Volume and impact of second-opinion consultations by radiologists at a tertiary care cancer center: data

Second-opinion interpretation of outside facility general ultrasound studies: rate of discrepancies and management change

BACKGROUND

Second-opinion reads on imaging studies are common for CT and MRI, but many institutions are hesitant to implement a workflow for second read of ultrasound studies performed at other facilities due to quality considerations.

OBJECTIVE

The purpose of this study was to assess discrepancy rates between initial and second-opinion general ultrasound reports METHODS: We reviewed all requests of second-opinion US studies referred to our tertiary care center between 02/01/2020 and 06/23/2022. We evaluated percentage of exams that were interpreted versus archived. Whenever the original report was available (n = 196 studies), we evaluated any discrepancy in findings, interpretation, and potential management change based on second report compared to the initial report as evaluated by consensus agreement of 3 subspecialized radiologists.

RESULTS

A total of 586 ultrasound studies for 533 patients were nominated for consult. After excluding 58 studies for technical reasons (e.g., duplicate nomination, images for procedure guidance, modality is not ultrasound) and 282 studies that were archived by the reading radiologist due to various objective (e.g., studies such as echocardiography not interpreted by the abdominal imagers or more recent study available obviating need for consultation) and subjective (e.g., suboptimal image quality, lack of cine clips) reasons, a total of 246 studies were reinterpreted and were further analyzed. Only 21/246 patients (8.5%) got repeat ultrasound of the same body part within 3 months of original study date. The original (first-read) report was available for 196/246 studies, with discrepancy present between the first and second reads in 74/196 (37.8%) studies, with potential management change in 51/196 (26.0%) studies.

CONCLUSION

Second-opinion interpretation of outside ultrasound examinations by subspecialized radiologists can result in recommended management change in 26% of studies indicating potential for added value to reinterpreting ultrasound studies despite the concerns for quality control.

Variations and Challenges to Performing Outside Study Interpretations in Breast Imaging: A National Survey of the Society of Breast Imaging Membership

OBJECTIVE

Second-opinion interpretations of outside facility breast imaging provide value-added care but are operationally challenging for breast radiologists. Our objective was to survey members of the Society of Breast Imaging (SBI) to assess practice patterns and perceived barriers to performing outside study interpretations (OSIs).

METHODS

An anonymous survey was developed by the Patient Care and Delivery Committee of the SBI and distributed via e-mail to SBI radiologist members. Survey questions included practice demographics and OSI volumes, billing practices, clinical scenarios, and imaging modalities, logistics, and barriers. Responses were aggregated and comparisons were made by univariate analysis using likelihood ratio tests, t-tests, and Spearman's rank correlation tests as appropriate. Ordinal or nominal logistic modeling and linear regression modeling was also performed.

RESULTS

There were 371 responses (response rate of 13%). Most respondents practice at an affiliated specialty breast care center (306/371, 83%) and said their practice performed OSIs (256/371, 69%). Academic practices reported the highest OSI volumes (median 75 per month) and were most likely to indicate increases in OSI volumes over time (100/144, 69%). The most common indication for OSI was second opinion for a biopsy recommendation (245/256, 96%). Most practices provide a final BI-RADS assessment (183/261, 70%). The most cited barrier to performing OSIs was physician time constraints (252/369, 68%).

CONCLUSION

Breast imaging OSI practice patterns are variable among SBI members with notable differences by practice setting and multiple barriers identified. More unified guidelines and recommendations may be needed for radiologists to better perform this valuable task.

Musculoskeletal Outside Interpretation (MOI-RADS): an automated quality assurance tool to prospectively track discrepancies in second-opinion interpretations in musculoskeletal imaging

OBJECTIVE

To implement an automated quality assurance tool to prospectively track discrepancies in musculoskeletal (MSK) exams submitted for second-opinion radiology interpretation at a tertiary center.

METHODS

From 2013 to 2020, a standardized template was included in re-interpretation MSK reports, and a concordance assessment compared with primary interpretation was assigned. Analysis of standardized template implementation and discordance rates was performed. Of the re-interpretations that demonstrated likely clinically relevant discordance, a sample was randomly selected and the EMR was reviewed to evaluate the impact on patient care and change in medical management.

