Recommendations For Additional Imaging Research Articles

Lack of Timely Follow-Up of Abnormal Imaging Results and Radiologists’ Recommendations

PurposeAbnormal imaging results may not always lead to timely follow-up. We tested whether certain aspects of communication in radiology reports influence the response of the referring providers, and hence follow-up on abnormal findings. MethodsWe focused on 2 communication-related items that we hypothesized could affect follow-up: expressions of doubt in the radiology report, and recommendations for further imaging. After institutional review board approval, we conducted a retrospective review of 250 outpatient radiology reports from a multispecialty ambulatory clinic of a tertiary-care Veterans Affairs facility. The selected studies included 92 cases confirmed to lack timely follow-up (ie, further tests or consultations, treatment, and/or communication to the patient within 4 weeks), as determined in a previous study. An additional 158 cases with documented timely follow-up served as controls. Doubt in the narrative was measured by the presence of key phrases (eg, “unable to exclude,” “cannot exclude,” “cannot rule out,” “possibly,” and “unlikely”), in the absence of which we used reviewer interpretation. A physician blinded to follow-up outcomes collected the data. ResultsPatients whose reports contained recommendations for further imaging were more likely to have been lost to follow-up at 4 weeks compared with patients without such recommendations (P = .01). Language in the report suggestive of doubt did not affect the timeliness of follow-up (P = .59). ConclusionsAbnormal imaging results with recommendations for additional imaging may be more vulnerable to lack of timely follow-up. Additional safeguards, such as tracking systems, should be developed to prevent failure to follow up on such results.

ACR Members' Response to JACR White Paper on the Management of Incidental Abdominal CT Findings

In October 2010, a white paper was published in this journal that represented a consensus of the ACR Incidental Findings Committee, including guidance for characterizing, reporting, and managing incidental findings in the liver, kidneys, adrenal glands, and pancreas. A survey was conducted of the ACR membership to determine how widely this paper had been read, how the information is being used, and how management of incidental findings may be improved. A survey consisting of 14 multiple-choice and 5 free-text responses was distributed by e-mail to 14,336 ACR physician members. The survey was open during June and July 2012 using SurveyMonkey. Topics included how the paper's recommendations had affected practice and the frequency of recommendations for additional imaging, how incidental findings are reported, the content and the form of the white paper, and the possible effects of tort reform. Of the 14,336 radiologists contacted, 2,892 (20%) returned the survey; of these, 1,099 (38%) indicated that they had read the paper. Of the 1,099 radiologists who read the paper, 978 (89%) responded that the content was used in clinical practice. The white paper led 560 radiologists (51%) to recommend additional imaging less often and 33 radiologists (3%) to recommend imaging more often. Tort reform was cited by 835 radiologists (76%) as a means to decrease the likelihood of their recommending additional imaging. The 2010 JACR white paper on incidental abdominal CT findings has been read by a substantial number of radiologists, and among those who read it, the recommendations are being largely followed and are leading to a reduction in imaging recommendations. Future similar consensus-based white papers could lead to more consistent and effective management of incidental imaging findings and likely reduce the overall number of patients for whom additional imaging is recommended.

Automated Detection Using Natural Language Processing of Radiologists Recommendations for Additional Imaging of Incidental Findings

As use of radiology studies increases, there is a concurrent increase in incidental findings (eg, lung nodules) for which the radiologist issues recommendations for additional imaging for follow-up. Busy emergency physicians may be challenged to carefully communicate recommendations for additional imaging not relevant to the patient's primary evaluation. The emergence of electronic health records and natural language processing algorithms may help address this quality gap. We seek to describe recommendations for additional imaging from our institution and develop and validate an automated natural language processing algorithm to reliably identify recommendations for additional imaging. We developed a natural language processing algorithm to detect recommendations for additional imaging, using 3 iterative cycles of training and validation. The third cycle used 3,235 radiology reports (1,600 for algorithm training and 1,635 for validation) of discharged emergency department (ED) patients from which we determined the incidence of discharge-relevant recommendations for additional imaging and the frequency of appropriate discharge documentation. The test characteristics of the 3 natural language processing algorithm iterations were compared, using blinded chart review as the criterion standard. Discharge-relevant recommendations for additional imaging were found in 4.5% (95% confidence interval [CI] 3.5% to 5.5%) of ED radiology reports, but 51% (95% CI 43% to 59%) of discharge instructions failed to note those findings. The final natural language processing algorithm had 89% (95% CI 82% to 94%) sensitivity and 98% (95% CI 97% to 98%) specificity for detecting recommendations for additional imaging. For discharge-relevant recommendations for additional imaging, sensitivity improved to 97% (95% CI 89% to 100%). Recommendations for additional imaging are common, and failure to document relevant recommendations for additional imaging in ED discharge instructions occurs frequently. The natural language processing algorithm's performance improved with each iteration and offers a promising error-prevention tool.

