Quality and Value of Subspecialty Reinterpretation of Thoracic CT Scans of Patients Referred to a Tertiary Cancer Center

What is the added value of specialist radiology review of multidisciplinary team meeting cases in a tertiary care center?

PURPOSE

Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. This study investigated how often subspecialized radiologists change patient management in MDTMs at a tertiary care institution.

MATERIALS AND METHODS

Over 2 years, six subspecialty radiologists documented their contributions to MDTMs at a tertiary care center. Both in-house and external imaging examinations were discussed at the MDTMs. All imaging examinations (whether primary or second opinion) were interpreted and reported by subspecialty radiologist prior to the MDTMs. The management change ratio (MCratio) of the radiologist was defined as the number of cases in which the radiologist's input in the MDTM changed patient management beyond the information that was already provided by the in-house (primary or second opinion) radiology report, as a proportion of the total number of cases whose imaging examinations were prepared for demonstration in the MDTM.

RESULTS

Sixty-eight MDTMs were included. The time required for preparing and attending all MDTMs (excluding imaging examinations that had not been reported yet) was 11,000 min, with a median of 172 min (IQR 113-200 min) per MDTM, and a median of 9 min (IQR 8-13 min) per patient. The radiologists' input changed patient management in 113 out of 1138 cases, corresponding to an MCratio of 8.4%. The median MCratio per MDTM was 6% (IQR 0-17%).

CONCLUSION

Radiologists' time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM. The use of radiologists for MDTMs should therefore be improved.

CLINICAL RELEVANCE STATEMENT

The use of radiologists for MDTMs (multidisciplinary team meetings) should be improved, because their time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM.

KEY POINTS

• Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. • In a tertiary care center in which all imaging examinations have already been interpreted and reported by subspecialized radiologists before the MDTM takes place, the median time investment of a radiologist for preparing and demonstrating one MDTM patient is 9 min. • In this setting, the radiologist changes patient management in only a minority of cases in the MDTM.

Frequency and Clinical Utility of Alerts for Intra-Institutional Radiologist Discrepant Opinions

OBJECTIVE

Determine the rate of documented notification, via an alert, for intra-institutional discrepant radiologist opinions and addended reports and resulting clinical management changes.

METHODS

This institutional review board-exempt, retrospective study was performed at a large academic medical center. We defined an intra-institutional discrepant opinion as when a consultant radiologist provides a different interpretation from that formally rendered by a colleague at our institution. We implemented a discrepant opinion policy requiring closed-loop notification of the consulting radiologist's second opinion to the original radiologist, who must acknowledge this alert within 30 days. This study included all discrepant opinion alerts created December 1, 2019, to December 31, 2021, of which two radiologists and an internal medicine physician performed consensus review. Primary outcomes were degree of discrepancy and percent of discrepant opinions leading to change in clinical management. Secondary outcome was report addendum rate compared with an existing peer learning program using Fisher's exact test.

RESULTS

Of 114 discrepant opinion alerts among 1,888,147 reports generated during the study period (0.006%), 58 alerts were categorized as major (50.9%), 41 as moderate (36.0%), and 15 as minor discrepancies (13.1%). Clinical management change occurred in 64 of 114 cases (56.1%). Report addendum rate for discrepant opinion alerts was 4-fold higher than for peer learning alerts at our institution (66 of 315 = 21% versus 432 of 8,273 =5.2%; P < .0001).

DISCUSSION

Although discrepant intra-institutional radiologist second opinions were rare, they frequently led to changes in clinical management. Capturing these discrepancies by encouraging alert use may help optimize patient care and document what was communicated to the referring or consulting care team by consulting radiologists.

Interpretations of Examinations Outside of Radiologists' Fellowship Training: Assessment of Discrepancy Rates Among 5.9 Million Examinations From a National Teleradiology Databank

