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Alruwaili AR, Jamea AA, Alayed RN, Alebrah AY, Alshowaiman RY, Almugbel LA, Heikal AG, Alkhanbashi AS, Maflahi AA. A Critical Examination of Academic Hospital Practices-Paving the Way for Standardized Structured Reports in Neuroimaging. J Clin Med 2024; 13:4334. [PMID: 39124601 PMCID: PMC11313519 DOI: 10.3390/jcm13154334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Imaging studies are often an integral part of patient evaluation and serve as the primary means of communication between radiologists and referring physicians. This study aimed to evaluate brain Magnetic Resonance Imaging (MRI) reports and to determine whether these reports follow a standardized or narrative format. Methods: A series of 466 anonymized MRI reports from an academic hospital were downloaded from the Picture Archiving and Communication System (PACS) in portable document format (pdf) for the period between August 2017 and March 2018. Two hundred brain MRI reports, written by four radiologists, were compared to a structured report template from the Radiology Society of North America (RSNA) and were included, whereas MR-modified techniques, such as MRI orbits and MR venography reports, were excluded (n = 266). All statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) statistical software (version 16.4.1, MedCalc Software). Results: None of the included studies used the RSNA template for structured reports (SRs). The highest number of brain-reported pathologies was for vascular disease (24%), while the lowest was for infections (3.5%) and motor dysfunction (5.5%). Radiologists specified the Technique (n = 170, 85%), Clinical Information (n = 187, 93.5%), and Impression (n = 197, 98.5%) in almost all reports. However, information in the Findings section was often missing. As hypothesized, radiologists with less experience showed a greater commitment to reporting additional elements than those with more experience. Conclusions: The SR template for medical imaging has been accessible online for over a decade. However, many hospitals and radiologists still use the free-text style for reporting. Our study was conducted in an academic hospital with a fellowship program, and we found that structured reporting had not yet been implemented. As the health system transitions towards teleservices and teleradiology, more efforts need to be put into advocating standardized reporting in medical imaging.
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Affiliation(s)
- Ashwag Rafea Alruwaili
- Radiological Sciences Department, King Saud University, Riyadh 11451, Saudi Arabia
- Scientists Unit, Central Research Laboratory, King Saud University, Riyadh 11495, Saudi Arabia
| | - Abdullah Abu Jamea
- College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
- Department of Radiology and Medical Imaging, King Saud University Medical City, Riyadh 145111, Saudi Arabia
| | - Reema N. Alayed
- Magnetic Resonance Imaging Unit, King Faisal Specialist Hospital & Research Center (KFSHRC), Riyadh 12713, Saudi Arabia
| | - Alhatoun Y. Alebrah
- Department of Radiology and Medical Imaging, King Saud University Medical City, Riyadh 145111, Saudi Arabia
| | - Reem Y. Alshowaiman
- Department of Radiology and Medical Imaging, King Saud University Medical City, Riyadh 145111, Saudi Arabia
| | - Loulwah A. Almugbel
- Cath Lab, Radiological Imaging, Prince Sultan Cardiac Center, Riyadh 11625, Saudi Arabia
| | - Ataf G. Heikal
- Radiological Sciences Department, King Saud University, Riyadh 11451, Saudi Arabia
| | | | - Anwar A. Maflahi
- Radiological Sciences Department, King Saud University, Riyadh 11451, Saudi Arabia
- Health Gates—Center of Excellence for Primary Health Care, Riyadh 12214, Saudi Arabia
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Hagemann J, Seifen C, Koll L, Reissig M, Leggewie B, Hackenberg B, Döge J, Helling K, Becker S, Klimek L, Matthias C, Ernst BP. [Enhanced quality of documentation for biologic therapy of chronic rhinosinusitis through structured digital reporting and indication?]