Patient-centered Imaging

Causes and diagnostic utility of musculoskeletal MRI recall examinations

AIM

To determine the causes and diagnostic utility of musculoskeletal (MSK) magnetic resonance imaging (MRI) recall examinations.

MATERIALS AND METHODS

An institutional review board-approved retrospective review was conducted of all MSK MRI examinations performed at a single academic institution over 10 years where radiologists requested the patient return for additional imaging. The reason for the recall was documented. Recalls were reviewed in consensus by two MSK radiologists to determine whether additional sequences resulted in a change in the final report. Recall causes were divided into four categories: (1) radiologist-related: incorrect field of view (FOV) or incorrect protocol; (2) technologist-related: incorrect FOV or incorrect/incomplete protocol performed, or technically poor-quality images; (3) patient-related motion artefact; (4) unexpected lesion discovered. Fisher's exact test was used to assess for statistical significance.

RESULTS

The recall rate was 0.25% (156/62,930). Of the total 129 recalls returning for imaging, 42 (33%) were radiologist-related, 45 (35%) were technologist-related, six (5%) were patient-related, and 36 (28%) had an unexpected lesion requiring additional sequences. For clinical utility, 42% resulted in a change from the initial report. Recalls due to radiologist error, incorrect FOV, or unexpected lesion caused a significant change in the final report; however, recalls due to technologist error, patient motion artefact, or incorrect protocol did not.

CONCLUSION

MRI MSK recalls are uncommon, and the most common reasons are incorrect FOV, incorrect protocol, and unexpected lesion. Radiologist-related errors in protocols and FOV led to a significant change in the final report and should be targeted as areas for improvement to reduce recall examinations.

Maximizing Value While Volumes are Increasing

Radiologists are facing ever increasing volumes while trying to provide value-based care. There are several drivers of increasing volumes: increasing population size, aging population, increased utilization, gaps in evidence-based care, changes in the provider workforce, defensive medicine, and increasing case complexity. Higher volumes result in increased cognitive and systemic errors and contribute to radiologist fatigue and burnout. We discuss several strategies for mitigating high volumes including abbreviated MRI protocols, 24/7 radiologist coverage, reading room assistants, and other strategies to tackle radiologist burnout.

Reducing radiation to patients and improving image quality in a real-world nuclear cardiology laboratory

In part because of aging equipment and reduced reimbursement for imaging services in the last several years, nuclear cardiologists who remain in private practice face challenges in maintaining high quality and in reducing radiation exposure to patients. We review patient-centered approaches and affordable software solutions employed in our practice combined with supine-prone myocardial perfusion imaging to achieve increased interpretive confidence with reduced radiation exposure to patients.

Use of Health Information Exchange and Repeat Imaging Costs

PURPOSE

The aim of this study was to quantify the association between health information exchange (HIE) use and cost savings attributable to repeat imaging.

METHODS

Imaging procedures associated with HIE were compared with concurrent controls on the basis of propensity score matching over the period from 2009 to 2010 in a longitudinal cohort study. The study sample (n = 12,620) included patients ages 18 years and older enrolled in the two largest commercial health plans in a 13-county region of western New York State served by the Rochester Regional Health Information Organization. The primary outcome was a continuous measure of costs associated with repeat imaging. The determinant of interest, HIE use, was defined as system access after the initial imaging procedure and before repeat imaging.

RESULTS

HIE use was associated with an overall estimated annual savings of $32,460 in avoided repeat imaging, or $2.57 per patient. Basic imaging (radiography, ultrasound, and mammography) accounted for 85% of the estimated avoided cases of repeat imaging. Advanced imaging (CT and MRI) accounted for 13% of avoided procedures but constituted half of the estimated savings (50%).

CONCLUSIONS

HIE systems may reduce costs associated with repeat imaging. Although inexpensive imaging procedures constituted the largest proportion of avoided repeat imaging in our study, most of the estimated cost savings were due to small reductions in repeated advanced imaging procedures. HIE systems will need to be leveraged in ways that facilitate greater reductions in advanced imaging to achieve appreciable cost savings.

