The actionable imaging report

Imaging 3.0: A scoping review

We aim to provide a comprehensive summary of the current body of literature concerning the Imaging 3.0 initiative and its implications for patient care within the field of radiology. We offer a thorough analysis of the literature pertaining to the Imaging 3.0 initiative, emphasizing the practical application of the five pillars of the program, their cost-effectiveness, and their benefits in patient management. By doing so, we hope to illustrate the impact the Imaging 3.0 Initiative can have on the future of radiology and patient care.

An approach to evaluate the quality of radiological reports in Head and Neck cancer loco-regional staging: experience of two Academic Hospitals

OBJECTIVES

To evaluate the quality of the reports of loco-regional staging computed tomography (CT) or magnetic resonance imaging (MRI) in head and neck (H&N) cancer.

METHODS

Consecutive reports of staging CT and MRI of all H&N cancer cases from 2018 to 2020 were collected. We created lists of quality indicators for tumor (T) for each district and for node (N). We marked these as 0 or 1 in the report calculating a report score (RS) and a maximum sum (MS) of each list. Two radiologists and two otolaryngologists in consensus classified reports as low quality (LQ) if the RS fell in the percentage range 0-59% of MS and as high quality (HQ) if it fell in the range 60-100%, annotating technique and district. We evaluated the distribution of reports in these categories.

RESULTS

Two hundred thirty-seven reports (97 CT and 140 MRI) of 95 oral cavity, 52 laryngeal, 47 oropharyngeal, 19 hypo-pharyngeal, 14 parotid, and 10 nasopharyngeal cancers were included. Sixty-six percent of all the reports were LQ for T, 66% out of all the MRI reports, and 65% out of all CT reports were LQ. Eight-five percent of reports were HQ for N, 85% out of all the MRI reports, and 82% out of all CT reports were HQ. Reports of oral cavity, oro-nasopharynx, and parotid were LQ, respectively, in 76%, 73%, 100% and 92 out of cases.

CONCLUSION

Reports of staging CT/MRI in H&N cancer were LQ for T description and HQ for N description.

Adoption of a diagnostic certainty scale in abdominal imaging: 2-year experience at an academic institution

PURPOSE

Assess use of a diagnostic certainty scale (CS) for abdominal imaging reports and identify factors associated with greater adoption.

METHODS

This retrospective, Institutional Review Board-exempt study was conducted at an academic health system. Abdominal radiology reports containing diagnostic certainty phrases (DCPs) generated 4/1/2019-3/31/2021 were identified by a natural language processing tool. Reports containing DCPs were subdivided into those with/without a CS inserted at the end. Primary outcome was monthly CS use rate in reports containing DCPs. Secondary outcomes were assessment of factors associated with CS use, and usage of recommended DCPs over time. Chi-square test was used to compare proportions; univariable and multivariable regression assessed impact of other variables.

RESULTS

DCPs were used in 81,281/124,501 reports (65.3%). One-month post-implementation, 82/2310 (3.6%) of reports with DCPs contained the CS, increasing to 1862/4644 (40.1%) by study completion (p < 0.001). Multivariable analysis demonstrated reports containing recommended DCPs were more likely to have the CS (Odds Ratio [OR] 4.5; p < 0.001). Using CT as a reference, CS use was lower for ultrasound (OR 0.73; p < 0.001) and X-ray (OR 0.38; p < 0.001). There was substantial inter-radiologist variation in CS use (OR 0.01-26.3, multiple p values).

CONCLUSION

DCPs are very common in abdominal imaging reports and can be further clarified with CS use. Although voluntary CS adoption increased 13-fold over 2 years, > 50% of reports with DCPs lacked the CS at study's end. More stringent interventions, including embedding the scale in report templates, are likely needed to reduce inter-radiologist variation and decrease ambiguity in conveying diagnostic certainty to referring providers and patients.

Deep Learning-Based Natural Language Processing in Radiology: The Impact of Report Complexity, Disease Prevalence, Dataset Size, and Algorithm Type on Model Performance

In radiology, natural language processing (NLP) allows the extraction of valuable information from radiology reports. It can be used for various downstream tasks such as quality improvement, epidemiological research, and monitoring guideline adherence. Class imbalance, variation in dataset size, variation in report complexity, and algorithm type all influence NLP performance but have not yet been systematically and interrelatedly evaluated. In this study, we investigate these factors on the performance of four types [a fully connected neural network (Dense), a long short-term memory recurrent neural network (LSTM), a convolutional neural network (CNN), and a Bidirectional Encoder Representations from Transformers (BERT)] of deep learning-based NLP. Two datasets consisting of radiologist-annotated reports of both trauma radiographs (n = 2469) and chest radiographs and computer tomography (CT) studies (n = 2255) were split into training sets (80%) and testing sets (20%). The training data was used as a source to train all four model types in 84 experiments (Fracture-data) and 45 experiments (Chest-data) with variation in size and prevalence. The performance was evaluated on sensitivity, specificity, positive predictive value, negative predictive value, area under the curve, and F score. After the NLP of radiology reports, all four model-architectures demonstrated high performance with metrics up to > 0.90. CNN, LSTM, and Dense were outperformed by the BERT algorithm because of its stable results despite variation in training size and prevalence. Awareness of variation in prevalence is warranted because it impacts sensitivity and specificity in opposite directions.

A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program. Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports. Results: Enrollees (n = 13) were median age 61 (IQR 52-65.5), and 129 (52-486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3-56.7) h. Non-compliance doubled during weeks 7-12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5-12.5) points in the arm and 1 (-0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached. Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR. Clinical Trial Registration: Clinicaltrials.gov, # NCT03460587.