Recommendations for additional imaging on emergency department CT examinations: comparison of emergency- and organ-based subspecialty radiologists

Past studies have identified a high frequency of recommendations for additional imaging (RAI) for computed tomography (CT) studies performed in an emergency department (ED), thereby potentially contributing to increased imaging utilization and costs. The purpose of this study was to compare rates of RAI within the ED setting between ED-based and organ-based subspecialty radiologists. We identified 600 ED CT studies, comprising 200 head, chest, and abdominal CT studies, split equally between cases reviewed by ED-based and organ-based radiologists. Frequency of RAI for the three examinations was compared between these subspecialty groups. Frequencies of RAI were 21.5 %, 13.5 %, and 5.5 % for CT examinations of the chest, abdomen, and brain, respectively. There was a significantly higher frequency of RAI for chest CT studies interpreted by chest radiologists than by ED radiologists (28.0 % vs. 15.0 %, respectively, p = 0.036), largely due to a higher rate of RAI for incidentally detected lung nodules and masses as well as other pulmonary parenchymal abnormalities by chest radiologists. There was no significant difference in RAI on brain or abdominal CT studies between the two groups (p = 0.426-1.0). However, on abdominal studies, only ED-based radiologists provided RAI for abnormalities of the bowel or uterus, while only organ-based radiologists provided RAI for pancreatic abnormalities. Only 25.6 % of RAI were subsequently performed at our institution. For chest CT studies performed at the authors' institution, differences in management of incidental pulmonary nodules contributed to a significantly higher frequency of RAI by chest radiologists than by ED-based radiologists. Further investigation of the impact of these differences on cost and patient outcomes is warranted.

Decision Support for Radiologist Report Recommendations

The past 2 decades have seen a remarkable increase in the capabilities, utilization, and cost burden of medical imaging [1-6]. This increase in demand for diagnostic imaging has put imaging in the spotlight as a target for cuts in reimbursement [1-7]. Much of the growth in imaging utilization is clearly beneficial to medical practice and increased quality of care [8]. However, we are also facing a challenge from some referring physicians who regard recommendations for additional imaging made by radiologists in their official reports as a form of “self-referral” [9].

Timeliness of Follow-up after Abnormal Screening Mammogram: Variability of Facilities

To describe the timeliness of follow-up care in community-based settings among women who receive a recommendation for immediate follow-up during the screening mammography process and how follow-up timeliness varies according to facility and facility-level characteristics. This was an institutional review board-approved and HIPAA-compliant study. Screening mammograms obtained from 1996 to 2007 in women 40-80 years old in the Breast Cancer Surveillance Consortium were examined. Inclusion criteria were a recommendation for immediate follow-up at screening, or subsequent imaging, and observed follow-up within 180 days of the recommendation. Recommendations for additional imaging (AI) and biopsy or surgical consultation (BSC) were analyzed separately. The distribution of time to follow-up care was estimated by using the Kaplan-Meier estimator. Data were available on 214,897 AI recommendations from 118 facilities and 35,622 BSC recommendations from 101 facilities. The median time to subsequent follow-up care after recommendation was 14 days for AI and 16 days for BSC. Approximately 90% of AI follow-up and 81% of BSC follow-up occurred within 30 days. Facilities with higher recall rates tended to have longer AI follow-up times (P < .001). Over the study period, BSC follow-up rates at 15 and 30 days improved (P < .001). Follow-up times varied substantially across facilities. Timely follow-up was associated with larger volumes of the recommended procedures but not notably associated with facility type nor observed facility-level characteristics. Most patients with follow-up returned within 3 weeks of the recommendation.

CT Colonography in Senior versus Nonsenior Patients: Extracolonic Findings, Recommendations for Additional Imaging, and Polyp Prevalence

