Pediatric Emergency Imaging Studies in Academic Radiology Departments: A Nationwide Survey of Staffing Practices

ObjectiveParticularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests.MethodsWe conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher’s exact test and an α of 0.05.ResultsSurveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend.DiscussionA minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.     

Academic radiology and the emergency department: does it need changing?

RATIONAL AND OBJECTIVES: The increasing importance of imaging for both diagnosis and management in patient care has resulted in a demand for radiology services 7 days a week, 24 hours a day, especially in the emergency department (ED). We hypothesized the resident preliminary reports were better than generalist radiology interpretations, although inferior to subspecialty interpretations. MATERIALS AND METHODS: Total radiology volume through our Level I pediatric and adult academic trauma ED was obtained from the radiology information system. We conducted a literature search for error and discordant rates between radiologists of varying experience. For a 2-week prospective period, all preliminary reports generated by the residents and final interpretations were collected. Significant changes in the report were tabulated. RESULTS: The ED requested 72,886 imaging studies in 2004 (16% of the total radiology department volume). In a 2-week period, 12 of 1929 (0.6%) preliminary reports by residents were discordant to the final subspecialty dictation. In the 15 peer-reviewed publications documenting error rates in radiology, the error rate between American Board of Radiology (ABR)-certified radiologists is greater than that between residents and subspecialists in the literature and in our study. However, the perceived error rate by clinicians outside radiology is significantly higher. CONCLUSION: Sixteen percent of the volume of imaging studies comes through the ED. The residents handle off-hours cases with a radiology-detected error rate below the error rate between ABR-certified radiologists. To decrease the perceived clinician-identified error rate, we need to change how academic radiology handles ED cases.     

Preliminary Reports in the Emergency Department: Is a Subspecialist Radiologist More Accurate Than a Radiology Resident?

RATIONALE AND OBJECTIVES: To determine whether emergency department (ED) preliminary reports rendered by subspecialist attending radiologists who are reading outside their field of expertise are more accurate than reports rendered by radiology residents, and to compare error rates between radiologists and nonradiologists in the ED setting. MATERIALS AND METHODS: The study was performed at a large academic medical center with a busy ED. An electronic preliminary report generator was used in the ED to capture preliminary interpretations rendered in a clinical setting by radiology residents, junior attendings (within 2 years of taking their oral boards), senior attendings, and ED clinicians between August 1999 and November 2004. Each preliminary report was later reviewed by a final interpreting radiologist, and the preliminary interpretation was adjudicated for the presence of substantial discordances, defined as a difference in interpretation that might immediately impact the care of the patient. Of the 612,890 preliminary reports in the database, 65,780 (11%) met inclusion criteria for this study. A log-linear analysis was used to assess the effects of modality and type of author on preliminary report error rates. RESULTS: ED clinicians had significantly higher error rates when compared with any type of radiologist, regardless of modality. Within the radiologists, residents and junior attendings had lower error rates than did senior attendings, but the differences were not statistically significant. CONCLUSION: Subspecialized attending radiologists who interpret ED examinations outside their area of expertise have error rates similar to those of radiology residents. Nonradiologists have significantly higher error rates than radiologists and radiology residents when interpreting examinations in the ED.     

The DePICTORS Study: discrepancies in preliminary interpretation of CT scans between on-call residents and staff

At many academic hospitals, radiology residents provide preliminary interpretations of CT studies performed outside of regular working hours. We examined the rate of discrepancies between resident interpretations and final reports issued by staff. We prospectively obtained 1,756 preliminary reports and corresponding final reports for computed tomography (CT) scans performed on call between November 2006 and March 2007. The overall rate of clinically significant discrepancies (those that would potentially alter the patient’s clinical course prior to issue of the final report) was 2.0%. Major discrepancy rates for abdominal/pelvic, chest, cervical spine and head CT were 4.1%, 2.5%, 1.0% and 0.7%, respectively. Senior residents had fewer major discrepancies compared to their junior colleagues. Time of interpretation was also evaluated, but a statistically significant relationship was not observed. In summary, this study demonstrates a low discrepancy rate between residents and staff radiologists and identifies areas where after-hours service may be further improved.     