Background: In community settings, radiologists commonly function as multispecialty radiologists, interpreting examinations outside of their fellowship training. Objective: To compare discrepancy rates for preliminary interpretations of acute community-setting examinations concordant versus discordant with interpreting radiologists' fellowship training. Methods: This retrospective study used the databank of a U.S. teleradiology company that provides preliminary interpretations for client community hospitals. The analysis included 5,883,980 acute examinations performed from 2012 to 2016 that were preliminarily interpreted by 269 teleradiologists with a fellowship of neuroradiology, abdominal radiology, or musculoskeletal radiology. When providing final interpretations, client on-site radiologists voluntarily submitted quality assurance (QA) requests if preliminary and final interpretations were discrepant; the teleradiology company's QA committee categorized discrepancies as major (n=8,444) or minor (n=17,208). Associations among examination type (common vs advanced), relationship between examination subspecialty and the teleradiologist's fellowship (concordant vs discordant), and major and minor discrepancies were assessed using three-way conditional analyses with generalized estimating equations. Results: For examinations with concordant subspecialty, major discrepancy rate was lower for common than advanced examinations [0.13% vs 0.26%; relative risk (RR) 0.50, 95% CI: 0.42, 0.60; p < .001]. For examinations with discordant subspecialty, major discrepancy rate was lower for common than advanced examinations (0.14% vs 0.18%; RR 0.81, 95% CI: 0.72, 0.90; p < .001). For common examinations, major discrepancy rate was not different between examinations with concordant versus discordant subspecialty (0.13% vs 0.14%; RR 0.90, 95% CI: 0.81, 1.01; p = .07). For advanced examinations, major discrepancy rate was higher for examinations with concordant versus discordant subspecialty (0.26% vs 0.18%; RR 1.45, 95% CI: 1.18, 1.79; p < .001). Minor discrepancy rate was higher among advanced examinations for those with concordant versus discordant subspecialty (0.34% vs 0.29%; RR 1.17, 95% CI: 1.001, 1.36; p = .04), but not different for other comparisons (p > .05). Conclusion: Major and minor discrepancy rates were not higher for acute community-setting examinations outside of interpreting radiologists' fellowship training. Discrepancy rates increased for advanced examinations. Clinical Impact: The findings support multispecialty radiologist practice in acute community settings. Efforts to match examination and interpreting radiologist subspecialty may not reduce diagnostic discrepancies.

Effects of Changing the Reporting System from Decentralized/Modality-Based to Centralized/Subspecialized Radiology on Radiologists, Radiologic Technicians and Referring Physicians of a Multi-Center Radiology Network

Objectives:

To determine the effects of reorganizing a radiology institute from decentralized/modality-based to centralized/subspecialized radiology on radiologists, radiologic technicians, and referring physicians at a multi-center radiology network.

Material and Methods:

In 2017/2018 our multi-center radiology network was changed from decentralized/modality-based to centralized/subspecialized reporting. A survey was conducted among radiologists, technicians and two groups of referring physicians (main hospital and non-main hospitals). The following items were tested: Overall satisfaction, perceived quality of radiological reports, subjective productivity/efficiency, confidence of radiologists in their subspecialty, availability of radiologists and turnaround time. Two of five answering options on a 5-point Likert scale were considered to represent agreement. The Mann-Whitney-U-test served for statistical analyses in agreement before and after reorganization in each group.

Results:

For radiologists, a significant difference was observed in perceived quality of radiological reports 42/46 (91.3%) compared to 51/52 (98.1%; p = 0.013).

For technicians, no significant differences were observed. In the group of main hospital referring physicians, significant differences were observed in overall satisfaction 129/152 (84.9%) compared to 164/174 (94.3%; p < 0.001) and in perceived quality of radiological reports 125/148 (72.8%) compared to 157/170 (92.4%; p = 0.001). In the group of non-main hospital referring physicians no significant differences were observed.

Conclusion:

The reorganization resulted in a significantly higher perceived quality of radiological reports for the groups of radiologists and main hospital referring physicians besides overall satisfaction for main hospital referring physicians. Specialized main hospital referring physicians value reports of specialized radiology, whereas less specialized, non-main hospital referring physicians did not experience any significant effect.

Providing second-opinion interpretations of pediatric imaging: embracing the call for value-added medicine

The value of obtaining second-opinion interpretations by specialty radiologists has been established. In pediatric radiology, this has primarily been explored in general terms, comparing tertiary pediatric radiologists' interpretations to referral reads. In adults, second reads by subspecialty radiologists have been shown to yield changes in patient management, including in neuroradiology, musculoskeletal radiology and oncological radiology. Here, we examine second-opinion reads by pediatric radiologists by reviewing the pediatric and adult subspecialty literature. We also present our experience in providing subspecialty outside reads, summarizing lessons learned in implementing a system for outside interpretations into a pediatric radiology practice.

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

PURPOSE

The 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.

METHODS

This 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.

RESULTS

Two 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).

CONCLUSIONS

Academic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.

Why do delays to diagnosis and treatment of lung cancer occur? A mixed methods study of insights from Australian clinicians

AIMS

Delays in lung cancer diagnosis and treatment can impact survival. We explored reasons for delays experienced by patients with lung cancer to identify themes and strategies for improvement.

METHODS

We used national timeframe recommendations and standardized definitions to identify General Practitioners and specialists caring for 34 patients who experienced delays in our previous Medicare data linkage study. Clinicians participated in a survey and interview, including qualitative (exploratory, open-ended questions) and quantitative (rating scales) components. Exploratory content analysis, cross-case triangulation, and descriptive statistics were performed. Krippendorff's coefficient was used to assess level of agreement between clinicians and patients, and among clinicians, on perceived delays.