. HNO 2024:10.1007/s00106-024-01488-x. [PMID: 38829524 DOI: 10.1007/s00106-024-01488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND With targeted inhibition of type 2 inflammation, biologics represent the standard add-on therapy for inadequately controlled severe forms of chronic rhinosinusitis with nasal polyps (CRSwNP). Despite standardization with paper-based checklists, the documentation of medical history and current findings pertinent to indication criteria are a significant challenge for physicians. Through development of an application based on structured reporting, the current study aimed to improve documentation quality and simplify the decision-making process. Previously available paper checklists served as a comparison. METHODS For this study, a digital incremental tool was programmed to record current findings and check for fulfilment of indication criteria. The tool was compared with other checklists in terms of completeness, time required, and readability. RESULTS A total of 20 findings were collected for each of the three documentation options and included in the analysis. Documentation with the two paper-based checklists had comparable information content: 17.5 ± 5.1/21.7 ± 7.6 points out of a maximum of 43 points; p > 0.05. Documentation using the digital application led to a significant increase in information content compared to all paper-based documentation. The average score was 38.25 ± 3.7 (88.9% of maximum; p < 0.001). On average, user satisfaction was high (9.6/10). Use of the digital application was initially more time consuming, but as more cases were documented, the time taken improved significantly. CONCLUSION In the future, structured reporting using apps could replace paper-based reporting for the indication of biologic therapy in CRSwNP patients and offer additional benefits in terms of data quality and traceability of results. The increasing volume of documentation in the future, the progress of digitalization, and the possibility of networking between individual centers make introduction of the app in the near future both likely and economical.
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Affiliation(s)
- Jan Hagemann
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
- Zentrum für Allergologie und Rhinologie, An den Quellen 10, 65183, Wiesbaden, Deutschland.
| | - Christopher Seifen
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Laura Koll
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Manuel Reissig
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Barbara Leggewie
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Berit Hackenberg
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Julia Döge
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Kai Helling
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Sven Becker
- Universitätsklinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Tübingen, Elfriede-Aulhorn-Straße 5, 72076, Tübingen, Deutschland
| | - Ludger Klimek
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
- Zentrum für Allergologie und Rhinologie, An den Quellen 10, 65183, Wiesbaden, Deutschland
| | - Christoph Matthias
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - Benjamin-Philipp Ernst
- Klinik für Hals‑, Nasen‑, Ohrenheilkunde, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Deutschland
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Lasrich M, Helling K, Strieth S, Bahr-Hamm K, Vogt TJ, Fröhlich L, Send T, Hill K, Nitsch L, Rader T, Bärhold F, Becker S, Ernst BP. [Increased report completeness and satisfaction with structured neurotological reporting in the interdisciplinary assessment of vertigo]. HNO 2024:10.1007/s00106-024-01464-5. [PMID: 38592481 DOI: 10.1007/s00106-024-01464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Results of neurotological function diagnostics in the context of interdisciplinary vertigo assessment are usually formulated as free-text reports (FTR). These are often subject to high variability, which may lead to loss of information. The aim of the present study was to evaluate the completeness of structured reports (SR) and referrer satisfaction in the neurotological assessment of vertigo. MATERIALS AND METHODS Neurotological function diagnostics performed as referrals (n = 88) were evaluated retrospectively. On the basis of the available raw data, SRs corresponding to FTRs from clinical routine were created by means of a specific SR template for neurotological function diagnostics. FTRs and SRs were evaluated for completeness and referring physician satisfaction (n = 8) using a visual analog scale (VAS) questionnaire. RESULTS Compared to FTRs, SRs showed significantly increased overall completeness (73.7% vs. 51.7%, p < 0.001), especially in terms of patient history (92.5% vs. 66.7%, p < 0.001), description of previous findings (87.5% vs. 38%, p < 0.001), and neurotological (33.5% vs. 26.7%, p < 0.001) and audiometric function diagnostics (58% vs. 32.3%, p < 0.001). In addition, SR showed significantly increased referring physician satisfaction (VAS 8.8 vs. 4.9, p < 0.001). CONCLUSION Neurotological SRs enable a significantly increased report completeness with higher referrer satisfaction in the context of interdisciplinary assessment of vertigo. Furthermore, SRs are particularly suitable for scientific data analysis, especially in the context of big data analyses.