RESULTS

A total of 1052 re-interpretations were identified using the standardized template. Services with higher requests for second-opinion interpretation were oncology (n = 351, 33%) and orthopedic surgery (n = 255, 24%). Overall utilization rate of the template was 65% with marked decreased during the last year (22% rate). In comparison to the primary report, there was a 30% discordance rate (n = 309) with 18% (n = 184) classified as likely clinically relevant. From the subset of discrepancies that could be clinically relevant, there was a change in management in 63% of the cases (19/30) with the re-interpretation ultimately proving correct in 80% of the cases (24/30).

CONCLUSION

Implementation of a quality assurance tool embedded in the radiology workflow of second-opinion interpretations can facilitate the analysis of patient care impact; however, stricter implementation is necessary. Oncologic studies were the most common indication for re-interpretations. Although the primary and second interpretations in the majority of cases were in agreement, subspecialty MSK radiology interpretation was shown to be more accurate than primary interpretations and impacted clinical management in cases of discrepancy.

Nonpalpable breast lesions: impact of a second-opinion review at a breast unit on BI-RADS classification

OBJECTIVE

To compare BI-RADS classification, management, and outcome of nonpalpable breast lesions assessed both by community practices and by a multidisciplinary tumor board (MTB) at a breast unit.

METHODS

All nonpalpable lesions that were first assigned a BI-RADS score by community practices and then reassessed by an MTB at a single breast unit from 2009 to 2017 were retrospectively reviewed. Inter-review agreement was assessed with Cohen's kappa statistic. Changes in biopsy recommendation were calculated. The percentage of additional tumor lesions detected by the MTB was obtained. The sensitivity, AUC, and cancer rates for BI-RADS category 3, 4, and 5 lesions were computed for both reviews.

RESULTS

A total of 1909 nonpalpable lesions in 1732 patients were included. For BI-RADS scores in the whole cohort, a fair agreement was found (κ = 0.40 [0.36-0.45]) between the two reviews. Agreement was higher when considering only mammography combined with ultrasound (κ = 0.53 [0.44-0.62]), masses (κ = 0.50 [0.44-0.56]), and architectural distortion (κ = 0.44 [0.11-0.78]). Changes in biopsy recommendation occurred in 589 cases (31%). Ninety of 345 additional biopsies revealed high-risk or malignant lesions. Overall, the MTB identified 27% additional high-risk and malignant lesions compared to community practices. The BI-RADS classification AUCs for detecting malignant lesions were 0.66 (0.63-0.69) for community practices and 0.76 (0.75-0.78) for the MTB (p < 0.001).

CONCLUSION

Agreement between community practices and MTB reviews for BI-RADS classification in nonpalpable lesions is only fair. MTB review improves diagnostic performances of breast imaging and patient management.

KEY POINTS

• The inter-review agreement for BI-RADS classification between community practices and the multidisciplinary board was only fair (κ = 0.40). • Disagreements resulted in changes of biopsy recommendation in 31% of the lesions. • The multidisciplinary board identified 27% additional high-risk and malignant lesions compared to community practices.

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.

Clinical Impact of Second Opinion Radiology Consultation for Patients With Breast Cancer

PURPOSE

To assess the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast imaging examinations for newly diagnosed breast cancer patients presenting to a tertiary cancer center.

MATERIALS AND METHODS

This Institutional Review Board-approved retrospective study included patients presenting from July 2016 to March 2017 to a National Cancer Institute-designated comprehensive cancer center for second opinion after breast cancer diagnosis. Outside and second opinion radiology reports of 252 randomly selected patients were compared by two subspecialty breast radiologists to consensus. A peer review score was assigned, modeled after ACR's RADPEER^TM peer review metric: 1-agree; 2-minor discrepancy (unlikely clinically significant); 3-moderate discrepancy (may be clinically significant); 4-major discrepancy (likely clinically significant). Among cases with clinically significant discrepancies, rates of clinical management change (management alterations including change in follow-up, neoadjuvant therapy use, and surgical management as a direct result of image review), and detection of additional malignancy were assessed through electronic medical record review.

RESULTS

A significant difference in interpretation (scores = 3 or 4) was seen in 41 of 252 cases (16%, 95% confidence interval [CI], 11.7%-20.8%). The difference led to additional workup in 38 of 252 cases (15%, 95% CI 10.6%-19.5%) and change in clinical management in 18 of 252 cases (7.1%, 95% CI 4.0%-10.2%), including 15 of 252 with change in surgical management (6.0%, 95% CI, 3.0%-8.9%). An additional malignancy or larger area of disease was identified in 11 of 252 cases (4.4%, 95% CI, 1.8%-6.9%).