To retrospectively evaluate the frequency of recommendations for additional imaging (RAIs) for important extracolonic findings and polyp prevalence among a cohort of seniors (age ≥ 65 years) and nonseniors (age < 65 years) undergoing low-dose computed tomographic (CT) colonography. Institutional review board approval was obtained for this HIPAA-compliant retrospective study. Four hundred fifty-four patients (204 nonseniors: mean age, 52 years; 250 seniors: mean age, 69 years) underwent CT colonography at an outpatient facility. Cases were prospectively reported by one of four abdominal radiologists with expertise in CT colonography. The dictated reports were reviewed to determine the frequency of polyps (≥6 mm), the number of extracolonic findings, and the number of RAIs generated. The Fisher exact test was used to compare the percentage of seniors and nonseniors with at least one reported polyp, with at least one extracolonic finding, as well as the frequency of RAIs. The percentage of patients with at least one reported polyp was 14.2% (29 of 204) for the nonsenior group and 13.2% (33 of 250) for seniors, which was not significantly different (P = .772). The percentage of patients with at least one extracolonic finding was 55.4% (113 of 204) for nonseniors and 74.0% (185 of 250) for seniors (P < .0001). The percentage of patients in which an RAI was suggested was 4.4% (nine of 204) for nonseniors and 6.0% (15 of 250) for seniors, which was not significantly different (P = .450). Extracolonic findings were more frequent in seniors than in nonseniors; however, there was no significant difference in the frequency of RAIs between the two groups. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11102144/-/DC1.

Recommendations for Additional Imaging in Radiology Reports: Radiologists' Self-Referral or Good Clinical Practice?

HomeRadiologyVol. 253, No. 2 PreviousNext Recommendations for Additional Imaging in Radiology Reports: Radiologists' Self-Referral or Good Clinical Practice?Ronald L. ArensonRonald L. ArensonAuthor Affiliations1From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, Room M-391, San Francisco, CA 94143-0628.Address correspondence to the author (e-mail: [email protected]).Ronald L. ArensonPublished Online:Nov 1 2009https://doi.org/10.1148/radiol.2532091216MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractWhether recommendations for additional imaging in radiology reports are considered self-referral or good clinical practice depends on the appropriateness of both the original and recommended additional procedures, which can only be determined through good outcomes studies.© RSNA, 2009 References 1 Sistrom CL, Dreyer KJ, Dang PPet al.. Recommendations for additional imaging in radiology reports: multifactorial analysis of 5.9 million examinations. Radiology 2009;253(2):453–461. Link, Google Scholar2 Kerlikowske K, Smith-Bindman R, Abraham LAet al.. Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up. Radiology 2005;234(3):684–692. Link, Google Scholar3 Orel S. Who should have breast magnetic resonance imaging evaluation? J Clin Oncol 2008;26(5):703–711. Crossref, Medline, Google Scholar4 Khan KY, Xiong T, McCafferty Iet al.. Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population. Br J Surg 2007;94(3):355–361. Crossref, Medline, Google Scholar5 Pickhardt PJ, Taylor AJ. Extracolonic findings identified in asymptomatic adults at screening CT colonography. AJR Am J Roentgenol 2006;186(3):718–728. Crossref, Medline, Google Scholar6 Yee J, Kumar NN, Godara Set al.. Extracolonic abnormalities discovered incidentally at CT colonography in a male population. Radiology 2005;236(2):519–526. Link, Google Scholar7 Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology 2009;251(1):147–155. Link, Google Scholar8 Boonn WW, Langlotz CP. Radiologist use of and perceived need for patient data access. J Digit Imaging 2009;22(4):357–362. Crossref, Medline, Google Scholar9 Levin DC, Rao VM. Turf wars in radiology: updated evidence on the relationship between self-referral and the overutilization of imaging. J Am Coll Radiol 2008;5(7):806–810. Crossref, Medline, Google Scholar10 Levin DC, Rao VM. Turf wars in radiology: other causes of overutilization and what can be done about it. J Am Coll Radiol 2004;1(5):317–321. Crossref, Medline, Google Scholar11 Levin DC, Rao VM, Parker L, Frangos AJ, Sunshine JH. Ownership or leasing of CT scanners by nonradiologist physicians: a rapidly growing trend that raises concern about self-referral. J Am Coll Radiol 2008;5(12):1206–1209. Crossref, Medline, Google ScholarArticle HistoryReceived July 7, 2009; revision requested July 22; revision received July 24; final version accepted July 24.Published in print: Nov 2009 FiguresReferencesRelatedDetailsCited ByJournal of Medical Imaging and Radiation Oncology, Vol. 64, No. 3Pediatric Radiology, Vol. 47, No. 13Journal of the American College of Radiology, Vol. 14, No. 5Journal of the American College of Radiology, Vol. 13, No. 9Emergency Radiology, Vol. 21, No. 4JMIR Medical Informatics, Vol. 2, No. 1JMIR Medical Informatics, Vol. 2, No. 1Clinical Radiology, Vol. 68, No. 2Journal of Nuclear Medicine, Vol. 54, No. 5Journal of the American College of Radiology, Vol. 8, No. 12Compliance with Fleischner Society Guidelines for Management of Lung Nodules: Lessons and Opportunities1Heber MacMahon, 10 March 2010 | Radiology, Vol. 255, No. 1Recommended Articles Overview of Noninterpretive Artificial Intelligence Models for Safety, Quality, Workflow, and Education Applications in Radiology PracticeRadiology: Artificial Intelligence2022Volume: 4Issue: 2Whole-Body Clinical Applications of Digital TomosynthesisRadioGraphics2016Volume: 36Issue: 3pp. 735-750Factors Affecting Interpretative Accuracy: How Can We Reduce Errors?Radiology2018Volume: 287Issue: 1pp. 213-214Electronic Health Record Closed-Loop Communication Program for Unexpected Nonemergent FindingsRadiology2021Volume: 301Issue: 1pp. 123-130Patient Exposure from Radiologic and Nuclear Medicine Procedures in the United States: Procedure Volume and Effective Dose for the Period 2006–2016Radiology2020Volume: 295Issue: 2pp. 418-427See More RSNA Education Exhibits A Cased-Based Health Equity Primer for Radiologists: Real Cases, Real Problems, Real SolutionsDigital Posters2020Introduction to Artificial Intelligence and Big Data Research in Chest RadiologyDigital Posters2019The Value of Adding Contrast Enhanced Spectral Mammography to the Diagnostic Breast Imaging Practice: How to Implement a Program and Examples of the Utility of CESM as a Problem Solving ToolDigital Posters2018 RSNA Case Collection Chagas diseaseRSNA Case Collection2021SclerodermaRSNA Case Collection2022Neonatal tuberous sclerosis RSNA Case Collection2020 Vol. 253, No. 2 Metrics Altmetric Score PDF download