RESULTS

Overall, 27 out of 50 (54%) eligible clinicians participated (including 11 respiratory physicians and seven medical oncologists). Dominant themes for perceived causes of delay included referral barriers, limited General Practitioner (GP) awareness of subtle clinical presentations, insufficient radiology interpretation, and lack of cancer coordinators. "Unavoidable" delays may occur due to clinical circumstances. Awareness and uptake of referral and timeframe guidelines were low, with clinicians using professional networks over guidelines. There was no consistent agreement on perceived delays between patients and clinicians, and among clinicians (Krippendorff's coefficient .03 [P = .8]).

CONCLUSIONS

Strategies for minimizing avoidable delays include efficient GP to specialist referral and more lung cancer coordinators to assist with patient expectations and waitlist management. Clinicians' reliance on experience, rather than guidelines, indicates need to review guideline utility. Raising awareness of benchmarks and unavoidable barriers may recalibrate perceptions of "delays" to diagnosis and treatment of lung cancer.

Low-Volume and High-Volume Readers of Neurological and Musculoskeletal MRI: Achieving Subspecialization in Radiology

OBJECTIVE

Differentiate high- versus low-volume radiologists who interpret neurological (Neuro) MRI or musculoskeletal (MSK) MRI and measure the proportion of Neuro and MSK MRIs read by low-volume radiologists.

METHODS

We queried the 2015 Medicare Physician and Other Supplier Public Use File for radiologists who submitted claims for Neuro or MSK MRIs. Radiologists were classified as high-volume versus low-volume based on their work relative value units (wRVUs) focus or volume of studies interpreted using three different methodologies: Method 1, percentage of wRVUs in Neuro or MSK MRI; Method 2, absolute number of Neuro or MSK MRIs interpreted; and Method 3, both percentage and absolute number. Multiple thresholds with each methodology were tested, and the percentage of Neuro or MSK MRIs interpreted by low-volume radiologists was calculated for each threshold.

RESULTS

With Method 1, 33% of Neuro MRI and 50% of MSK MRI studies were interpreted by a radiologist whose wRVUs in Neuro or MSK MRI were less than 20% (Method 1). With Method 2, 22% of Neuro MRIs and 37% of MSK MRIs were interpreted by radiologists who read fewer than the mean number of Neuro or MSK MRIs interpreted by an "average full-time radiologist" whose wRVUs in Neuro or MSK MRI were approximately 20%. With Method 3, 38% of Neuro MRIs and 57% of MSK MRIs were interpreted by "low-volume" radiologists. If instead a 50% wRVU threshold is used for Methods One, Two, and Three, then 70%, 58%, and 77% of Neuro MRIs and 86%, 80%, and 90% of MSK MRIs are read by low-volume radiologists.

DISCUSSION

A large number of radiologists read a low volume of Neuro or MSK MRIs; these low-volume Neuro or MSK MRI radiologists read a substantial portion of Neuro or MSK MRIs. It is unknown which of the methods for distinguishing low-volume radiologists, combined with which threshold, may best correlate with high-performing or low-performing radiologists.

European Society of Paediatric Radiology 2019 strategic research agenda: improving imaging for tomorrow's children

The European Society of Paediatric Radiology (ESPR) research committee was established to initiate, drive forward and foster excellence in paediatric imaging, paediatric image-guided intervention and radiation protection research, by facilitating more evidence-based standards, protocols and multi-institutional collaborations. The ESPR Strategic Research Agenda outlines our current research approach, highlighting several areas of paediatric imaging where the society can help guide current and future research, and emphasizing those areas where early research ("seed") funding may need to be allocated by this and other societies as precursors to larger grant applications. The key aims are to evaluate normal variation in order to be able to confidently diagnose disease states, develop robust image-based classification systems to aid diagnosis and treatment monitoring, and help develop evidence-based clinical guidelines using current literature and experience to identify knowledge gaps. For this reason, the development of evidence-based imaging pipelines, broken down step-by-step to include diagnosis, classification and clinical effectiveness, should be the end goal for each disease entity for each affected child. Here, we outline the 2019 ESPR Strategic Research Agenda along three points in the clinical imaging pipeline: clinical referral, disease diagnosis and evolution, and clinical therapeutic evaluation and effectiveness. Through multicentre trials, using existing high-level experience and expertise, and nurturing the next generation of researchers, we will be able to achieve these aims.

Second opinions in orthopedic oncology imaging: can fellowship training reduce clinically significant discrepancies?

OBJECTIVE

To determine factors that lead to significant discrepancies in second-opinion consultation of orthopedic oncology patients, and particularly if musculoskeletal fellowship training can decrease clinically significant discrepancies.