CONCLUSION

Discrepancy between outside and second-opinion breast imaging subspecialists frequently results in additional workup for breast cancer patients, changes in treatment plan, and identification of new malignancies.

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.

Maximizing Value Through Innovations in Radiologist-Driven Communications in Breast Imaging

OBJECTIVE

The purposes of this article are to provide an overview of current and emerging practices in radiologist communications with both referring physicians and patients across the breast cancer care continuum; to highlight areas in which radiologist-driven communications can improve value in breast cancer screening, diagnosis, and treatment; and describe how the integrative reporting and consultative practices of breast imagers can serve as models of higher-value patient-centered care in other radiology subspecialties.

CONCLUSION

The traditional radiology report will eventually no longer be viewed as the sole consultation by radiologists but instead act as a starting point for more detailed communications between radiologists and both patients and physicians. The value-creating practices of breast imagers can be used as a road map for similar practices across other radiologic specialties, similar to the use of BI-RADS as a road map for structured breast imaging reporting.

Second Opinion by In-House Radiologists: Present Picture and Emphasis on Standardizing Imaging Protocol in Oncology

Standardization of imaging acquisition protocol, modification in protocols for specific tumor and standardization in providing image data sets for outside referral, will help not only patients but also oncologists (who requests the second read) and the radiologists (who provides the second read on outside imaging). The practical benefits to patients include, cost savings (limiting the repeat radiological examination), timely initiation of treatment; the unrealized benefits include prevention of unnecessary anxiety and discomfort. In such second opinions, the radiologists should answer key clinical issues about resectability and other relevant findings in provisionally diagnosed cancers. In this article we will discuss the present scenario regarding second opinion of outside diagnostic imaging, the current approach, challenges and its optimization.

Radiology Consultation in the Era of Precision Oncology: A Review of Consultation Models and Services in the Tertiary Setting

The purpose of the article is to describe the various radiology consultation models in the Era of Precision Medicine. Since the inception of our specialty, radiologists have served as consultants to physicians of various disciplines. A variety of radiology consultation services have been described in the literature, including clinical decision support, patient-centric, subspecialty interpretation, and/or some combination of these. In oncology care in particular, case complexity often merits open dialogue with clinical providers. To explore the utility and impact of radiology consultation services in the academic setting, this article will further describe existing consultation models and the circumstances that precipitated their development. The hybrid model successful at our tertiary cancer center is discussed. In addition, the contributions of a consultant radiologist in breast cancer care are reviewed as the archetype of radiology consultation services provided to oncology practitioners.

Second-Opinion Subspecialty Consultations in Musculoskeletal Radiology

OBJECTIVE

The purpose of this article is to evaluate the significance of subspecialty second-opinion consultations for CT and MRI examinations in musculoskeletal (MSK) radiology.

MATERIALS AND METHODS

All 3165 MSK CT and MRI examinations referred to one academic institution for second-opinion consultation during a 24-month period were reviewed by three MSK-trained radiologists. Outside and inside reports were compared by two independent MSK radiology fellows using a previously published 5-point scale. Clinically important differences (categories 4 and 5) were defined as those likely to change patient management. Statistical comparisons of rates were performed using a chi-square test with Bonferroni corrections. Interobserver reliability was reported using linear weighted kappa statistics and the percentage of agreement.

RESULTS

Of all second-opinion examinations, 73.5% (2326/3165) had an outside report available for comparison and inclusion in this study. There were 610 of 2326 (26.2%) examinations with clinically important differences. The rate of clinically important discrepant readings was even higher in oncologic cases (36.3%; 331/911). When the final diagnosis was determined from pathology reports performed after internal interpretation, the second-opinion consultation was noted to be correct in 82.0% (334/407) of examinations with category 4 or 5 discrepancies. There was very good agreement (κ = 0.93) in scoring the discrepancies between second-opinion consultants.

CONCLUSION

The subspecialty second-opinion consultation was more accurate than outside reports in 82.0% of examinations when pathologic confirmation was made. A moderate rate (26.2%) of discrepant interpretations was noted between outside and inside MSK imaging examinations, especially in tumor cases (36.3%). Most discrepancies were in interpreting rather than detecting abnormalities.

