Large-Scale Implementation of Structured Reporting of Adnexal Masses on Ultrasound

Ovarian cancer risk among older patients with stable adnexal masses

BACKGROUND

Few studies have evaluated the risk of cancer among older patients with stable adnexal masses in community-based settings to determine the duration of observation time needed.

OBJECTIVE

This study aimed to assess the ovarian cancer risk among older patients with stable adnexal masses on ultrasound.

STUDY DESIGN

This was a retrospective cohort study of patients in a large community-based health system aged ≥50 years with an adnexal mass <10 cm on ultrasound between 2016 and 2020 who had at least 1 follow-up ultrasound performed ≥6 weeks after initial ultrasound. Masses were considered stable on follow-up examination if they did not exhibit an increase of >1 cm in the greatest dimension or a change in standardized reported ultrasound characteristics. Ovarian cancer risk was determined at increasing time intervals of stability after initial ultrasound.

RESULTS

Among 4061 patients with stable masses, the average age was 61 years (range, 50-99), with an initial mass size of 3.8 cm (range, 0.2-9.9). With a median follow-up of 3.7 years, 11 cancers were detected, with an absolute risk of 0.27%. Ovarian cancer risk declined with longer duration of stability, from 0.73 (95% confidence interval, 0.30-1.17) per 1000 person-years at 6 to 12 weeks, 0.63 (95% confidence interval, 0.19-1.07) at 13 to 24 weeks, 0.44 (95% confidence interval, 0.01-0.87) at 25 to 52 weeks, and 0.00 (95% confidence interval, 0.00-0.00) at >52 weeks. Expressed as number needed to reimage, ongoing ultrasound imaging would be needed for 369 patients whose masses show stability at 6 to 12 weeks, 410 patients at 13 to 24 weeks, 583 patients at 25 to 52 weeks, and >1142 patients with stable masses at 53 to 104 weeks to detect 1 case of ovarian cancer.

CONCLUSION

In a diverse community-based setting, among patients aged ≥50 years with an adnexal mass that was stable for at least 6 weeks after initial ultrasound, the risk of ovarian cancer was very low at 0.27%. Longer demonstrated duration of stability was associated with progressively lower risk, with no cancer cases observed after 52 weeks of stability. These findings suggest that the benefit of ultrasound monitoring of stable masses beyond 12 months is minimal and may be outweighed by potential risks of repeated imaging.

The implementation checklist: A pragmatic instrument for accelerating research-to-implementation cycles

Introduction

Learning health systems require rapid-cycle research and nimble implementation processes to maximize innovation across disparate specialties and operations. Existing detailed research-to-implementation frameworks require extensive time commitments and can be overwhelming for physician-researchers with clinical and operational responsibilities, inhibiting their widespread adoption. The creation of a short, pragmatic checklist to inform implementation processes may substantially improve uptake and implementation efficiency across a variety of health systems.

Methods

We conducted a systematic review of existing implementation frameworks to identify core concepts. Utilizing comprehensive stakeholder engagement with 25 operational leaders, embedded physician-researchers, and delivery scientists, concepts were iteratively integrated to create and implement a final concise instrument.

Results

A systematic review identified 894 publications describing implementation frameworks, which included 15 systematic reviews. Among these, domains were extracted from three commonly utilized instruments: the Quality Implementation Framework (QIF), the Consolidated Framework for Implementation Research (CFIR), and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Iterative testing and stakeholder engagement revision of a four-page draft implementation document with five domains resulted in a concise, one-page implementation planning instrument to be used at project outset and periodically throughout project implementation planning. The instrument addresses end-user feasibility concerns while retaining the main goals of more complex tools. This instrument was then systematically integrated into projects within the Kaiser Permanente Northern California Delivery Science and Applied Research program to address stakeholder engagement, efficiency, project planning, and operational implementation of study results.

