Responsible conduct of radiology research: part I. The regulatory framework for human research

The purpose of the articles in this series is to explain the ethical and legal basis for responsible conduct of radiology research. In the current article, the regulatory framework of human research is explained. There is no overall regulatory process for protecting the rights and welfare of humans participating in research. Instead, legal protections in the United States are an amalgam of regulations from multiple federal and state agencies. The key regulations are from the Department of Health and Human Services, the Food and Drug Administration, and the Federal Privacy Rule of the Health Insurance Portability and Accountability Act. Which of these apply in any situation depends on many factors, including the funding source of the research, the site of the research, and the items being tested. Radiologists conducting human research need to know which regulations apply and how to comply with them. The regulations represent a set of rules based on the ethical principles of respect for persons, beneficence, and justice. Radiologists should understand these ethical principles for situations when the regulations are silent, ambiguous, or incomplete. (c) RSNA, 2005.

The American Board of Radiology Maintenance of Certification (MOC) Program in Radiologic Physics

Maintenance of Certification (MOC) recognizes that in addition to medical knowledge, several essential elements involved in delivering quality care must be developed and maintained throughout one's career. The MOC process is designed to facilitate and document the professional development of each diplomate of The American Board of Radiology (ABR) through its focus on the essential elements of quality care in Diagnostic Radiology and its subspecialties, and in the specialties of Radiation Oncology and Radiologic Physics. The initial elements of the ABR-MOC have been developed in accord with guidelines of The American Board of Medical Specialties. All diplomates with a ten-year, time-limited primary certificate in Diagnostic Radiologic Physics, Therapeutic Radiologic Physics, or Medical Nuclear Physics who wish to maintain certification must successfully complete the requirements of the appropriate ABR-MOC program for their specialty. Holders of multiple certificates must meet ABR-MOC requirements specific to the certificates held. Diplomates with lifelong certificates are not required to participate in the MOC, but are strongly encouraged to do so. MOC is based on documentation of individual participation in the four components of MOC: (1) professional standing, (2) lifelong learning and self-assessment, (3) cognitive expertise, and (4) performance in practice. Within these components, MOC addresses six competencies: medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

Is radiologists' volume of mammography reading related to accuracy? A critical review of the literature

The current UK quality assurance guidelines for radiologists in the NHS breast screening programme require those reporting screening mammograms to read a minimum of 5000 cases per year. We aimed to review the evidence for this and to assess whether there was justification for lowering the required level. A literature search was conducted to identify relevant studies where accuracy of reporting mammograms was related to reading volume. Three of the five studies reviewed suggested a positive association between reading volume and sensitivity, but there were few data on volumes above 5000 cases per year. The available evidence did not provide any basis for reducing the threshold volume. Further work is needed, in a UK or European setting, to study the relationship between reading volume and accuracy at higher volume levels and also the separate effects of reading volume and reading experience.

Radiographers and radiologists reporting plain radiograph requests from accident and emergency and general practice

AIM

To assess selectively trained radiographers and consultant radiologists reporting plain radiographs for the Accident and Emergency Department (A&E) and general practitioners (GPs) within a typical hospital setting.

METHODS

Two radiographers, a group of eight consultant radiologists, and a reference standard radiologist independently reported under controlled conditions a retrospectively selected, random, stratified sample of 400 A&E and 400 GP plain radiographs. An independent consultant radiologist judged whether the radiographer and radiologist reports agreed with the reference standard report. Clinicians then assessed whether radiographer and radiologist incorrect reports affected confidence in their diagnosis and treatment plans, and patient outcome.

RESULTS

For A&E and GP plain radiographs, respectively, there was a 1% (95% confidence interval (CI) -2 to 5) and 4% (95% CI -1 to 8) difference in reporting accuracy between the two professional groups. For both A&E and GP cases there was an 8% difference in the clinicians' confidence in their diagnosis based on radiographer or radiologist incorrect reports. For A&E and GP cases, respectively, there was a 2% and 8% difference in the clinicians' confidence in their management plans based on radiographer or radiologist incorrect reports. For A&E and GP cases, respectively, there was a 1% and 11% difference in effect on patient outcome of radiographer or radiologist incorrect reports.

CONCLUSION

There is the potential to extend the reporting role of selectively trained radiographers to include plain radiographs for all A&E and GP patients. Further research conducted during clinical practice at a number of sites is recommended.

Medical Devices and the US Food and Drug Administration: Regulating the Tools of Radiology

The radiology community has an ever-expanding array of technologies to use in the care of patients. Regulated by the US Food and Drug Administration, these technologies often raise complex regulatory and legal questions in everyday practice that can be daunting for practicing radiologists. This article reviews the federal medical device regulatory framework pertinent to the practice of radiology, with the aims of highlighting the potential impact of federal regulation on everyday practice and minimizing misunderstandings about enforcement exposure.