Cancer Imaging at the Crossroads of Precision Medicine: Perspective From an Academic Imaging Department in a Comprehensive Cancer Center

The authors propose one possible vision for the transformative role that cancer imaging in an academic setting can play in the current era of personalized and precision medicine by sharing a conceptual model that is based on experience and lessons learned designing a multidisciplinary, integrated clinical and research practice at their institution. The authors' practice and focus are disease-centric rather than imaging-centric. A "wall-less" infrastructure has been developed, with bidirectional integration of preclinical and clinical cancer imaging research platforms, enabling rapid translation of novel cancer drugs from discovery to clinical trial evaluation. The talents and expertise of medical professionals, scientists, and staff members have been coordinated in a horizontal and vertical fashion through the creation of Cancer Imaging Consultation Services and the "Adopt-a-Radiologist" campaign. Subspecialized imaging consultation services at the hub of an outpatient cancer center facilitate patient decision support and management at the point of care. The Adopt-a-Radiologist campaign has led to the creation of a novel generation of imaging clinician-scientists, fostered new collaborations, increased clinical and academic productivity, and improved employee satisfaction. Translational cancer research is supported, with a focus on early in vivo testing of novel cancer drugs, co-clinical trials, and longitudinal tumor imaging metrics through the imaging research core laboratory. Finally, a dedicated cancer imaging fellowship has been developed, promoting the future generation of cancer imaging specialists as multidisciplinary, multitalented professionals who are trained to effectively communicate with clinical colleagues and positively influence patient care.

Diagnosis of Extracapsular Extension of Prostate Cancer on Prostate MRI: Impact of Second-Opinion Readings by Subspecialized Genitourinary Oncologic Radiologists

OBJECTIVE

The purpose of this article is to investigate the added value of second-opinion evaluation of prostate MRI by subspecialized genitourinary oncologic radiologists for the assessment of extracapsular extension (ECE) of prostate cancer.

MATERIALS AND METHODS

We performed a retrospective evaluation of initial and second-opinion radiology reports of 76 patients who underwent MRI of the prostate before prostatectomy for histologically proven prostate cancer. Initial outside reports and second-opinion reports were unpaired and reviewed in random order by a urologist who was blinded to patients' clinical details and histopathologic data. Histopathologic analysis of the prostatectomy specimen served as the reference standard.

RESULTS

Among cases with diagnostic-quality images available (71/76; 93%), disagreement between the initial report and the second-opinion report was observed in 30% of cases (21/71; κ = 0.35); in 18 of these 21 cases (86%), histopathologic analysis proved that the second-opinion report was correct. The second-opinion interpretations had statistically significantly higher sensitivity (66% vs 24%; p < 0.0001) than did the initial reports, whereas there was no statistically significant difference in specificity (87% vs 93%; p = 0.317). On ROC curve analysis, the second-opinion reports yielded a statistically significantly higher AUC for the detection of ECE (0.80 vs 0.65; p = 0.004).

CONCLUSION

The reinterpretation of prostate MRI examinations by subspecialized genitourinary oncologic radiologists improved the detection of ECE of prostate cancer.

The clinical impact of subspecialized radiologist reinterpretation of abdominal imaging studies, with analysis of the types and relative frequency of interpretation discrepancies

PURPOSE

The primary objective of this study was to determine the clinical impact and value of abdominal imaging reinterpretations by subspecialized abdominal imagers.

METHODS

Secondary interpretations for computed tomography (CT), magnetic resonance (MR), and ultrasound (US) abdominal studies performed outside our institution over a 7-month period were retrospectively compared to the primary (outside) interpretation, with interpretive differences recorded. Clinical notes, pathology and subsequent imaging determined ground truth diagnosis and the clinical impact of any interpretive discrepancies were graded as having high, medium, or little/no clinical impact. Interpretive comparisons were scored into categories: (1) no difference; (2) incidental findings of no clinical impact; (3) finding not reported; (4) significance of finding undercalled; (5) significance of finding overcalled; (6) finding misinterpreted; and (7) multiple discrepancy types in one report.

RESULTS

398 report comparisons were reviewed on 380 patients. There were 300 CT, 60 MR, and 38 US examinations. The primary report had 5.0% (20/398) high clinical impact interpretive discrepancies and 7.5% (30/398) medium clinical impact discrepancies. The subspecialized secondary report had no high clinical impact discrepancies and 8/398 (2.0%) medium clinical impact discrepancies. In order of frequency, high and medium impact discrepancies in the primary report consisted of 50% overcalls, 26% unreported findings, 18% undercalls, 4% misinterpretations, and 2% multiple discrepancies.