Conclusion

A streamlined one-page implementation planning instrument, incorporating core concepts of existing frameworks, provides a pragmatic, robust framework for evidence-based healthcare innovation cycles that is being broadly implemented within a learning health system. These streamlined processes could inform other settings needing a best practice rapid-cycle research-to-implementation tool for large numbers of diverse projects.

Association of Standardized Radiology Reporting and Management of Abdominal CT and MRI With Diagnosis of Pancreatic Cancer

BACKGROUND & AIMS

Follow-up of abdominal computed tomography (CT) and magnetic resonance imaging (MRI) findings suspicious for pancreatic cancer may be delayed if documentation is unclear. We evaluated whether standardized reporting and follow-up of imaging results reduced time to diagnosis of pancreatic cancer.

METHODS

We used a quasi-experimental stepped-wedge cluster design to evaluate the effectiveness of newly implemented radiology reporting system. The system standardizes the reporting of CT and MRI reports using hashtags that classify pancreatic findings. The system also automates referral of patients with findings suspicious for pancreatic cancer to a multidisciplinary care team for rapid review and follow-up. The study examined 318,331 patients who underwent CT or MRI that included the abdomen from 2016 through 2019 who had not had an eligible CT or MRI in the preceding 24 months. We evaluated the association of the intervention with incidence of pancreatic cancer within 60 days and 120 days after imaging.

RESULTS

Thirty-eight percent of patients received the intervention, and 1523 patients (0.48%) were diagnosed with pancreatic cancer. In multivariable analysis accounting for age, race/ethnicity, sex, Charlson comorbidity, history of cancer, diabetes, and 4-month calendar period, the intervention was associated with nearly 50% greater odds of diagnosing pancreatic cancer within 60 days (adjusted odds ratio, 1.47; 95% confidence interval, 1.05-2.06) and 120 days (adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.06).

CONCLUSIONS

In this large quasi-experimental, community-based observational study, implementing standardized reporting of abdominal CT and MRI reports with clinical navigation was effective for increasing the detection and diagnosis of pancreatic cancer.

Accuracy of Magnetic Resonance Imaging for Identifying Ovarian Cancer in a Community-Based Setting

Introduction: Many ovarian or adnexal masses have an indeterminate appearance on ultrasound that can raise concerns about cancer. Although magnetic resonance imaging (MRI) has been reported to reliably distinguish between benign and malignant masses, studies evaluating the accuracy of MRI in community-based practice settings are lacking.

Methods: Women who underwent MRI to further evaluate an ultrasound-detected adnexal mass in 2016–2017 within a large community-based health system were identified. MRI reports were classified as favoring malignancy, benign disease, or indeterminate, blinded to pathological outcome. With a minimum of 2 years of follow-up, all ovarian cancers and borderline tumors were identified, and the accuracy of MRI assessment was determined.

Results: Among 338 women who had MRI to evaluate an adnexal mass, 144 (42.6%) subsequently underwent surgery. MRI favored malignancy in 7 (4.9%) cases, benign disease in 89 (62.2%) cases, and was indeterminate in 48 (33.6%) cases. Of the seven cases in which MRI favored malignancy, two cancers and five benign tumors were found. An additional 10 cases of cancer or borderline tumor were found among women who had MRI reports that were read as indeterminate (n = 6) or that favored benign disease (n = 4). The sensitivity, specificity, positive predictive value, and negative predictive value of an MRI favoring malignancy were 16.7%, 96.2%, 28.5%, and 92.7%, respectively.

Discussion: In a large community-based setting, an MRI favoring malignancy was more likely to be associated with benign disease than cancer and identified only 16.7% of true malignant cases. The findings suggest that the ability of MRI to differentiate between benign and malignant adnexal masses in community-based practice settings is currently limited.

Ovarian cancer surveillance in the clinical follow up of women with known BRCA1 or BRCA2 pathogenic variants in a large health care system

OBJECTIVE

To assess CA 125 and transvaginal ultrasound surveillance in women with BRCA1 or BRCA2 pathogenic variants in a pragmatic clinical setting with>1 year follow up.

