopausal, and two had undergone a hysterectomy. Thirteen women presented acutely. Family history of breast, ovary or colon cancer was not ascertained in any of the women. None had CA125 levels performed. In 22 cases, the cyst was aspirated; only 10 of these had follow-up ultrasound. Laparotomy was performed in 25 premenopausal women, the two perimenopausal women and eight postmenopausal women. Average cyst size was 71 mm (range 40-80 mm) in the laparoscopy group, and 72 mm (range 36-180 mm) in the laparotomy group. After initial diagnosis at ultrasound, a follow-up scan was performed 4-16 weeks later. The final diagnosis was ovarian neoplasm in 13 and hydrosalpinx in two. None had a malignancy. Documentation at ultrasound was often inadequate, and management of the women with an ovarian cyst was haphazard. Guidelines on management of simple ovarian cysts are likely to improve clinical practice.