Improvement of radiology reporting in a clinical cancer network: impact of an optimised multidisciplinary workflow

Automatic Classification of Tumor Response From Radiology Reports With Rule-Based Natural Language Processing Integrated Into the Clinical Oncology Workflow

PURPOSE

Imaging reports in oncology provide critical information about the disease evolution that should be timely shared to tailor the clinical decision making and care coordination of patients with advanced cancer. However, tumor response stays unstructured in free-text and underexploited. Natural language processing (NLP) methods can help provide this critical information into the electronic health records (EHR) in real time to assist health care workers.

METHODS

A rule-based algorithm was developed using SAS tools to automatically extract and categorize tumor response within progression or no progression categories. 2,970 magnetic resonance imaging, computed tomography scan, and positron emission tomography French reports were extracted from the EHR of a large comprehensive cancer center to build a 2,637-document training set and a 603-document validation set. The model was also tested on 189 imaging reports from 46 different radiology centers. A tumor dashboard was created in the EHR using the Timeline tool of the vis.js javascript library.

RESULTS

An NLP methodology was applied to create an ontology of radiographic terms defining tumor response, mapping text to five main concepts, and application decision rules on the basis of clinical practice RECIST guidelines. The model achieved an overall accuracy of 0.88 (ranging from 0.87 to 0.94), with similar performance on both progression and no progression classification. The overall accuracy was 0.82 on reports from different radiology centers. Data were visualized and organized in a dynamic tumor response timeline. This tool was deployed successfully at our institution both retrospectively and prospectively as part of an automatic pipeline to screen reports and classify tumor response in real time for all metastatic patients.

CONCLUSION

Our approach provides an NLP-based framework to structure and classify tumor response from the EHR and integrate tumor response classification into the clinical oncology workflow.

Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error

Background

Strategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences.

Results

We analysed 241 MDCs with a total of 973 examinations. 14.0% (n = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, n = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, n = 25/139, e.g. technical issue) and indication-related events (5.8%, n = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% (n = 109/476) to 6.0% (n = 30/497) (p < 0.0001). Significance of this effect was confirmed by linear regression (p < 0.0001).

Conclusions

Establishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01313-5.

Clinical Routine and Necessary Advances in Soft Tissue Tumor Imaging Based on the ESSR Guideline: Initial Findings

Soft tissue sarcomas are malignant diseases with a complex classification and various histological subtypes, mostly clinically inconspicuous appearance, and a rare occurrence. To ensure safe patient care, the European Society of Musculoskeletal Radiology (ESSR) issued a guideline for diagnostic imaging of soft tissue tumors in adults in 2015. In this study, we investigated whether implementation of these guidelines resulted in improved MRI protocol and report quality in patients with soft tissue sarcomas in our cancer center. All cases of histologically confirmed soft tissue sarcomas that were treated at our study center from 2006 to 2018 were evaluated retrospectively. The radiological reports were examined for their compliance with the recommendations of the ESSR. Patients were divided into two groups, before and after the introduction of the 2015 ESSR guidelines. In total, 103 cases of histologically confirmed sarcomas were studied. The distribution of, age, gender, number of subjects, performing radiology, and MRI indication on both groups did not show any significant differences. Only using the required MRI sequences showed a significant improvement after the introduction of the guidelines (p = 0.048). All other criteria, especially the requirements for the report of findings, showed no improvement. The guidelines of the European Society for Musculoskeletal Radiology are not regularly followed, and their establishment did not consistently improve MRI quality in our study group. This poses a risk for incorrect or delayed diagnosis and, ultimately, therapy of soft tissue tumors. However, this study is the first of its kind and involves a limited collective. A European-wide multicenter study would be appreciated to confirm these results.