CONCLUSIONS

Subspecialty review of abdominal imaging exams can provide clinical benefit. Half of the discrepancies in this series of abdominal reinterpretations were due to overcalls.

The degree of abdominal imaging (AI) subspecialization of the reviewing radiologist significantly impacts the number of clinically relevant and incidental discrepancies identified during peer review of emergency after-hours body CT studies

PURPOSE

To evaluate if and to what extent the degree of subspecialization in abdominal imaging (AI) affects rates of discrepancies identified on review of body CT studies initially interpreted by board-certified radiologists not specialized in AI.

METHOD AND MATERIALS

AI division radiologists at one academic medical center were classified as primary or secondary members of the division based on whether they perform more or less than 50% of their clinical duties in AI. Primary AI division radiologists were further subdivided based on whether or not they focus their clinical duties almost exclusively in AI. All AI radiologists performed subspecialty review of all after-hours body CT studies initially interpreted by any non-division radiologist. The discrepancies identified in the subspecialty review of consecutive after-hours body CT scans performed between 7/1/10 and 12/31/10 were analyzed and placed into one of three categories: (1) discrepancies that potentially affect patient care ("clinically relevant discrepancies", or CRD); (2) discrepancies that would not affect patient care ("incidental discrepancies", or ID); and (3) other types of comments. Rates of CRD and ID detection were compared between subgroups of Abdominal Imaging Division radiologists divided by the degree of subspecialization.

RESULTS

1303 studies met the inclusion criteria. Of 742 cases reviewed by primary members of the AI division, 33 (4.4%) had CRD and 78 (10.5%) had ID. Of 561 cases reviewed by secondary members of the AI division, 11 (2.0%) had CRD and 36 (6.5%) had ID. The differences between the groups for both types of discrepancies were statistically significant (p = 0.01). When primary members of the AI division were further subdivided based on extent of clinical focus on abdominal imaging, rates of CRD and ID detection were higher for the subgroup with more clinical focus on abdominal imaging.

CONCLUSION

The degree of AI subspecialization affects the rate of clinically relevant and ID identified in body CT interpretations initially rendered by board certified but non-abdominal imaging subspecialized radiologists.

Providing formal reports for outside imaging and the rate of repeat imaging

OBJECTIVE

The purpose of this study is to assess whether providing a formal report for outside imaging reduces repeat imaging.

MATERIALS AND METHODS

From January 1, 2006, through December 31, 2011, patients transferred with an abdominal CT from another ("outside") institution that was imported to our institution's PACS within 60 days of the original CT were considered. Repeat imaging was defined as when an abdominal CT performed at another institution was followed by the same study at our institution in the 14 days after import to PACS. The rate of repeat imaging was compared between patients whose outside imaging did and did not receive a formal report from our radiologists.

RESULTS

Consecutive patients (n = 10,330) who imported an outside abdominal CT to our PACS were considered. Thirty-six percent (3719/10,330) received a formal report. These patients were 32% less likely than the other patients to undergo repeat imaging (9.4% [350/3719] vs 14% [919/6611]; p < 0.001). The odds of repeat imaging were statistically significantly lower for patients who received a formal report after adjusting for potential confounding variables, including the age of the outside imaging study and the referring specialty (multivariate odds ratio, 0.53; 95% CI, 0.47-0.61; p < 0.001).

CONCLUSION

Patients who received a formal report for their outside abdominal CT examinations were less likely to have repeat imaging. Institutions, payers, and policy makers should consider providing and supporting formal reports for outside imaging.

Analysis of dominant factors affecting fatigue caused by soft-copy reading

RATIONALE AND OBJECTIVES

The aim of this study was to analyze the dominant factors affecting fatigue caused by soft-copy reading to identify a method for decreasing fatigue in clinical practice.

MATERIALS AND METHODS

Two types of fatigue-fatigue in the central nervous system and subjective visual fatigue-were evaluated using a critical fusion frequency test and a questionnaire administered to 17 male radiologists before and after soft-copy reading. Reading-induced fatigue was assumed to be affected by 20 hypothetical factors associated with personal characteristics, time required for reading, content or amount of reading, and the reading environment. We used multiple linear regression analysis with a variable selection method to detect the best combination of factors capable of expressing variations in each of the measured fatigue values. The effects of the detected (dominant) factors on fatigue were also examined based on coefficients of the dominant factors in multiple regression models.