Ureteral Stones: Implementation of a Reduced-Dose CT Protocol in Patients in the Emergency Department with Moderate to High Likelihood of Calculi on the Basis of STONE Score

Purpose To determine if a reduced-dose computed tomography (CT) protocol could effectively help to identify patients in the emergency department (ED) with moderate to high likelihood of calculi who would require urologic intervention within 90 days. Materials and Methods The study was approved by the institutional review board and written informed consent with HIPAA authorization was obtained. This was a prospective, single-center study of patients in the ED with moderate to high likelihood of ureteral stone undergoing CT imaging. Objective likelihood of ureteral stone was determined by using the previously derived and validated STONE clinical prediction rule, which includes five elements: sex, timing, origin, nausea, and erythrocytes. All patients with high STONE score (STONE score, 10-13) underwent reduced-dose CT, while those with moderate likelihood of ureteral stone (moderate STONE score, 6-9) underwent reduced-dose CT or standard CT based on clinician discretion. Patients were followed to 90 days after initial imaging for clinical course and for the primary outcome of any intervention. Statistics are primarily descriptive and are reported as percentages, sensitivities, and specificities with 95% confidence intervals. Results There were 264 participants enrolled and 165 reduced-dose CTs performed; of these participants, 108 underwent reduced-dose CT alone with complete follow-up. Overall, 46 of 264 (17.4%) of patients underwent urologic intervention, and 25 of 108 (23.1%) patients who underwent reduced-dose CT underwent a urologic intervention; all were correctly diagnosed on the clinical report of the reduced-dose CT (sensitivity, 100%; 95% confidence interval: 86.7%, 100%). The average dose-length product for all standard-dose CTs was 857 mGy · cm ± 395 compared with 101 mGy · cm ± 39 for all reduced-dose CTs (average dose reduction, 88.2%). There were five interventions for nonurologic causes, three of which were urgent and none of which were missed when reduced-dose CT was performed. Conclusion A CT protocol with over 85% dose reduction can be used in patients with moderate to high likelihood of ureteral stone to safely and effectively identify patients in the ED who will require urologic intervention. (©) RSNA, 2016 Online supplemental material is available for this article.

Patient Recall Imaging in the Ambulatory Setting

OBJECTIVE

Recalling a patient to repeat a radiology examination is an adverse and, in certain cases, preventable event. Our objectives were to assess the rate of patient recalls for all imaging performed in the outpatient setting at our institution and to characterize the underlying reasons for the recalls.

MATERIALS AND METHODS

We performed a retrospective review of all repeat imaging requests for an inadequate initial imaging study between January 2012 and March 2015.

RESULTS

We identified 100 recall requests (mean, 2.6 requests per month), for an overall recall rate of approximately 1 in 8046 ambulatory studies and 1 in 1684 MRI studies. Nearly all recalls (98%) involved adults. A total of 95% of the recalls were for MRI studies. The most common reason for a patient recall request was an incomplete examination, making up 24% of all requests. The other causes were inadequate coverage of the area of interest (22%), protocoling errors (20%), poor imaging quality (15%), additional imaging to clarify a finding (11%), insufficient contrast visualization (7%), and incorrect patient information (1%).

CONCLUSION

We found that patient recalls for imaging in the outpatient setting at our institution are not common. When recalls did occur, they were most often related to the acquisition of MR images. Improved technologist education on MRI protocoling and enhanced communication between ordering clinicians and radiologists to clarify the purpose of imaging might reduce the need for repeat ambulatory imaging.

Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone--the STONE score: retrospective and prospective observational cohort studies

OBJECTIVE

To derive and validate an objective clinical prediction rule for the presence of uncomplicated ureteral stones in patients eligible for computed tomography (CT). We hypothesized that patients with a high probability of ureteral stones would have a low probability of acutely important alternative findings.

DESIGN

Retrospective observational derivation cohort; prospective observational validation cohort.

SETTING

Urban tertiary care emergency department and suburban freestanding community emergency department.

PARTICIPANTS

Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The derivation cohort comprised a random selection of patients undergoing CT between April 2005 and November 2010 (1040 patients); the validation cohort included consecutive prospectively enrolled patients from May 2011 to January 2013 (491 patients).

MAIN OUTCOME MEASURES

In the derivation phase a priori factors potentially related to symptomatic ureteral stone were derived from the medical record blinded to the dictated CT report, which was separately categorized by diagnosis. Multivariate logistic regression was used to determine the top five factors associated with ureteral stone and these were assigned integer points to create a scoring system that was stratified into low, moderate, and high probability of ureteral stone. In the prospective phase this score was observationally derived blinded to CT results and compared with the prevalence of ureteral stone and important alternative causes of symptoms.