[DRG and OPS-301: effects on the acquisition performance in radiology]

Reimbursement for inpatient services rendered based on comparable daily care rates, case-based flat rates, and special fees as practiced until now has been replaced by the system of diagnosis-related groups. Up until 2004, operation and procedure system (OPS 301) codes could be processed completely automatically by appropriate adaptation of the radiology information system (RIS). Because of further differentiation of OPS codes in the 2005 version, it is no longer possible to unambiguously determine OPS codes automatically. Our goal was to fulfill these additional requirements with as little extra effort as possible. In 36 of 2138 procedures during an observation period of 12 days, i.e., 4/day, manual input on the part of the radiology technical assistant and quality assurance by the diagnosing physician were necessary. This is only needed in complicated procedures for which the minor added effort is negligible in comparison to the entire effort expended for the procedure. We were thus able to achieve the goal of near automation of ascertaining OPS codes.

Rôle de la personne compétente dans la sensibilisation au principe ALARA à travers l’application de la directive européenne 97-43

The purpose of this article is to define the role of the radiation safety officer in raising the awareness of the radiology staff to the ALARA (As low as reasonable achievable) principle specified in European directive 97-43. The actions taken and the techniques used in our hospital, as well as the potential improvements that could be achieved with extra funding, will be presented. The didactic value of flow charts recording technical factors and fluoroscopy times for quality improvement will be demonstrated. In the future, a dosimeter incorporated on the new equipment could allow direct recording of the dose. The different items presented in this paper should allow routine implementation of the required elements described in the law 2003-270, i.e the French translation of European Directive 97-43.

Taming the Expert: Standards and Implications of Radiologist Expert Witness Testimony

In light of the proliferation and pitfalls of expert witness testimony provided by radiologists, this article offers an overview of the standards for such testimony, as enforced by the courts, the relevant professional societies, and peer-review processes. The article also offers practical suggestions that encourage radiologist expert witnesses to be both ethical and effective in spite of the often inconsistent ambitions, expectations, and obligations of the expert's role.

Development of radiology prediction models using feature analysis

RATIONALE AND OBJECTIVES

This article provides an introduction to prediction models and their application in diagnostic imaging research. Prediction models capitalize on the different degrees of association among variables to make a prediction of a health state, formulate a rule, or quantify individual contributions of various predictor variables. The purpose of this article is to elucidate the rationale, implication, and interpretation of prediction models using imaging features.

MATERIALS AND METHODS

The techniques and challenges of developing, testing, and implementing prediction models are described. Prediction model development methods are similar to data-mining techniques.

RESULTS

Learning objectives are to review prediction rule (model) methods, learn how prediction models may be applied to feature analysis, and understand the challenges of developing, testing, and implementing prediction models.

"Memory effect" in observer performance studies of mammograms

RATIONALE AND OBJECTIVE

To evaluate breast radiologists' recognition of mammograms showing cancers that they correctly detected or "missed" during clinical interpretations.

MATERIALS AND METHODS

Two similar experiments were conducted. In the first, 33 bilateral screening mammograms were reviewed by four breast imagers. These included five cancers that each radiologist had detected, two cancers that each radiologist had "missed," and five mammograms recalled by other radiologists that were not cancer. Radiologists were asked if they had interpreted the mammogram in clinic and if the mammogram was suspicious for cancer. In the second experiment, four different breast imagers reviewed 48 mammograms that included five cancers that each radiologist had detected, two cancers that each radiologist had "missed," and five mammograms that were recalled by each radiologist but were not cancer. Using chi-square analysis, the performance of the radiologists on screening mammograms they had read in clinic was compared with their performance on mammograms read in clinic by other radiologists.

RESULTS

Seven of eight radiologists did not remember interpreting any of the mammograms in clinic. One radiologist correctly remembered interpreting one mammogram in clinic, but interpreted it incorrectly. Average performance showed no significant difference (P = .60) between mammograms they had interpreted in clinic and those interpreted by others.

CONCLUSION

Radiologists do not remember most mammograms showing cancer that they have interpreted, either correctly or incorrectly, after they are mixed with mammograms showing cancer that were interpreted by other radiologists. Screening mammograms can be used in observer performance studies in which the interpreting radiologist participates as an observer.

Radiographic human identification using bones of the hand: a validation study

The 1993 Supreme Court case Daubert v. Merrell-Dow Pharmaceuticals, Inc. underscores the importance of validating forensic science techniques. This research examines the validity of using posterior-anterior radiographs of the hand to make positive identifications of unknown human remains. Furthermore, this study was constructed to satisfy the requirements of Daubert's guidelines of scientific validity by establishing a standard methodology for hand radiograph analysis, testing the technique, and noting rates of error. This validation study required twelve participant examiners from the forensic science community, working independently, to attempt to match 10 simulated postmortem radiographs of skeletonized hands to 40 simulated antemortem radiographs of fleshed cadaver hands. The overall accuracy rate of the twelve examiners was 95%, while their collective sensitivity and specificity were 95% and 92%, respectively. However, the accuracy of each examiner was related to the amount of radiological training and experience of the observer. Six Ph.D. forensic anthropologists and four experienced forensic anthropology graduate students correctly identified all the matches. Participant examiners noted bone morphology, trabecular patterns of the proximal and middle phalanges, and distinctive radiopaque and radiolucent features as the anatomical features that aided the identification process. The hand can be an important skeletal element for radiographic positive identification because it contains 27 individual bones for comparative analysis.