Specialized Second Opinion Review of Breast MRI Impacts Management and Increases Cancer Detection

ObjectiveThe aim of our study is to determine MRI review discrepancy frequency and the subsequent impact on patient management for patients pursuing breast imaging second opinions.MethodsA retrospective chart review was conducted on 1,000 consecutive patients with second opinion radiology interpretations performed by subspecialty-trained breast radiologists at a dedicated cancer center July 1 through December 31, 2016. Of these, 205 included review of outside breast MRI. Outside imaging reports were compared with second opinion reports to categorize breast MRI review discrepancies. These included relevant BI-RADS category changes or identification of additional extent of disease >4 cm. The discrepancy frequency, relevant alterations in patient management, and incremental cancer detection were measured. Statistical analyses were performed using Fisher’s exact test.ResultsDiscrepant second opinion breast MRI review was seen in 36 of 205 patients (18%). Additional cancer was detected through image-guided biopsy in 3 of these 36 patients and through excision in 2 (5 of 205, 2%). Additionally, five biopsies yielded high-risk pathologic results without upstage on excision. Findings suspicious for additional extent of disease >4 cm were noted in five patients (2%) treated with mastectomies. Finally, five patients had BI-RADS category downgrades. Ultimately, completion of second opinion MRI review recommendations resulted in altered management in 10% of patients (20 of 205). The absence of prior imaging studies for comparison was associated with increased discrepancy frequency (P = .005).ConclusionSecond opinion breast MRI review by subspecialized breast imaging radiologists increases cancer detection and results in clinically relevant changes in patient management.     

Transfer patient imaging: a survey of members of the American Society of Emergency Radiology

When trauma patients are transferred from outside hospitals, the receiving clinicians often consult their local radiologists for definitive interpretations of outside examinations (IOE). Such requests introduce a host of logistical, medicolegal, and financial concerns related to quality control and resource utilization. We surveyed 701 members of the American Society of Emergency Radiology to elucidate these concerns. We found that the majority of emergency departments still rely on compact disks for conveyance of outside images; hard film and network transfers were minor mechanisms for most respondents. Sixty-nine percent of the respondents indicated that radiologist reports accompany fewer than 25?% of all transferred imaging studies; of the reports that do arrive, most are unverified preliminary reads. There is considerable variability in billing practices and reimbursement patterns for radiologic second opinions; 68?% of the respondents do not know how often their IOEs are reimbursed. Suboptimal communication between community hospitals and referral centers may result in duplicated efforts and inconsistent quality of medical imaging studies. Further investigation into the role of radiology trainees in the handling of outside studies is also highly recommended.     

Improving the quality of care through routine teleradiology consultation

RATIONALE AND OBJECTIVES: The hypotheses of this study were as follows: (a) University subspecialty radiologists can provide consultations effectively to general radiologists as part of routine clinical operations; (b) these consultations will improve the quality of the final radiologic report; and (c) the consultations will improve the care process and may save money, as well. MATERIALS AND METHODS: For 2,012 consecutive computed tomographic or magnetic resonance (MR) imaging studies, the initial interpretations provided by radiology generalists were subsequently reviewed by specialists, with a final consensus report available. "Truth" was established by final consensus reports. To control for potential bias, 150 adult MR imaging and 250 pediatric radiologic studies were interpreted initially by specialists and then by generalists. Again, truth was established by final consensus reports. RESULTS: There was disagreement between generalist and specialist radiologist interpretations in 427 (21.2%) of the cases reviewed. These disagreements were stratified further by independent specialists, who graded them as important, very important, or unimportant. Differences were considered important or very important in 99% of the cases reviewed. CONCLUSION: Consultations by subspecialty radiologists improved the quality of the radiology reports studied and, at least in some cases, improved the process of care by eliminating unnecessary procedures or suggesting more specific follow-up examinations. The consultation services can be provided cost-effectively from the payer's perspective and may save additional costs when unnecessary procedures can be eliminated.     