RESULTS

The derivation sample included 1040 records, with five factors found to be most predictive of ureteral stone: male sex, short duration of pain, non-black race, presence of nausea or vomiting, and microscopic hematuria, yielding a score of 0-13 (the STONE score). Prospective validation was performed on 491 participants. In the derivation and validation cohorts ureteral stone was present in, respectively, 8.3% and 9.2% of the low probability (score 0-5) group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6% and 88.6% of the high probability (score 10-13) group. In the high score group, acutely important alternative findings were present in 0.3% of the derivation cohort and 1.6% of the validation cohort.

CONCLUSIONS

The STONE score reliably predicts the presence of uncomplicated ureteral stone and lower likelihood of acutely important alternative findings. Incorporation in future investigations may help to limit exposure to radiation and over-utilization of imaging.

TRIAL REGISTRATION

www.clinicaltrials.gov NCT01352676.

Awareness and use of the Canadian computed tomography head rule for mild head injury patients among Chinese emergency physicians

Objective: Computed tomography (CT) scan has been an increasingly essential diagnostic tool for emergency physicians (EPs) to triage emergency patients. Canadian computed tomography Head Rule (CCHR) had been established and widely used to spare patients with mild head injury from unnecessary radiation. However, the awareness of CCHR and its actual utilization among Chinese EPs were unknown. This survey was to investigate the awareness and use of CCHR and their associated characteristics among Chinese EPs.

Methods: Questionnaire was randomly sent to EPs from different Chinese hospitals. Surveyed EPs were asked how well they know about the CCHR and how often they use the CCHR to guide head CT use. Association between the awareness and utilization of CCHR and the physicians’ characteristics were analyzed using repeated-measures logistic regression.

Results: About 41.7% of the total 247 responders noted they “very familiar” or “somewhat familiar” with CCHR while the utilization rate was 24.7%. With respect to the most important underlying barriers for the use of CCHR, approximate half (48.5%) cited “fear of malpractice” as the leading cause. “Received specific training regarding radiation dose of CT” was the significant predicting factor both for the awareness (OR 5.87; 95% CI, 3.08-11.21) and the use (OR 6.10, 95% CI, 2.91-12.80) of CCHR.

Conclusions: Fear of malpractice and lack of radiation risk knowledge were two main barriers to apply CCHR in the request of CT for patients with mild head injury. Furthermore, EPs with specific training about radiation risk of CT were more likely to know and use of CCHR.

The overuse of serum ceruloplasmin measurement

BACKGROUND

Wilson disease is rare, found in 3 of 100,000 people (0.03%). Ceruloplasmin is often ordered to evaluate liver enzyme elevations. Because Wilson disease often presents before middle-age, the American Association for the Study of Liver Disease recommends screening patients between the ages of 3 and 55 years with liver abnormalities of uncertain cause. We evaluate guideline adherence and the clinical and economic impact of current clinical use of ceruloplasmin.

METHODS

We reviewed all ceruloplasmin measurements at a clinical laboratory that serves a large primary care network, specialty clinics, and a 600-bed tertiary referral center between January 1, 2003, and December 12, 2011.

RESULTS

Ceruloplasmin was measured 5325 times in 5023 unique patients, resulting in 8 (0.16%) new Wilson disease diagnoses. Ceruloplasmin's positive predictive value was 8.4% (95% confidence interval, 7.7-9.3) and false-positive rate was 98.1% (95% confidence interval, 96.2-99.1). A total of 1109 ceruloplasmin levels (20.8%) were ordered in the 1066 patients aged more than 55 years (none with Wilson disease). A "shotgun" approach to liver disease diagnosis was found: Ceruloplasmin was ordered on the same day as hepatitis B (81.0%), hepatitis C (76.0%), autoimmune hepatitis (75.1%), and hemochromatosis (73.1%). Of 424 positive ceruloplasmin results, 91% were not pursued further.

CONCLUSIONS

Guideline adherence restricts ceruloplasmin use to a population with a higher pre-test probability of Wilson disease: patients with chronic liver disease aged 3 to 55 years who have been tested for common causes of liver disease. The majority of the serum ceruloplasmin was measured in patients not indicated by the guidelines, resulting in poor test performance and wasted healthcare resources. Our data on ceruloplasmin use could serve as a touchstone for broader discussions on rational clinical decision making.