METHODS

Retrospective cohort study in a large integrated health care system of women identified from 1/1/2003 to 12/31/2017 with a BRCA1 or BRCA2 pathogenic variant with at least one intact ovary. Demographic and clinical data were collected from date of genetic testing until oophorectomy, an ovarian cancer diagnosis, or 7/1/2019. Primary outcome was frequency and findings of CA 125 tests and ultrasounds performed; secondary outcome was epithelial ovarian cancers diagnosed.

RESULTS

There were 1418 women, age ≥ 30 years with a BRCA1 or BRCA2 pathogenic variant with at least one intact ovary. Of the total of 1683 ultrasounds and 2437 CA 125 tests done, 1022 ultrasounds and 1709 CA 125 tests were performed for surveillance in 771 women followed >1 year. Of these women 241 (31%) women had no surveillance, and 530 (69%) women underwent any surveillance. Only 108 (20%) underwent regular surveillance. The number who underwent regular surveillance declined each year. Twenty-one women underwent surveillance indicated surgery with only 2 ovarian cancers found by surveillance.

CONCLUSIONS

Many women with BRCA1 or BRCA2 pathogenic variants undergo ultrasound and CA 125 surveillance testing but abnormal surveillance testing led to diagnosis of ovarian cancer in only two cases. These findings question the use of CA 125 and ultrasound surveillance in the clinical setting for ovarian cancer detection in women with BRCA1 or BRCA2 pathogenic variants.

Structured reporting of brain MRI following mechanical thrombectomy in acute ischemic stroke patients

Background

To compare the quality of free-text reports (FTR) and structured reports (SR) of brain magnetic resonance imaging (MRI) examinations in patients following mechanical thrombectomy for acute stroke treatment.

Methods

A template for SR of brain MRI examinations based on decision trees was designed and developed in house and applied to twenty patients with acute ischemic stroke in addition to FTR. Two experienced stroke neurologists independently evaluated the quality of FTR and SR regarding clarity, content, presence of key features, information extraction, and overall report quality. The statistical analysis for the differences between FTR and SR was performed using the Mann–Whitney U-test or the Chi-squared test.

Results

Clarity (p < 0.001), comprehensibility (p < 0.001), inclusion of relevant findings (p = 0.016), structure (p = 0.005), and satisfaction with the content of the report for immediate patient management (p < 0.001) were evaluated significantly superior for the SR by both neurologist raters. One rater additionally found the explanation of the patient’s clinical symptoms (p = 0.003), completeness (p < 0.009) and length (p < 0.001) of SR to be significantly superior compared to FTR and stated that there remained no open questions, requiring further consultation of the radiologist (p < 0.001). Both neurologists preferred SR over FTR.

Conclusions

The use of SR for brain magnetic resonance imaging may increase the report quality and satisfaction of the referring physicians in acute ischemic stroke patients following mechanical thrombectomy.

Trial registration Retrospectively registered.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

The diagnostic performance of the Gynecologic Imaging Reporting and Data System (GI-RADS) in adnexal masses

Background

Adnexal masses, mostly benign, are common in the female genital system. However, adnexal masses are the leading cause of death among women with gynecologic cancer. Ultrasound is a common imaging method for diagnosing adnexal masses. Gynecologic Imaging Reporting and Data System (GI-RADS) is a useful diagnostic tool based on objective ultrasound features to diagnose the malignancy of the female genital system. Therefore, we conducted a meta-analysis to evaluate the ability of GI-RADS to differentiate adnexal masses.

Methods

Published articles were searched in PubMed, Medline, and Embase from 1990 to February 2020. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio, and area under the curve (AUC) were estimated via the extracted data from the selected studies.

