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Hammer MM. Risk and Time to Diagnosis of Lung Cancer in Incidental Pulmonary Nodules. J Thorac Imaging 2024; 39:275-280. [PMID: 38095275 PMCID: PMC11128536 DOI: 10.1097/rti.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
PURPOSE To determine the risk of lung cancer in incidental pulmonary nodules, as well as the time until cancer growth is detected. PATIENTS AND METHODS This retrospective study examined patients with incidental nodules detected on chest computed tomography (CT) in 2017. Characteristics of the dominant nodule were automatically extracted from CT reports, and cancer diagnoses were manually verified by a thoracic radiologist. Nodules were categorized per Fleischner Society guideline categories: solid <6 mm, solid 6 to 8 mm, solid >8 mm, subsolid <6 mm, ground glass nodules ≥6 mm, and part-solid nodules ≥6 mm. The time to nodule growth was determined by CT reports. RESULTS A total of 3180 patients (nodules) were included, of which 155 (5%) were diagnosed with lung cancer. By category, 7/1601 (0.4%) solid nodules <6 mm, 11/713 (1.5%) solid nodules 6 to 8 mm, 71/446 (15.9%) solid nodules >8 mm, 1/124 (0.8%) subsolid nodules <6 mm, 29/202 (14.4%) ground glass nodules ≥6 mm, and 36/94 (37.9%) part-solid nodules ≥6 mm were malignant. Of solid lung cancers <6 mm, growth was observed in 1/4 imaged by 1 year and 2/5 by 2 years; of solid lung cancers 6 to 8 mm, growth was observed in 3/10 imaged by 1 year and 6/10 by 2 years. CONCLUSION Solid nodules <6 mm have a very low risk of malignancy and may not require routine follow-up. However, when malignant, growth is often not observed until 2 or more years later; therefore, stability at 1 to 2 years does not imply benignity.
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Affiliation(s)
- Mark M Hammer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Guenette JP, Lynch E, Abbasi N, Schulz K, Kumar S, Haneuse S, Kapoor N, Lacson R, Khorasani R. Recommendations for Additional Imaging on Head and Neck Imaging Examinations: Interradiologist Variation and Associated Factors. AJR Am J Roentgenol 2024; 222:e2330511. [PMID: 38294159 DOI: 10.2214/ajr.23.30511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND. A paucity of relevant guidelines may lead to pronounced variation among radiologists in issuing recommendations for additional imaging (RAI) for head and neck imaging. OBJECTIVE. The purpose of this article was to explore associations of RAI for head and neck imaging examinations with examination, patient, and radiologist factors and to assess the role of individual radiologist-specific behavior in issuing such RAI. METHODS. This retrospective study included 39,200 patients (median age, 58 years; 21,855 women, 17,315 men, 30 with missing sex information) who underwent 39,200 head and neck CT or MRI examinations, interpreted by 61 radiologists, from June 1, 2021, through May 31, 2022. A natural language processing (NLP) tool with manual review of NLP results was used to identify RAI in report impressions. Interradiologist variation in RAI rates was assessed. A generalized mixed-effects model was used to assess associations between RAI and examination, patient, and radiologist factors. RESULTS. A total of 2943 (7.5%) reports contained RAI. Individual radiologist RAI rates ranged from 0.8% to 22.0% (median, 7.1%; IQR, 5.2-10.2%), representing a 27.5-fold difference between minimum and a maximum values and 1.8-fold difference between 25th and 75th percentiles. In multivariable analysis, RAI likelihood was higher for CTA than for CT examinations (OR, 1.32), for examinations that included a trainee in report generation (OR, 1.23), and for patients with self-identified race of Black or African American versus White (OR, 1.25); was lower for male than female patients (OR, 0.90); and was associated with increasing patient age (OR, 1.09 per decade) and inversely associated with radiologist years since training (OR, 0.90 per 5 years). The model accounted for 10.9% of the likelihood of RAI. Of explainable likelihood of RAI, 25.7% was attributable to examination, patient, and radiologist factors; 74.3% was attributable to radiologist-specific behavior. CONCLUSION. Interradiologist variation in RAI rates for head and neck imaging was substantial. RAI appear to be more substantially associated with individual radiologist-specific behavior than with measurable systemic factors. CLINICAL IMPACT. Quality improvement initiatives, incorporating best practices for incidental findings management, may help reduce radiologist preference-sensitive decision-making in issuing RAI for head and neck imaging and associated care variation.