24/7/365 Neuroradiologist Coverage Improves Resident Perception of Educational Experience,Referring Physician Satisfaction,and Turnaround Time

PurposeTo quantitatively and qualitatively assess the impact of attending neuroradiology coverage on radiology resident perceptions of the on-call experience, referring physician satisfaction, and final report turnaround times.Materials and Methods24/7/365 attending neuroradiologist coverage began in October 2016 at our institution. In March 2017, an online survey of referring physicians, (emergency medicine, neurosurgery, and stroke neurology) and radiology residents was administered at a large academic medical center. Referring physicians were queried regarding their perceptions of patient care, report accuracy, timeliness, and availability of attending radiologists before and after the implementation of overnight neuroradiology coverage. Radiology residents were asked about their level of independence, workload, and education while on-call. Turnaround time (TAT) was measured over a 5-month period before and after the implementation of overnight neuroradiology coverage.ResultsA total of 28 of 64 referring physicians surveyed responded, for a response rate of 67%. Specifically, 19 of 23 second (junior resident on-call) and third year radiology residents (senior resident on-call) replied, 4 of 4 stroke neurology fellows replied, 8 of 21 neurosurgery residents, and 16 of 39 emergency medicine residents replied. Ninety-five percent of radiology residents stated they had adequate independence on call, 100% felt they have enough faculty support while on call, and 84% reported that overnight attending coverage has improved the educational value of their on-call experience. Residents who were present both before and after the implementation of TAT metrics thought their education, and independence had been positively affected. After overnight neuroradiology coverage, 85% of emergency physicians perceived improved accuracy of reports, 69% noted improved timeliness, and 77% found that attending radiologists were more accessible for consultation. The surveyed stroke neurology fellows and neurosurgery residents reported positive perception of the TAT, report quality, and availability of accessibility of attending radiologist.ConclusionsIn concordance with prior results, overnight attending coverage significantly reduced turnaround time. As expected, referring physicians report increased satisfaction with overnight attending coverage, particularly with respect to patient care and report accuracy. In contrast to some prior studies, radiology residents reported both improved educational value of the on-call shifts and preserved independence. This may be due to the tasking the overnight neuroradiology attending with dual goals of optimized TAT, and trainee growth. Unique implementation including subspecialty trained attendings may facilitate radiology resident independence and educational experience with improved finalized report turnaround.     

The Radiology Resident as Teaching Consultant: An Innovative Peer-to-Peer Teaching Consultation Service to Strengthen Relationships With Referring Colleagues in the Era of Imaging 3.0

BackgroundThe American College of Radiology Imaging 3.0 paradigm emphasizes the need for radiologists to serve as imaging consultants to their referring colleagues. However, outside the reading room, teaching interactions between radiology and nonradiology residents are limited. Internal Medicine Morning Report (IMMR) is a resident-run educational program widely employed by internal medicine (IM) residencies. Although medical imaging is regularly discussed in IMMR, radiology residents are not typically involved in case preparation. We aimed to develop a peer-to-peer imaging teaching consultation service (TCS) incorporated into the well-established structure of IMMR. By creating illustrative, “dynamic” teaching slides for use at these conferences, we sought to provide salient radiology teaching material, demystify jargon, discuss appropriate imaging use, and review relevant anatomy. We hypothesized that TCS could improve the quality of IMMR as perceived by the IM presenter.MethodsTCS was piloted over a 7-month period. Each referred case was reviewed by a senior radiology resident who produced a set of “dynamic” teaching slides for each case. These included patient imaging overlayed with extensive annotations and animations highlighting teaching points, with particular attention to radiologic terminology. Slides were shared with the IM presenter, who could use them for preparation and include the animations in the talk if desired. TCS effectiveness was evaluated with a survey distributed to participating IM residents.ResultsIn the pilot period, 12 TCS requests were received and 10 were performed in collaboration with 6 IM residents. Survey results indicated that most IM residents did not consult radiologists prior to TCS (5/6, 83%). IM residents used the “dynamic” teaching slides to both prepare for and present at IMMR (5/6, 83%). TCS improved IM residents’ perceived ability to engage their audience (6/6, 100%), confidence in teaching radiology material (4/6, 67%), ability to understand radiology reports (4/6, 67%) and appreciation for what radiologists do (6/6, 100%).ConclusionsThe TCS pilot resulted in successful radiology-IM collaboration and improved knowledge and confidence in teaching imaging concepts. Continuous program evaluation will be performed and future work will assess the effect of TCS on radiologist confidence in real-world clinical consultations.     