RESULTS

Fatigue in the central nervous system decreased with a higher corrected visual acuity and a higher ambient illuminance in the reading room and was also affected by the type of monitor used. Visual fatigue was relieved when there was a larger difference in the brightness of the monitor and the surfaces surrounding the monitor and tended to be more severe when glasses rather than contact lenses were worn.

CONCLUSIONS

Increasing the ambient illuminance, using an appropriate type of monitor, improving the corrected visual acuity, and using contact lenses rather than eyeglasses could help decrease reading-induced fatigue in male radiologists.

Medical imaging displays and their use in image interpretation

The adequate and repeatable performance of the image display system is a key element of information technology platforms in a modern radiology department. However, despite the wide availability of high-end computing platforms and advanced color and gray-scale monitors, the quality and properties of the final displayed medical image may often be inadequate for diagnostic purposes if the displays are not configured and maintained properly. In this article-an expanded version of the Radiological Society of North America educational module "Image Display"-the authors discuss fundamentals of image display hardware, quality control and quality assurance processes for optimal image interpretation settings, and parameters of the viewing environment that influence reader performance. Radiologists, medical physicists, and other allied professionals should strive to understand the role of display technology and proper usage for a quality radiology practice. The display settings and display quality control and quality assurance processes described in this article can help ensure high standards of perceived image quality and image interpretation accuracy.

Impact of neuroradiologist second opinion on staging and management of head and neck cancer

OBJECTIVE

Patients with head and neck cancer frequently present to academic tertiary referral centers with imaging studies that have been performed and interpreted elsewhere. At our institution, these outside head and neck imaging studies undergo formal second opinion reporting by a fellowship-trained academic neuroradiologist with expertise in head and neck imaging. The purpose of this study was to determine the impact of this practice on cancer staging and patient management.

METHODS

Our institutional review board approved the retrospective review of randomized original and second opinion reports for 94 consecutive cases of biopsy proven or clinically suspected head and neck cancer in calendar year 2010. Discrepancy rates for staging and recommended patient management were calculated and, for the 32% (30/94) of cases that subsequently went to surgery, the accuracies of the reports were determined relative to the pathologic staging gold standard.

RESULTS

Following neuroradiologist second opinion review, the cancer stage changed in 56% (53/94) of cases and the recommended management changed in 38% (36/94) of patients with head and neck cancer. When compared to the pathologic staging gold standard, the second opinion was correct 93% (28/30) of the time.

CONCLUSION

In a majority of patients with head and neck cancer, neuroradiologist second opinion review of their outside imaging studies resulted in an accurate change in their cancer stage and this frequently led to a change in their management plan.

Do long radiology workdays affect nodule detection in dynamic CT interpretation?

PURPOSE

A previous study demonstrated decreased diagnostic accuracy for finding fractures and decreased ability to focus on skeletal radiographs after a long working day. Skeletal radiographic examinations commonly have images that are displayed statically. The aim of this study was to investigate whether diagnostic accuracy for detecting pulmonary nodules on CT of the chest displayed dynamically would be similarly affected by fatigue.

METHODS

Twenty-two radiologists and 22 residents were given 2 tests searching CT chest sequences for a solitary pulmonary nodule before and after a day of clinical reading. To measure search time, 10 lung CT sequences, each containing 20 consecutive sections and a single nodule, were inspected using free search and navigation. To measure diagnostic accuracy, 100 CT sequences, each with 20 sections and half with nodules, were displayed at preset scrolling speed and duration. Accuracy was measured using receiver operating characteristic curve analysis. Visual strain was measured via dark vergence, an indicator of the ability to keep the eyes focused on the display.

RESULTS

Diagnostic accuracy was reduced after a day of clinical reading (P = .0246), but search time was not affected (P > .05). After a day of reading, dark vergence was significantly larger and more variable (P = .0098), reflecting higher levels of visual strain, and subjective ratings of fatigue were also higher.

CONCLUSIONS

After their usual workday, radiologists experience increased fatigue and decreased diagnostic accuracy for detecting pulmonary nodules on CT. Effects of fatigue may be mitigated by active interaction with the display.

The effect of a Radiology Conference consultation on cancer patients management

BACKGROUND

The quantitative effect of consultation on cancer patient's management at a Radiology Conference was studied.