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Affiliation(s)
- Jeffrey P Guenette
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Elyse Lynch
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Nooshin Abbasi
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Kathryn Schulz
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Shweta Kumar
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
- Present affiliation: Department of Radiology, Stanford University, Stanford, CA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Neena Kapoor
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Ronilda Lacson
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
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DeSimone AK, Kapoor N, Lacson R, Budiawan E, Hammer MM, Desai SP, Eappen S, Khorasani R. Impact of an Automated Closed-Loop Communication and Tracking Tool on the Rate of Recommendations for Additional Imaging in Thoracic Radiology Reports. J Am Coll Radiol 2023; 20:781-788. [PMID: 37307897 DOI: 10.1016/j.jacr.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Assess the effects of feedback reports and implementing a closed-loop communication system on rates of recommendations for additional imaging (RAIs) in thoracic radiology reports. METHODS In this retrospective, institutional review board-approved study at an academic quaternary care hospital, we analyzed 176,498 thoracic radiology reports during a pre-intervention (baseline) period from April 1, 2018, to November 30, 2018; a feedback report only period from December 1, 2018, to September 30, 2019; and a closed-loop communication system plus feedback report (IT intervention) period from October 1, 2019, to December 31, 2020, promoting explicit documentation of rationale, time frame, and imaging modality for RAI, defined as complete RAI. A previously validated natural language processing tool was used to classify reports with an RAI. Primary outcome of rate of RAI was compared using a control chart. Multivariable logistic regression determined factors associated with likelihood of RAI. We also estimated the completeness of RAI in reports comparing IT intervention to baseline using χ2 statistic. RESULTS The natural language processing tool classified 3.2% (5,682 of 176,498) reports as having an RAI; 3.5% (1,783 of 51,323) during the pre-intervention period, 3.8% (2,147 of 56,722) during the feedback report only period (odds ratio: 1.1, P = .03), and 2.6% (1,752 of 68,453) during the IT intervention period (odds ratio: 0.60, P < .001). In subanalysis, the proportion of incomplete RAI decreased from 84.0% (79 of 94) during the pre-intervention period to 48.5% (47 of 97) during the IT intervention period (P < .001). DISCUSSION Feedback reports alone increased RAI rates, and an IT intervention promoting documentation of complete RAI in addition to feedback reports led to significant reductions in RAI rate, incomplete RAI, and improved overall completeness of the radiology recommendations.
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Affiliation(s)
- Ariadne K DeSimone
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Neena Kapoor
- Director of Diversity, Inclusion, and Equity and Quality and Patient Safety Officer, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Brigham and Women's Hospital, and Director of Clinical Informatics, Harvard Medical School Library of Evidence, Boston, Massachusetts
| | - Elvira Budiawan
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark M Hammer
- Cardiothoracic Fellowship Program Director, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sonali P Desai
- Senior Vice President and Chief Quality Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sunil Eappen
- Senior Vice President, Medical Affairs, and Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Vice Chair of Radiology Quality and Safety, Mass General Brigham; Director of the Center for Evidence-Based Imaging and Vice Chair of Quality/Safety, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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White T, Aronson MD, Sternberg SB, Shafiq U, Berkowitz SJ, Benneyan J, Phillips RS, Schiff GD. Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance. JAMA Netw Open 2022; 5:e2222549. [PMID: 35867062 PMCID: PMC9308057 DOI: 10.1001/jamanetworkopen.2022.22549] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
IMPORTANCE Following up on recommendations from radiologic findings is important for patient care, but frequently there are failures to carry out these recommendations. The lack of reliable systems to characterize and track completion of actionable radiology report recommendations poses an important patient safety challenge. OBJECTIVES To characterize actionable radiology recommendations and, using this taxonomy, track and understand rates of loop closure for radiology recommendations in a primary care setting. DESIGN, SETTING, AND PARTICIPANTS Radiology reports in a primary care clinic at a large academic center were redesigned to include actionable recommendations in a separate dedicated field. Manual review of all reports generated from imaging tests ordered between January 1 and December 31, 2018, by primary care physicians that contained actionable recommendations was performed. For this quality improvement study, a taxonomy system that conceptualized recommendations was developed based on 3 domains: (1) what is recommended (eg, repeat a test or perform a different test, specialty referral), (2) specified time frame in which to perform the recommended action, and (3) contingency language qualifying the recommendation. Using this framework, a 2-stage process was used to review patients' records to classify recommendations and determine loop closure rates and factors associated with failure to complete recommended actions. Data analysis was conducted from April to July 2021. MAIN OUTCOMES AND MEASURES Radiology recommendations, time frames, and contingencies. Rates of carrying out vs not closing the loop on these recommendations in the recommended time frame were assessed. RESULTS A total of 598 radiology reports were identified with structured recommendations: 462 for additional or future radiologic studies and 196 for nonradiologic actions (119 specialty referrals, 47 invasive procedures, and 43 other actions). The overall rate of completed actions (loop closure) within the recommended time frame was 87.4%, with 31 open loop cases rated by quality expert reviewers to pose substantial clinical risks. Factors associated with successful loop closure included (1) absence of accompanying contingency language, (2) shorter recommended time frames, and (3) evidence of direct radiologist communication with the ordering primary care physicians. A clinically significant lack of loop closure was found in approximately 5% of cases. CONCLUSIONS AND RELEVANCE The findings of this study suggest that creating structured radiology reports featuring a dedicated recommendations field permits the development of taxonomy to classify such recommendations and determine whether they were carried out. The lack of loop closure suggests the need for more reliable systems.