Value of Second-Opinion Interpretation of Outside-Facility Breast Imaging Studies to a Radiology Department and Cancer Center

PurposeThe aim of this study was to estimate the physician work effort for formal written breast radiology second-opinion reports of imaging performed at outside facilities, to compare this effort with a per-report credit system, and to estimate the downstream value of subsequent services provided by the radiology department and institution at a National Comprehensive Cancer Network–designated comprehensive cancer center.MethodsA retrospective review was conducted of consecutive reports for “outside film review” from July 1, 2015, to June 30, 2018. The number and types of breast imaging studies reinterpreted for each individual patient request were tabulated for requests for a 3-month sample from each year. Physician effort was estimated on the basis of the primary interpretation CMS fee schedule for work relative value units (wRVUs) for the study-specific Current Procedural Terminology (CPT) code and study type. This effort was compared with the interpreting radiologist credit of 0.44 wRVUs per report. Subsequent imaging and evaluation and management encounters generated by these second-opinion patient requests were tracked through June 30, 2019.ResultsFor the 3-year period reviewed, 2,513 unique patient requests were identified, averaging 837 per fiscal year. For January to March of 2016, 2017, and 2018, 645 unique patient reports were identified. For these reports, 2,216 studies were reinterpreted, with an estimated physician effort of 2,660 wRVUs compared with 284 wRVUs on the basis of per-report credit. The range of annualized wRVUs for all outside studies interpreted and credited per specific CPT code was 3,135 to 3,804 (mean, 3,547). However, the institutional relative value unit credit received for fiscal years 2015, 2016, and 2017, on the basis of the number of patient requests, was only 385, 375, and 345 wRVUs, respectively.ConclusionsThis study demonstrates the substantial work effort necessary to provide formal second-opinion interpretations for breast imaging studies at a National Comprehensive Cancer Network cancer center. The authors believe that these data support billing for the study-specific CPT code and crediting the radiologist with the full wRVUs for each study reinterpreted.     

Technology-Assisted Virtual Consultation for Medical Imaging

PurposeThe aim of this study was to report the investigators’ preliminary experience in the implementation of a “virtual consult” (VC) system enabling consultations between radiologists and referring physicians in physically remote locations throughout their enterprise.MethodsReferrers and radiologists directly access the VC through the electronic medical record and PACS, respectively. Referrers may click a VC link associated with any examination report to instant message the appropriate subspecialist radiologist, who receives an alert allowing automatic loading of the examination. The radiologist and referrer may then discuss the examination via instant messaging as well as launch a real-time screen-share of the radiologist’s PACS display, with the option for either participant to control the display. Radiologists’ and referrers’ feedback was evaluated after the institution’s first 110 VC sessions.ResultsReferrers’ most common specialties were emergency medicine (27.3%) and internal medicine (13.6%); radiologists’ most common subspecialties were abdominal (33.6%) and thoracic (16.4%) imaging. Screen-shares lasted on average 12 ± 16 minutes. From 80% to 90% of referrers agreed that the VC was easy to use, improved their understanding of the radiology report, affected patient management, and enhanced radiologists’ role. Referrers found the VC to be particularly useful when traditional consultation was difficult because of location or time constraints or when seeking a quick response to a targeted question. Radiologists recognized referrers’ positive response to the VC, although they tended to view the VC as disruptive to normal workflow.ConclusionsThe VC addresses a key challenge in the current era of digital radiology practice and provides added value to referrers, though continued radiologists’ workflow optimization is warranted.     