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Affiliation(s)
- M Lasrich
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Bonn, Deutschland
| | - K Helling
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik - Plastische Operationen, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - S Strieth
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Bonn, Deutschland
| | - K Bahr-Hamm
- Hals‑, Nasen‑, Ohrenklinik und Poliklinik - Plastische Operationen, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - T J Vogt
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Bonn, Deutschland
| | - L Fröhlich
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Bonn, Deutschland
| | - T Send
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinikum Bonn, Bonn, Deutschland
| | - K Hill
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - L Nitsch
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - T Rader
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Abteilung Audiologie, LMU Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - F Bärhold
- Nasen- und Ohrenheilkunde, Universitätsklinikum Tübingen, Universitätsklinik für Hals-, Tübingen, Deutschland
| | - S Becker
- Nasen- und Ohrenheilkunde, Universitätsklinikum Tübingen, Universitätsklinik für Hals-, Tübingen, Deutschland
| | - B P Ernst
- Klinik für Hals‑, Nasen‑, Ohrenheilkunde, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
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Ginocchio LA, Dane B, Smereka PN, Megibow AJ, Remzi FH, Esen E, Huang C. Structured versus non-structured reporting of pelvic MRI for ileal pouch evaluation: clarity and effectiveness. Abdom Radiol (NY) 2023; 48:2978-2985. [PMID: 36871233 DOI: 10.1007/s00261-023-03858-5] [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] [Received: 12/27/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023]
Abstract
PURPOSE Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness. METHODS 164 consecutive pelvic MRI's for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (n = 2), other intra-institutional (n = 20), or affiliate site (n = 6). RESULTS 57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 [SD:4.0] key features whereas non-structured reports contained 6.3 [SD:2.5] key features (p < .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%, p < .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers. CONCLUSION Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.
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Affiliation(s)
- Luke A Ginocchio
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA.
| | - Bari Dane
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
| | - Paul N Smereka
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
| | - Alec J Megibow
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
| | - Feza H Remzi
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
| | - Eren Esen
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, New York, NY, 10016, USA
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5
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Seyedhasani SN, Dorri S, Pournik O, Alamdaran SA, Eslami S. Improving data adequacy of ultrasonography reports for non-alcoholic fatty liver disease (NAFLD) through a national structured template. Acta Radiol 2023; 64:473-478. [PMID: 35538852 DOI: 10.1177/02841851221093141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is a prevalent disorder that increases due to lifestyle, the rising rate of obesity, and population ages worldwide. Diagnostic ways, including sonography, do not have an explicit reporting structure. PURPOSE To create a structure template for NAFLD reporting, investigate its completeness, and assess the specialist opinions of using it in clinical practice. MATERIAL AND METHODS A structured reporting template (SRT) was designed and implemented in four stages. At first, important features were extracted from a comprehensive literature review and were evaluated by 10 radiologists and gastroenterologists using the Likert scale. Finally, the usefulness of the SRT in comparison with the conventional reporting template (CRT) was judged by 10 gastroenterologists completing the questionnaire. RESULTS Demographic information and sonography of the liver, gallbladder, and spleen organs were the most critical features. The completeness scores of SRT reports were higher than CRT scores for almost all the factors studied. The difference in the scores was significant for most of the parameters. Moreover, the total completeness score increased from 42% in CRT to 92% in SRT. A comparison of the report adequacy of two reports was seen in all items. The SRT obtained more rates from specialists. CONCLUSION Introduction of the SRT for NAFLD significantly enhanced the completeness of reporting to reduce variability in the interpretation of the related reports by clinicians. Nevertheless, more studies are needed to generalize the results in real scales for patients with NAFLD.