PATIENTS AND METHODS

This prospective study included consecutive patients presented at the Radiology Conference of the Division of Oncology. Following the case presentation and discussion, the patient's oncologist completed a questionnaire which asked whether the consultation at the conference added new information regarding the patient's disease status, whether it influenced patient management and, if so, to what extent.

RESULTS

Three hundred and eighty-three patients were included in the study. Significant new information was added for 189 (49%) patients and less consequential information was added for 134 (35%) patients. Major changes in management occurred in 143 (37%) patients after the Radiology Conference and minor changes were made in 56 (15%) patients. The influence of the cancer type on the rate of significant change in treatment and on the rate of major information addition was not statistically significant.

CONCLUSION

Consultation at a Radiological Conference in a tertiary center led to major changes in the management of 37% of the cancer patients presented and provided important information regarding the patient's disease in up to 50% of patients.

Long radiology workdays reduce detection and accommodation accuracy

PURPOSE

The aim of this study was to measure the diagnostic accuracy of fracture detection, visual accommodation, reading time, and subjective ratings of fatigue and visual strain before and after a day of clinical reading.

METHODS

Forty attending radiologists and radiology residents viewed 60 deidentified, HIPAA-compliant bone examinations, half with fractures, once before any clinical reading (early) and once after a day of clinical reading (late). Reading time was recorded. Visual accommodation (the ability to maintain focus) was measured before and after each reading session. Subjective ratings of symptoms of fatigue and oculomotor strain were collected. The study was approved by local institutional review boards.

RESULTS

Diagnostic accuracy was reduced significantly after a day of clinical reading, with average areas under the receiver operating characteristic curves of 0.885 for early reading and 0.852 for late reading (P < .05). After a day of image interpretation, visual accommodation was no more variable, though error in visual accommodation was greater (P < .01), and subjective ratings of fatigue were higher.

CONCLUSIONS

After a day of clinical reading, radiologists have reduced ability to focus, increased symptoms of fatigue and oculomotor strain, and reduced ability to detect fractures. Radiologists need to be aware of the effects of fatigue on diagnostic accuracy and take steps to mitigate these effects.

Technology and Perception in the 21st-Century Reading Room

Radiology reading rooms have changed dramatically over the past 15 years, moving from analog-light-box-based environments to digital-display-based environments. Most of the focus in the early stages of this transition was on the technology, but it soon became obvious that it was not possible or even prudent to consider the technology without considering radiologists. The information being presented to radiologists in digital reading rooms is in many ways very different from that presented on traditional film. On one hand, the digital workstation display medium itself is very different from traditional film images hung on light boxes. On the other hand, without large-area light boxes, images such as those from computed tomography (CT) can no longer be displayed all at once in a series of film sheets. The digital world also introduces the possibility of manipulating image data in ways that were never possible with analog film. Not only can radiologists manipulate image data with various image-processing tools, but also, computers can analyze images and provide even more information to incorporate into the interpretation process. As a consequence of these differences, it has been necessary to focus attention on radiologists to discover ways to optimize the digital reading environment with respect to the human visual system and the way the eye-brain system processes information. This article reviews some of the important perceptual issues that have arisen in the digital reading rooms of the 21st century.

Quantification of clinical consultations in academic emergency radiology

RATIONALE AND OBJECTIVES

The purpose of this study is to quantify the impact of clinical consultation on the workload of an academic emergency radiology section.

MATERIALS AND METHODS

Data from a 7-day audit (24 h/d) of the number and length of clinical consultations was expressed as the mean number of consultations per 24 hours and consultation minutes per 24 hours. Consultations performed on images acquired from outside institutions were noted. The attending radiologist consultation fraction was defined as the attending consultation minutes per 24 hours divided by the number of minutes of attending coverage per 24 hours. Using annualized work relative value units per full-time employee (wRVU/FTE) over the 7 days, the consultation value unit per full-time employee (CVU/FTE) was defined and calculated as the consultation fraction multiplied by the annual wRVU/FTE.

RESULTS

For the attending radiologists, the consultation fraction was 0.13 and the CVU/FTE was 1216. Twenty-two percent of the total consultation minutes were spent on studies performed outside our institution.

CONCLUSIONS

Clinical consultation represents a significant portion of the workload in academic emergency radiology. The consultation fraction describes the fraction of the radiologist's time spent in consultation, and the CVU/FTE expresses the workload of clinical consultations in terms of wRVU/FTE, the factor used most commonly to determine the academic radiologist's productivity and staffing.