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Affiliation(s)
- Tiantian White
- Harvard Medical School, Boston, Massachusetts
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Mark D. Aronson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scot B. Sternberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Umber Shafiq
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Seth J. Berkowitz
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James Benneyan
- Healthcare Systems Engineering Institute, College of Engineering, Northeastern University, Boston, Massachusetts
| | - Russell S. Phillips
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts
| | - Gordon D. Schiff
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts
- Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, Massachusetts
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Kadom N, Venkatesh AK, Shugarman SA, Burleson JH, Moore CL, Seidenwurm D. Novel Quality Measure Set: Closing the Completion Loop on Radiology Follow-up Recommendations for Noncritical Actionable Incidental Findings. J Am Coll Radiol 2022; 19:881-890. [PMID: 35606263 DOI: 10.1016/j.jacr.2022.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Care gaps occur when radiology follow-up recommendations are poorly communicated or not completed, resulting in missed or delayed diagnosis potentially leading to worse patient outcomes. This ACR-led initiative assembled a technical expert panel (TEP) to advise development of quality measures intended to improve communication and drive increased completion rates for radiology follow-up recommendations. MATERIALS AND METHODS A multistakeholder TEP was assembled to advise the development of quality measures. The project scope, limited to noncritical actionable incidental findings (AIFs), encourages practices to develop and implement systems ensuring appropriate communication and follow-up to completion. RESULTS A suite of nine measures were developed: four outcome measures include closing the loop on completion of radiology follow-up recommendations for nonemergent AIFs (with pulmonary nodule and abdominal aortic aneurysm use cases) and overall cancer diagnoses. Five process measures address communication and tracking of AIFs: inclusion of available evidence or guidelines informing the recommendation, communication of AIFs to the practice managing ongoing care, identifying when AIFs have been communicated to the patient, and employing tracking and reminder systems for AIFs. CONCLUSION This ACR-led initiative developed a measure set intended to improve patient outcomes by ensuring that AIFs are appropriately communicated and followed up. The intent of these measures is to focus improvement on specific areas in which gaps in communication and AIF follow-up may occur, prompting systems to devote resources that will identify and implement solutions to improve patient care.