Improving follow-up of incomplete lower extremity venous duplex ultrasound examinations performed for deep and superficial vein thromboses

OBJECTIVE

A lower extremity venous duplex ultrasound (LEVDUS) examination is the standard diagnostic test to evaluate patients for lower extremity deep vein thrombosis (DVT). However, some studies will be incomplete for a variety of reasons, including patient-related factors such as pain, edema, a large leg circumference, or the presence of overlying bandages or orthopedic devices. We previously reported that the frequency of obtaining a follow-up examination after an incomplete and negative (I/N) LEVDUS examination was low but that the rates of DVT found on the follow-up studies of initially I/N LEVDUS studies were similar to the rates of DVT found with initially complete LEVDUS examinations. Therefore, we recommended process improvements to increase follow-up LEVDUS studies after an I/N LEVDUS examination. In the present study, we have described the results of appending a recommendation to obtain a follow-up LEVDUS study to preliminary and final reports of I/N LEVDUS.

METHODS

Starting in January 2019 through December 2019, a recommendation to obtain a repeat LEVDUS examination after an I/N study was appended to the preliminary and final reports of all I/N LEVDUS examination of patients who did not, otherwise, have an indication for anticoagulation (group 2). The patients were identified on an ongoing basis through the study period and entered into an Excel database (Microsoft Corp, Redmond, Wash). Group 2 was compared with a previously reported historic control cohort of patients identified from January 2017 to December 2017 (group 1). We compared groups 1 and 2 with respect to the frequency of the repeat studies performed within 4 weeks after an I/N LEVDUS examination and the DVT rates found from the follow-up LEVDUS examinations after an I/N LEVDUS study.

RESULTS

Of the patients in groups 1 and 2, 187 and 229 had had I/N LEVDUS examinations, with 28% and 40.2% of group 1 and 2 studies having follow-up LEVDUS examinations (P < .01). Previously unidentified lower extremity thrombi were discovered in 21% of the group 2 follow-up examinations. Also, the rate of new thrombi detected was not different between groups 2 and 1 (historic controls; DVT, 14.3% vs 18.5% [P = .25]; SVT, 6.3% vs 3.3% [P = .15]). A definitive finding of either positive or negative for DVT and SVT with a complete examination in 50% of the group 2 patients with follow-up examinations.

CONCLUSIONS

A recommendation to obtain a follow-up examination appended to the preliminary and final I/N LEVDUS reports was associated with an increased rate of follow-up examinations, which revealed many previously undetected DVTs and SVTs or had allowed for definitive exclusion of DVT.

Early Adoption of a Certainty Scale to Improve Diagnostic Certainty Communication

OBJECTIVE

Assess the early voluntary adoption of a certainty scale to improve communicating diagnostic certainty in radiology reports.

METHODS

This institutional review board-approved study was part of a multifaceted initiative to improve radiology report quality at a tertiary academic hospital. A committee comprised of radiology subspecialty division representatives worked to develop recommendations for communicating varying degrees of diagnostic certainty in radiology reports in the form of a certainty scale, made publicly available online, which specified the terms recommended and the terms to be avoided in radiology reports. Twelve radiologists voluntarily piloted the scale; use was not mandatory. We assessed proportion of recommended terms among all diagnostic certainty terms in the Impression section (primary outcome) of all reports generated by the radiologists. Certainty terms were extracted via natural language processing over a 22-week postintervention period (31,399 reports) and compared with the same 22 calendar weeks 1 year pre-intervention (24,244 reports) using Fisher's exact test and statistical process control charts.

RESULTS

Overall, the proportion of recommended terms significantly increased from 8,498 of 10,650 (80.0%) pre-intervention to 9,646 of 11,239 (85.8%) postintervention (P < .0001 and by statistical process control). The proportion of recommended terms significantly increased for 8 of 12 radiologists (P < .0005 each), increased insignificantly for 3 radiologists (P > .05), and decreased without significance for 1 radiologist.

CONCLUSION

Designing and implementing a certainty scale was associated with increased voluntary use of recommended certainty terms in a small radiologist cohort. Larger-scale interventions will be needed for adoption of the scale across a broad range of radiologists.

Perception of radiology reporting efficacy by neurologists in general and university hospitals

AIM

To investigate how neurologists perceive the value of the radiology report and to analyse the relation with the neurologists own expertise in radiology and the level of subspecialisation of radiologists.

MATERIALS AND METHODS

A web-based survey was distributed to neurologists. The level of subspecialisation was assessed by the percentage of fellowship-trained radiologists and the percentage of radiologists that were members of the Dutch Society of Neuroradiology.

RESULTS

Most neurologists interpret all computed tomography (CT) and magnetic resonance imaging (MRI) studies themselves, and their self-confidence in making correct interpretations is high. Residents gave higher scores than neurologists for "Radiologist report answers the question" (p=0.039) and for "Radiologist reports give helpful advice" (p=0.001). Neurologists from university hospitals stated more frequently that the report answered their questions than neurologists from general hospitals (p=0.008). The general appreciation for radiology reports was higher for neurologists from university hospitals than from general hospitals (8.2 versus 7.2; p=0.003). Radiologists at university hospitals have a higher level of subspecialisation than those at general hospitals.

CONCLUSION

Subspecialisation of radiologists leads to higher quality of radiology reporting as perceived by neurologists. Because of their expertise in radiology, neurologists are valuable sources of feedback for radiologists. Paying attention to the clinical questions and giving advice tailored to the needs of the referring physicians are opportunities to improve radiology reporting.