The role of radiologist in the changing world of healthcare: a White Paper of the European Society of Radiology (ESR)

Radiology as a specialty has been enormously successful since its beginnings, moving over time from an adjunct to clinical decision-making to a crucial component of multidisciplinary patient care. However, this increased centrality of radiology and reliance on our services carries within it dangers, prominent among them being the danger of our being viewed as deliverers of a commodity, and the risk of our becoming overwhelmed by increasing workload, unable to interact sufficiently with patients and referrers due to pressure of work. With this White Paper, the Board of Directors of the European Society of Radiology (ESR) seeks to briefly explain the position of the radiologist in the modern healthcare environment, considering our duties and contributions as doctors, protectors, communicators, innovators, scientists and teachers. This statement is intended to serve as a summary of the breadth of our responsibilities and roles, and to assist radiologists in countering misunderstanding of who we are and what we do.

iRECIST-based versus non-standardized free text reporting of CT scans for monitoring metastatic renal cell carcinoma: a retrospective comparison

Purpose

Therapy decision for patients with metastatic renal cell carcinoma (mRCC) is highly dependent on disease monitoring based on radiological reports. The purpose of the study was to compare non-standardized, common practice free text reporting (FTR) on disease response with reporting based on response evaluation criteria in solid tumors modified for immune-based therapeutics (iRECIST).

Methods

Fifty patients with advanced mRCC were included in the retrospective, single-center study. CT scans had been evaluated and FTR prepared in accordance with center’s routine practice. For study purposes, reports were re-evaluated using a dedicated computer program that applied iRECIST. Patients were followed up over a period of 22.8 ± 7.9 months in intervals of 2.7 ± 1.8 months.

Weighted kappa statistics was run to assess strength of agreement. Logistic regression was used to identify predictors for different rating.

Results

Agreement between FTR and iRECIST-based reporting was moderate (kappa 0.38 [95% CI 0.2–0.6] to 0.70 [95% CI 0.5–0.9]). Tumor response or progression according to FTR were not confirmed with iRECIST in 19 (38%) or 11 (22%) patients, respectively, in at least one follow-up examination. With FTR, new lesions were frequently not recognized if they were already identified in the recent prior follow-up examination (odds ratio for too favorable rating of disease response compared to iRECIST: 5.4 [95% CI 2.9–10.1].

Conclusions

Moderate agreement between disease response according to FTR or iRECIST in patients with mRCC suggests the need of standardized quantitative radiological assessment in daily clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-022-03997-0.

Structured reporting in radiology: a systematic review to explore its potential

OBJECTIVES

Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is necessary to verify that radiology reporting can benefit from SR. Therefore, the purpose of this systematic review is to explore the level of evidence of structured reporting in radiology. Additionally, this review provides an overview on the current status of SR in radiology.

METHODS

A narrative systematic review was conducted, searching PubMed, Embase, and the Cochrane Library using the syntax 'radiol*' AND 'structur*' AND 'report*'. Structured reporting was divided in SR level 1, structured layout (use of templates and checklists), and SR level 2, structured content (a drop-down menu, point-and-click or clickable decision trees). Two reviewers screened the search results and included all quantitative experimental studies that discussed SR in radiology. A thematic analysis was performed to appraise the evidence level.

RESULTS

The search resulted in 63 relevant full text articles out of a total of 8561 articles. Thematic analysis resulted in 44 SR level 1 and 19 level 2 reports. Only one paper was scored as highest level of evidence, which concerned a double cohort study with randomized trial design.

CONCLUSION

The level of evidence for implementing SR in radiology is still low and outcomes should be interpreted with caution.

KEY POINTS

• Structured reporting is increasingly being used in radiology, especially in abdominal and neuroradiological CT and MRI reports. • SR can be subdivided into structured layout (SR level 1) and structured content (SR level 2), in which the first is defined as being a template in which the reporter has to report; the latter is an IT-based manner in which the content of the radiology report can be inserted and displayed into the report. • Despite the extensive amount of research on the subject of structured reporting, the level of evidence is low.

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.

An International Survey of Quality and Safety Programs in Radiology

PURPOSE

The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide.