Recommendations for Additional Imaging in Radiology Reports: Multifactorial Analysis of 5.9 Million Examinations

To quantify the rates of recommendation for additional imaging (RAI) in a large number of radiology reports of different modalities and to estimate the effects of 11 clinically relevant factors. This HIPAA compliant research was approved by the institutional review board under an expedited protocol for analyzing anonymous aggregated radiology data. All diagnostic imaging examinations (n = 5 948 342) interpreted by radiologists between 1995 and 2008 were studied. A natural language processing technique specifically designed to extract information about any recommendations from radiology report texts was used. The analytic data set included three quantitative variables: the interpreting radiologist's experience, the year of study, and patient age. Categoric variables described patient location (inpatient, outpatient, emergency department), whether a resident dictated the case, patient sex, modality, body area studied, ordering service, radiologist's specialty division, and whether the examination result was positive. A multivariable logistic regression model was used to determine the effect of each of these factors on likelihood of RAI while holding all others equal. Recommendations increased during the 13 years of study, with the unadjusted rate rising from roughly 6% to 12%. After accounting for all other factors, the odds of any one examination resulting in an RAI increased by 2.16 times (95% confidence interval: 2.12, 2.21) from 1995 to 2008. As radiologist experience increased, the odds of an RAI decreased by about 15% per decade. Studies that had positive findings were more likely (odds ratio = 5.03; 95% confidence interval: 4.98, 5.07) to have an RAI. The remaining factors also had significant effects on the tendency for an RAI. The likelihood of RAI increased by 15% for each decade of radiologist experience and roughly doubled over 13 years of study.

Outcome of examinations self-referred as a result of spiral CT of the abdomen.

The interpretation of an abdominal computed tomographic (CT) scan is occasionally inconclusive. In many of these cases, the radiologist suggests an additional imaging test for further confirmation or clarification. The purpose of this study was to evaluate the outcome of self-referral by the radiologist after abdominal CT scanning. Reports from 545 consecutive abdominal CT scans were reviewed to track recommendations for additional imaging. In patients who underwent the additional work-up, a determination of the effect of the study was attempted. In patients who did not, explanations were sought. Wording of the recommendations was also recorded. Recommendations were made for additional imaging studies in 105 (19.3%) patients. Of these, 32 (30.5%) were performed and 31 (96.9%) were helpful by confirming malignancy (n = 5), confirming a benign process (n = 24), or being therapeutic (n = 2). In one, no information was added. There were 63 (60.0%) patients who did not undergo the recommended studies. Reasons included "no clinical indication" (n = 51), alternative study performed (n = 9), or study previously performed (n = 3). In eight (7.6%) patients the chart provided insufficient information about whether the patient underwent the study, and in two (1.9%) the chart was unavailable. Wording of the recommendation had no effect on whether the study was performed (P > .05). Although interpretation of abdominal CT scans leads to recommendations for additional imaging in a minority of cases, these recommendations were infrequently followed. When followed, however, the findings from the recommended studies were usually helpful. Better clinical information is perhaps the best way to reduce self-referral by radiologists.