METHODS

A PACS database was queried for secondary reads on outside cross-sectional imaging studies, as requested by orthopedic oncology from 2014 to 2017. Comparison of original and secondary reports was performed using a published seven-point scale that defines clinically significant discrepancies. An online search was performed for each original radiologist to record if a fellowship in musculoskeletal imaging was completed. Additionally, years of post-residency experience, number of Medicare part B patients billed per year (marker of practice volume), and average hierarchical condition category for each radiologist (marker of practice complexity) was recorded.

RESULTS

A total of 571 patients met the inclusion criteria, with 184 cases initially interpreted by an outside fellowship trained musculoskeletal (MSK) radiologist and 387 cases initially interpreted by a non-MSK trained radiologist. The rate of clinically significant discrepancy was 9.2% when initially interpreted by MSK radiologists compared with 27.9% when initially performed by non-MSK radiologists (p < 0.05). After adjustment by both patient characteristics and radiologist characteristics, the likelihood of clinically significant discrepancies was greater for initial interpretations by non-MSK radiologists compared with MSK radiologists (OR = 1.36; 95% CI = 1.23-2.49).

CONCLUSION

In orthopedic oncology patients, the rate of clinically significant discrepancies was significantly higher when initially interpreted by non-MSK radiologists compared with MSK radiologists. The lower rate of clinically significant discrepancies demonstrates that subspecialty training may direct more appropriate diagnosis and treatment.

The Need for Practical and Accurate Measures of Value for Radiology

Radiologists play a critical role in helping the health care system achieve greater value. Unfortunately, today radiology is often judged by simple "checkbox" metrics, which neither directly reflect the value radiologists provide nor the outcomes they help drive. To change this system, first, we must attempt to better define the elusive term value and, then, quantify the value of imaging through more relevant and meaningful metrics that can be more directly correlated with outcomes. This framework can further improve radiology's value by enhancing radiologists' integration into the care team and their engagement with patients. With these improvements, we can maximize the value of imaging in the overall care of patients.

Perception of Breast Oncologists and Physician Extenders on Imaging Consultation Service at a Tertiary Cancer Institute

OBJECTIVE

To evaluate the perception and ease of utilization of the imaging consultation service by different types of referring clinicians and physician extenders within the breast oncology disease center at our tertiary cancer institute using a survey-based questionnaire.

METHODS

An institutional review board-exempted survey was created using a freely available online survey software and questionnaire tool. The survey was sent to 83 clinicians associated with the breast oncology disease center at our tertiary cancer center through an institutional e-mail list. The survey included 2 questions about demographics and 8 statements regarding various aspects of the consultation service scored on a 5-point Likert-type scale. "1'' being "agree completely," "3" being "neutral/neither agree nor disagree," and "5" being "disagree completely." The survey was sent online and was answered anonymously. Responses were tallied and analyzed.

RESULTS

A total of 56 responses (67%) were received. The weighted average of each Likert item ranged from 1.07 to 1.58. Highest positive concordance (95%) pertained to the access to the consult radiologist having a positive impact on patient care. The least concordant statement (78%), though still strong (with weighted average of 1.58% and 78% of respondents agreeing or agreeing completely) pertained to the role of direct consultation with radiologist in clinical management. Although there was variability of agreement to all statements (including responders feeling neutral), there was no one that disagreed with any of the Likert items. The mean Likert score for all the statements together was 1.23 (range: 1.07-1.58).

CONCLUSION

Presence of dedicated oncologic imaging consultation service is perceived positively by the breast oncology team at our tertiary cancer center.

Building Imaging Institutes of Patient Care Outcomes: Imaging as a Nidus for Innovation in Clinical Care, Research, and Education

Traditionally, radiologists have been responsible for the protocol of imaging studies, imaging acquisition, supervision of imaging technologists, and interpretation and reporting of imaging findings. In this article, we outline how radiology needs to change and adapt to a role of providing value-based, integrated health-care delivery. We believe that the way to best serve our specialty and our patients is to undertake a fundamental paradigm shift in how we practice. We describe the need for imaging institutes centered on disease entities (eg, lung cancer, multiple sclerosis) to not only optimize clinical care and patient outcomes, but also spur the development of a new educational focus, which will increase opportunities for medical trainees and other health professionals. These institutes will also serve as unique environments for testing and implementing new technologies and for generating new ideas for research and health-care delivery. We propose that the imaging institutes focus on how imaging practices-including new innovations-improve patient care outcomes within a specific disease framework. These institutes will allow our specialty to lead patient care, provide the necessary infrastructure for state-of-the art-education of trainees, and stimulate innovative and clinically relevant research.