Results

Ten studies and 2,474 patients were included in this meta-analysis. The pooled sensitivity of selected studies was 0.95 [95% confidence intervals (CI): 0.94-0.97], and the pooled specificity was 0.86 (95% CI: 0.84-0.88). The pooled NLR and PLR were 0.06 (95% CI: 0.04-0.10), and 8.30 (95% CI: 4.93-13.97), respectively. Moreover, the pooled diagnostic odds ratio for GI-RADS was 174.59 (95% CI: 76.70-397.42), and the AUC was 0.9806.

Conclusions

This research indicates that GI-RADS might be a valuable tool to distinguish malignancies from adnexal masses.

Utilization of Structured Reporting to Monitor Outcomes of Doppler Ultrasound Performed for Deep Vein Thrombosis

Determining the clinical impact of imaging exams at the enterprise level is problematic, as radiology reports historically have been created with the content meant primarily for the referring provider. Structured reporting can establish the foundation for enterprise monitoring of imaging outcomes without manual review providing the framework for assessment of utilization and quality. Ultrasound (US) for deep vein thrombosis evaluation (DVT) is an ideal testbed for assessing this functionality. The system standard template for Doppler US for extremity venous evaluation for DVT was updated with a discrete fixed picklist of impression options and implemented system wide. Template utilization and interpretive outcomes were actively monitored and use reinforced as part of standard clinical practice. From January 1, 2017 to December 31, 2017, 9111 US exams for DVT were performed with 8997 utilizing structured reporting (98.75%). Of those in the structured reporting group, 1074 (11.79%) were positive for any type of DVT with 732 (8.03%) reported as Acute/New above the knee. Positive rates for any type of DVT were 10.29% emergency department, 14.17% inpatient, and 13.20% outpatient. While being the lowest positive rate, the emergency department had the highest overall volume of exams. Structured reporting for DVT US assessment outcomes can be implemented with a very high rate of radiologist adoption and adherence providing accurate determination of positive rates, month by month, in differing patient locations. Structured elements can be used to automatically trigger downstream processes; in our institution, this will alert providers in the EHR if the patient does not receive anticoagulation within 2 h of a positive test. This lays the foundation for effective enterprise assessment of imaging outcomes forming the basis of future quality and safety initiatives on optimizing health system resource utilization.

Standardized Reporting and Management of Suspicious Findings on Chest CT Imaging Is Associated With Improved Lung Cancer Diagnosis in an Observational Study

BACKGROUND

Follow-up of chest CT scan findings suspicious for lung cancer may be delayed because of inadequate documentation. Standardized reporting and follow-up may reduce time to diagnosis and care for lung cancer.

STUDY DESIGN AND METHODS

We implemented a reporting system that standardizes tagging of chest CT scan reports by classifying pulmonary findings. The system also automates referral of patients with findings suspicious for lung cancer to a multidisciplinary care team for rapid review and follow-up. The system was designed to reduce the time to diagnosis, particularly for early-stage lung cancer. We evaluated the effectiveness of this system, using a quasi-experimental stepped wedge cluster design, examining 99,148 patients who underwent diagnostic (nonscreening) chest CT imaging from 2015 to 2017 and who had not received a chest CT scan in the preceding 24 months. We evaluated the association of the intervention with the incidence of diagnosis and surgical treatment of early-stage (I, II) and late-stage (III, IV) lung cancer within 120 days of chest CT imaging.

RESULTS

Forty percent of patients received the intervention. Among 2,856 patients (2.9%) who received diagnoses of lung cancer, 28% had early-stage disease. In multivariable analyses, the intervention was associated with 24% greater odds of early-stage diagnosis (OR, 1.24; 95% CI, 1.09-1.41) and no change in the odds of late-stage diagnosis (OR, 1.04; 95% CI, 0.95-1.14). The intervention was not associated with the rate of surgical treatment within 120 days.

INTERPRETATION

In this large quasi-experimental community-based observational study, implementation of a system that combines standardized tagging of chest CT scan reports with clinical navigation was effective for increasing the diagnosis of early-stage lung cancer.