METHODS

A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it.

RESULTS

The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents.

CONCLUSION

There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Improving radiologic communication in oncology: a single-centre experience with structured reporting for cancer patients

Objectives

Our aim was to develop a structured reporting concept (structured oncology report, SOR) for general follow-up assessment of cancer patients in clinical routine. Furthermore, we analysed the report quality of SOR compared to conventional reports (CR) as assessed by referring oncologists.

Methods

SOR was designed to provide standardised layout, tabulated tumour burden documentation and standardised conclusion using uniform terminology. A software application for reporting was programmed to ensure consistency of layout and vocabulary and to facilitate utilisation of SOR. Report quality was analysed for 25 SOR and 25 CR retrospectively by 6 medical oncologists using a 7-point scale (score 1 representing the best score) for 6 questionnaire items addressing different elements of report quality and overall satisfaction. A score of ≤ 3 was defined as a positive rating.

Results

In the first year after full implementation, 7471 imaging examinations were reported using SOR. The proportion of SOR in relation to all oncology reports increased from 49 to 95% within a few months. Report quality scores were better for SOR for each questionnaire item (p < 0.001 each). Averaged over all questionnaire item scores were 1.98 ± 1.22 for SOR and 3.05 ± 1.93 for CR (p < 0.001). The overall satisfaction score was 2.15 ± 1.32 for SOR and 3.39 ± 2.08 for CR (p < 0.001). The proportion of positive ratings was higher for SOR (89% versus 67%; p < 0.001).

Conclusions

Department-wide structured reporting for follow-up imaging performed for assessment of anticancer treatment efficacy is feasible using a dedicated software application. Satisfaction of referring oncologist with report quality is superior for structured reports.

Structured reporting of chest CT in COVID-19 pneumonia: a consensus proposal

OBJECTIVES

The need of a standardized reporting scheme and language, in imaging of COVID-19 pneumonia, has been welcomed by major scientific societies. The aim of the study was to build the reporting scheme of chest CT in COVID-19 pneumonia.

METHODS

A team of experts, of the Italian Society of Medical and Interventional Radiology (SIRM), has been recruited to compose a consensus panel. They used a modified Delphi process to build a reporting scheme and expressed a level of agreement for each section of the report. To measure the internal consistency of the panelist ratings for each section of the report, a quality analysis based on the average inter-item correlation was performed with Cronbach's alpha (Cα) correlation coefficient.

RESULTS

The overall mean score of the experts and the sum of score were 3.1 (std.dev. ± 0.11) and 122 in the second round, and improved to 3.75 (std.dev. ± 0.40) and 154 in the third round. The Cronbach's alpha (Cα) correlation coefficient was 0.741 (acceptable) in the second round and improved to 0.789 in the third round. The final report was built in the management of radiology report template (MRRT) and includes n = 4 items in the procedure information, n = 5 items in the clinical information, n = 16 in the findings, and n = 3 in the impression, with overall 28 items.

CONCLUSIONS

The proposed structured report could be of help both for expert radiologists and for the less experienced who are faced with the management of these patients. The structured report is conceived as a guideline, to recommend the key items/findings of chest CT in COVID-19 pneumonia.

Communicating with the hepatobiliary surgeon through structured report

Communicating radiological findings to hepatobiliary surgeons is not an easy task due to the complexity of liver imaging, coexistence of multiple hepatic lesions and different surgical treatment options. Recently, the adoption and implementation of structured report in everyday clinical practice has been supported to achieve higher quality, more reproducibility in communication and closer adherence to current guidelines. In this review article, we will illustrate the main benefits, strengths and limitations of structured reporting, with particular attention on the advantages and challenges of structured template in the preoperative evaluation of cirrhotic and non-cirrhotic patients with focal liver lesions. Structured reporting may improve the preoperative evaluation, focusing on answering specific clinical questions that are requested by hepatobiliary surgeons in candidates to liver resection.