Integration of a Community Radiology Division into a Subspecialty-Focused Academic Radiology Department

IntroductionAssimilate a general radiology division into a subspecialty-focused radiology department at an academic medical center.MethodsThis Institutional Review Board-approved quality improvement initiative was performed at an academic medical centers’ subspecialty-focused academic radiology department, aiming to assimilate a general radiology division providing interpretive services for a distributed set of community ambulatory practices. An Oversight Committee charged by the department chair created a charter with unambiguous goal, timelines, clear decision-making, and conflict resolution processes. The Committee assessed the resources and clinical capabilities of the general radiologists, and the anticipated shift in exam volume from the community into subspecialty divisions. Primary outcome, percentage of targeted organ systems-specific interpretations by general radiologists based on assigned subspecialty division, and secondary outcome of report turnaround time (TAT) for all ambulatory exams, were compared before and after sub-specialization.ResultsAmong 10 general radiologists, 4.5 were assigned to subspecialty divisions; 5.5 continued to cover an independent general radiology practice in a for-profit delivery network. In the 5 months’ post-transition, a total 86.6% (11,668/13,477) of reports by the integrated general radiologists were within designated subspecialty divisions vs 23.9% (2,586/10,829) pre-transition (P < 0.01). There was no change in ambulatory radiology report TAT for non-urgent care center (UCC) or UCC exams pre- vs post-integration.DiscussionA quality improvement initiative with unambiguous decision-making and conflict resolution processes incorporated a general radiology practice (radiologists and exams) into a subspecialty-focused academic radiology practice without negatively impacting TAT metrics. Future studies would be needed to assess impact on quality of interpretations.     

Comparison of on-call radiology resident and faculty interpretation of 4- and 16-row multidetector CT pulmonary angiography with indirect CT venography

RATIONALE AND OBJECTIVES: On-call radiology residents frequently interpret computed tomography (CT) pulmonary angiography and CT venography studies outside of routine working hours. The purpose of this study was to compare resident and faculty interpretation concordance rates and to see if concordance rates differed depending on the number of CT detectors used. MATERIALS AND METHODS: The study population included 122 consecutive CT pulmonary angiography (CTPA) and CT venography (CTV) examinations performed on a four-row multidetector CT (MDCT) and 125 consecutive CTPA examinations performed using a 16-row MDCT scanner with CTV performed in 124 patients. Preliminary resident reports and final faculty reports were compared. Discrepant cases were independently reviewed by three cardiothoracic radiologists who were unaware of the initial interpretations. Interpretation concordance rates were calculated for both 4- and 16- row MDCT studies and compared using Fisher's exact test. RESULTS: Resident and faculty CTPA and CTV interpretations were concordant in 80% of the 4-row cases and 94% of the 16-row cases. When comparing resident interpretation to the final expert reference standard, the corrected resident error rate was 11% and 2% for 4-row CTPA and CTV, respectively and 4% and 2% for 16-row CTPA and CTV, respectively. Overall CTPA and CTV concordance was significantly lower for 4-row MDCT (80% versus 94%, P < .001 [two-sided] by Fisher's exact test). CONCLUSIONS: Radiology resident interpretation of CTPA and CTV studies demonstrates a high level of agreement with radiology faculty interpretation. Concordance rates are significantly higher for 16-row MDCT than 4-row MDCT which may be due to improved image quality.     

Second-Opinion Reads in Interstitial Lung Disease Imaging: Added Value of Subspecialty Interpretation

PurposeThe purpose of this study was to determine how often a second-opinion interpretation of interstitial lung disease (ILD) by an academic cardiothoracic radiologist is discordant with the initial interpretation by a nonacademic radiologists and how often the clinical diagnosis determined by multidisciplinary consensus agrees with the initial and second-opinion interpretations.MethodsThis retrospective study included 364 consecutive second-opinion CT examination reports of imaging from nonacademic radiology practices from July 2014 to May 2016. The second-opinion interpretations, provided by seven fellowship-trained cardiothoracic radiologists, were compared with the initial interpretations and the clinical diagnoses determined by multidisciplinary consensus.ResultsTwo hundred ninety-six consecutive reports met the inclusion criteria, and two hundred had findings of ILD. The initial interpretations lacked specific diagnoses in 41% of reports, but the second-opinion reports lacked specific diagnoses in only 7%. When a diagnosis was provided, the second-opinion diagnosis disagreed with the initial interpretation in 25% of cases. The clinical-consensus diagnosis was concordant with that of the academic radiologists 85% of the time but concordant with the initial interpretation only 44% of the time. The academic radiologists’ diagnostic sensitivity was higher than that of the initial radiologists for the four most common diagnoses: usual interstitial pneumonitis (0.91 versus 0.4), sarcoidosis (0.94 versus 0.60), hypersensitivity pneumonitis (0.79 versus 0.17), and nonspecific interstitial pneumonitis (0.72 versus 0.14).ConclusionsAcademic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.     

Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents

BACKGROUND AND PURPOSE: Studies have looked at the accuracy of radiologic interpretations by radiology residents as compared with staff radiologists with regard to emergency room plain films, emergency room body CT scans, and trauma head CT scans; however, to our knowledge, no study has evaluated on-call resident interpretations of all types of neuroradiologic CT scans. Both as a part of our departmental quality control program and to address concerns of clinical services about misinterpretation of neuroradiologic CT scans by on-call radiology residents, we evaluated the frequency of incorrect preliminary interpretations of neuroradiologic CT scans by on-call radiology residents and the effect of such misinterpretations on clinical management and patient outcome. METHODS: As determined by the staff neuroradiologist the next day, all potentially clinically significant changes to preliminary reports of emergency neuroradiologic CT scans rendered by on-call radiology residents were recorded over a 9-month period. A panel of neuroradiologists reviewed and graded all the changed cases by consensus. An emergency department staff physician reviewed medical records of all submitted cases to determine clinical consequences of the misinterpretations. RESULTS: Significant misinterpretations were made in 21 (0.9%) of 2388 cases during the study period. There was a significant change in patient management in 12 of the cases, with a potentially serious change in patient outcome in two cases (0.08%). CONCLUSION: On-call radiology residents have a low rate of significant misinterpretations of neuroradiologic CT scans, and the potential to affect patient outcome is rare.     

Radiology Resident Preliminary Reporting in an Independent Call Environment: Multiyear Assessment of Volume,Timeliness, and Accuracy

PurposeThe objective of this paper is to assess the volume, accuracy, and timeliness of radiology resident preliminary reports as part of an independent call system. This study seeks to understand the relationship between resident year in training, study modality, and discrepancy rate.MethodsResident preliminary interpretations on radiographs, ultrasound, CT, and MRI from October 2009 through December 2013 were prospectively scored by faculty on a modified RADPEER scoring system. Discrepancy rates were evaluated based on postgraduate year of the resident and the study modality. Turnaround times for reports were also reviewed. Differences between groups were compared with a chi-square test with a significance level of 0.05. Institutional review board approval was waived as only deidentified data were used in the study.ResultsA total of 416,413 studies were reported by 93 residents, yielding 135,902 resident scores. The rate of major resident–faculty assessment discrepancies was 1.7%. Discrepancy rates improved with increasing experience, both overall (PGY-3: 1.8%, PGY-4: 1.7%, PGY-5: 1.5%) and for each individual modality. Discrepancy rates were highest for MR (3.7%), followed by CT (2.4%), radiographs (1.4%), and ultrasound (0.6%). Emergency department report turnaround time averaged 31.7 min. The average graduating resident has been scored on 2,746 ± 267 reports during residency.ConclusionsResident preliminary reports have a low rate of major discrepancies, which improves over 3 years of call-taking experience. Although more complex cross-sectional studies have slightly higher discrepancy rates, discrepancies were still within the range of faculty report variation.     

Recommendations in Second Opinion Reports of Neurologic Head and Neck Imaging: Frequency,Referring Clinicians’ Compliance,and Diagnostic Yield

BACKGROUND AND PURPOSE:Second opinion reports of neurologic head and neck imaging are requested with increased regularity, and they may contain a recommendation to the clinician. Our aim was to investigate the frequency and determinants of the presence of a recommendation and the adherence by the referring physician to the recommendation in a second opinion neurology head and neck imaging report and the diagnostic yield of these recommendations.MATERIALS AND METHODS:This retrospective study included 994 consecutive second opinion reports of neurology head and neck imaging examinations performed at a tertiary care center.RESULTS:Of the 994 second opinion reports, 12.2% (121/994) contained a recommendation. An oncologic imaging indication was significantly (P = .030) associated with a lower chance of a recommendation in the second opinion report (OR = .67; 95% CI, 0.46–0.96). Clinicians followed 65.7% (88/134) of the recommendations. None of the investigated variables (patient age, sex, hospitalization status, indication for the second opinion report, experience of the radiologist who signed the second opinion report, strength of the recommendation, and whether the recommendation was made due to apparent quality issues of the original examination) were significantly associated with the compliance of the referring physician to this recommendation. The 134 individual recommendations eventually led to the establishment of 52 (38.2%) benign diagnoses and 28 (20.6%) malignant diagnoses, while no definitive diagnosis could be established in 56 (41.2%) cases.CONCLUSIONS:Recommendations are relatively common in second opinion reports of neurology head and neck imaging examinations, though less for oncologic indications. They are mostly followed by requesting physicians, thus affecting patient management. In most cases, they also lead to the establishment of a diagnosis, hence adding value to patient care.