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Kapoor N, Lacson R, Eskian M, Cochon L, Glazer D, Ip I, Khorasani R. Variation in Radiologists' Follow-Up Imaging Recommendations for Small Cystic Pancreatic Lesions. J Am Coll Radiol 2021; 18:1405-1414. [PMID: 34174205 DOI: 10.1016/j.jacr.2021.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/24/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to determine the incidence, identify imaging and patient factors, and measure individual radiologist variation associated with follow-up recommendations for small focal cystic pancreatic lesions (FCPLs), a common incidental imaging finding. METHODS This institutional review board-approved retrospective study analyzed 146,709 reports from abdominal CTs and MRIs performed in a large academic hospital from July 1, 2016, to June 30, 2018. A trained natural language processing tool identified 4,345 reports with FCPLs, which were manually reviewed to identify those containing one or more <1.5-cm pancreatic cysts. For these patients, patient, lesion, and radiologist features and follow-up recommendations for FCPL were extracted. A nonlinear random-effects model estimated degree of variation in follow-up recommendations across radiologists at department and division levels. RESULTS Of 2,872 reports with FCPLs < 1.5 cm, 708 (24.7%) had FCPL-related follow-up recommendations. Average patient age was 67 years (SD ± 11). In all, 1,721 (60.0%) reports were for female patients; 59.3% of patients had only one cyst. In multivariable analysis, older patients had slightly lower follow-up recommendation rates (odds ratio [OR]: 0.98 [0.98-1.00] per additional year), and lesions associated with main duct dilatation and septation were more likely to have a follow-up recommendation (ORs: 1.93 [1.11-3.36] and 2.88 [1.89-4.38], respectively). Radiologist years in practice (P = .51), trainee presence (P = .21), and radiologist gender (P = .52) were not associated with increased follow-up recommendations. There was significant interradiologist variation in the Abdominal Imaging Division (P = .04), but not in Emergency Radiology (P = .31) or Cancer Imaging Divisions (P = .29). DISCUSSION Interradiologist variation significantly contributes to variability in follow-up imaging recommendations for FCPLs.
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Affiliation(s)
- Neena Kapoor
- Director of Diversity, Equity, and Inclusion Quality and Patient Safety Officer, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Director of Clinical Informatics, Harvard Medical School Library of Evidence, Boston, Massachusetts
| | - Mahsa Eskian
- Research Fellow, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laila Cochon
- Research Fellow, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Glazer
- Medical Director of CT, and Director, Cross-Sectional Interventional Radiology (CSIR), Department or Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ivan Ip
- Faculty, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Director, Center for Evidence-Based Imaging, and Vice Chair of Quality/Safety, Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kapoor N, Lacson R, Cochon L, Hammer M, Ip I, Boland G, Khorasani R. Radiologist Variation in the Rates of Follow-up Imaging Recommendations Made for Pulmonary Nodules. J Am Coll Radiol 2021; 18:896-905. [PMID: 33567312 DOI: 10.1016/j.jacr.2020.12.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Determine whether differences exist in rates of follow-up recommendations made for pulmonary nodules after accounting for multiple patient and radiologist factors. METHODS This Institutional Review Board-approved, retrospective study was performed at an urban academic quaternary care hospital. We analyzed 142,001 chest and abdominal CT reports from January 1, 2016, to December 31, 2018, from abdominal, thoracic, and emergency radiology subspecialty divisions. A previously validated natural language processing (NLP) tool identified 24,512 reports documenting pulmonary nodule(s), excluding reports NLP-positive for lung cancer. A second validated NLP tool identified reports with follow-up recommendations specifically for pulmonary nodules. Multivariable logistic regression was used to determine the likelihood of pulmonary nodule follow-up recommendation. Interradiologist variability was quantified within subspecialty divisions. RESULTS NLP classified 4,939 of 24,512 (20.1%) reports as having a follow-up recommendation for pulmonary nodule. Male patients comprised 45.3% (11,097) of the patient cohort; average patient age was 61.4 years (±14.1 years). The majority of reports were from outpatient studies (62.7%, 15,376 of 24,512), were chest CTs (75.9%, 18,615 of 24,512), and were interpreted by thoracic radiologists (63.7%, 15,614 of 24,512). In multivariable analysis, studies for male patients (odds ratio [OR]: 0.9 [0.8-0.9]) and abdominal CTs (OR: 0.6 [0.6-0.7] compared with chest CT) were less likely to have a pulmonary nodule follow-up recommendation. Older patients had higher rates of follow-up recommendation (OR: 1.01 for each additional year). Division-level analysis showed up to 4.3-fold difference between radiologists in the probability of making a follow-up recommendation for a pulmonary nodule. DISCUSSION Significant differences exist in the probability of making a follow-up recommendation for pulmonary nodules among radiologists within the same subspecialty division.
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Affiliation(s)
- Neena Kapoor
- Director of Diversity, Inclusion, and Equity, Department of Radiology, Brigham and Women's Hospital, Quality and Patient Safety Officer, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Director of Clinical Informatics, Harvard Medical School Library of Evidence, Boston, Massachusetts
| | - Laila Cochon
- Research Fellow, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark Hammer
- Cardiothoracic Fellowship Program Director, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ivan Ip
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Giles Boland
- President of the Brigham and Women's Physicians Organization, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Director of the Center for Evidence Imaging and Vice Chair of Quality/Safety, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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