Tertiary care radiology departments frequently review imaging examinations that have been performed and interpreted elsewhere.^1,2 Neurology head and neck (NHN) imaging examinations comprise a large proportion of second opinion reports that are generated at tertiary care centers.²At present, there is an increase in the overall number of second opinion readings.¹ This also applies to second opinion re-evaluations of NHN imaging examinations, with reported growth rates of 245% in the United States from 2011 to 2015.³ Many hospitals also require an official record in the form of a second opinion report to be provided for all outside studies, which may also take extra time. This policy is followed by 37.4%–60.0% of the radiology departments in the United States.⁴ Altogether, the workload of radiologists due to second opinion interpretations is increasing.Second opinion interpretations may potentially be beneficial to patient care by avoiding unnecessary additional imaging examinations, improving disease detection, and establishing a more accurate differential diagnosis.^2,5-9 Tertiary care radiologists may also give a recommendation in the second opinion report to provide guidance on patient management to the clinician. These recommendations may include advice to perform additional imaging, perform a biopsy, refer the patient to another specialty, or compare an examination with previous imaging examinations, among others.Currently, it is unclear how many second opinion reports of NHN imaging examinations contain a recommendation to the clinician, which factors are associated with the presence of a recommendation in the second opinion report, how frequently the recommendation is followed by the clinician, and which factors affect the adherence of the clinician to the recommendation. Such information would be valuable to determine whether the practice of second opinion reporting with the provision of a recommendation to the clinician affects patient management in the field of NHN imaging. In addition, it is unknown how many of these recommendations eventually allow the establishment of a diagnosis. This information is important to understand their contribution to value-based patient care.The purpose of this study was, therefore, to investigate the frequency and determinants of the presence of a recommendation and the adherence by the referring physician to the recommendation in a second opinion NHN imaging report and the diagnostic yield of these recommendations.     

Transfer Patient Imaging: Assessment of the Impact of Discrepancies Identified by Emergency Radiologists

PurposeAdvanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED).MethodsAll CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services.ResultsOver a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%).ConclusionEmergency radiology overreading of transferred patients’ advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs.     

Best Reporting Practices for Multipart CT Scans: A Pilot Evaluation and Construction of the Optimal Analysis Methodology

PurposeCommunication failure between radiologists and referring physicians contributes to a substantial portion of medical errors. With a rising number of complex imaging orders and subspecialization among radiologists, the best method of reporting those results has yet to be evaluated. The aim of this study was to create, validate, and pilot a survey to reveal best practices for communication of radiologic findings, specifically addressing multipart CT scans of the chest, abdomen, and pelvis.MethodsA survey consisting of Likert-type and narrative response items was created, tested, and validated. It was then administered to physicians of five specialties (including radiology) at an urban quaternary care academic center and an affiliated community hospital.ResultsThe pilot survey results revealed that there was a small preference among both radiologists and referring physicians to have a single radiologist read in a single report for a multipart CT scan, rather than multiple subspecialist radiologists and reports. The findings were supported by narrative response explanations as well and demonstrate the importance of a rapid, clear, and cohesive image interpretation, despite the growing trend of radiology subspecialization. The results of the survey also confirmed its validity through an assessment with Messick’s five sources of validity evidence.ConclusionsThe survey’s validity indicates its generalizability to a future national survey to physicians of multiple specialties to further identify the preference of physicians on reporting of complex radiologic studies, in the setting of increased radiologic subspecialization.