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Affiliation(s)
- Seyedeh Nahid Seyedhasani
- Department of Health Information Technology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.,Health Sciences Research Center, 435810Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Sara Dorri
- Health Information Technology Research Center, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Pournik
- Department of Community Medicine, School of Medicine, 440827Iran University of Medical Sciences, Tehran, Iran
| | | | - Saeid Eslami
- Department of Medical Informatics, School of Medicine, 37552Mashhad University of Medical Sciences, Mashhad, Iran
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Vosshenrich J, Brantner P, Cyriac J, Jadczak A, Lieb JM, Blackham KA, Heye T. Quantifying the Effects of Structured Reporting on Report Turnaround Times and Proofreading Workload in Neuroradiology. Acad Radiol 2022; 30:727-736. [PMID: 35691879 DOI: 10.1016/j.acra.2022.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/17/2022] [Accepted: 05/17/2022] [Indexed: 11/01/2022]
Abstract
RATIONALE AND OBJECTIVES To assess the effects of a change from free text reporting to structured reporting on resident reports, the proofreading workload and report turnaround times in the neuroradiology daily routine. MATERIALS AND METHODS Our neuroradiology section introduced structured reporting templates in July 2019. Reports dictated by residents during dayshifts from January 2019 to March 2020 were retrospectively assessed using quantitative parameters from report comparison. Through automatic analysis of text-string differences between report states (i.e. draft, preliminary and final report), Jaccard similarities and edit distances of reports following read-out sessions as well as after report sign-off were calculated. Furthermore, turnaround times until preliminary and final report availability to clinicians were investigated. Parameters were visualized as trending line graphs and statistically compared between reporting standards. RESULTS Three thousand five hundred thirty-eight reports were included into analysis. Mean Jaccard similarity of resident drafts and staff-reviewed final reports increased from 0.53 ± 0.37 to 0.79 ± 0.22 after the introduction of structured reporting (p < .001). Both mean overall edits on draft reports by residents following read-out sessions (0.30 ± 0.45 vs. 0.09 ± 0.29; p < .001) and by staff radiologists during report sign-off (0.17 ± 0.28 vs. 0.12 ± 0.23, p < .001) decreased. With structured reporting, mean turnaround time until preliminary report availability to clinicians decreased by 20.7 minutes (246.9 ± 207.0 vs. 226.2 ± 224.9; p < .001). Similarly, final reports were available 35.0 minutes faster on average (558.05 ± 15.1 vs. 523.0 ± 497.3; p = .002). CONCLUSION Structured reporting is beneficial in the neuroradiology daily routine, as resident drafts require fewer edits in the report review process. This reduction in proofreading workload is likely responsible for lower report turnaround times.
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Affiliation(s)
- Jan Vosshenrich
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Philipp Brantner
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Radiology, Gesundheitszentrum Fricktal, Riburgerstrasse 12, 4031 Rheinfelden, Switzerland
| | - Joshy Cyriac
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Adam Jadczak
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Johanna M Lieb
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Kristine A Blackham
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Tobias Heye
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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Informe estructurado de la ecografía y la resonancia magnética de hombro. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Nobel JM, van Geel K, Robben SGF. Structured reporting in radiology: a systematic review to explore its potential. Eur Radiol 2022; 32:2837-2854. [PMID: 34652520 PMCID: PMC8921035 DOI: 10.1007/s00330-021-08327-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/15/2021] [Accepted: 09/13/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is necessary to verify that radiology reporting can benefit from SR. Therefore, the purpose of this systematic review is to explore the level of evidence of structured reporting in radiology. Additionally, this review provides an overview on the current status of SR in radiology. METHODS A narrative systematic review was conducted, searching PubMed, Embase, and the Cochrane Library using the syntax 'radiol*' AND 'structur*' AND 'report*'. Structured reporting was divided in SR level 1, structured layout (use of templates and checklists), and SR level 2, structured content (a drop-down menu, point-and-click or clickable decision trees). Two reviewers screened the search results and included all quantitative experimental studies that discussed SR in radiology. A thematic analysis was performed to appraise the evidence level. RESULTS The search resulted in 63 relevant full text articles out of a total of 8561 articles. Thematic analysis resulted in 44 SR level 1 and 19 level 2 reports. Only one paper was scored as highest level of evidence, which concerned a double cohort study with randomized trial design. CONCLUSION The level of evidence for implementing SR in radiology is still low and outcomes should be interpreted with caution. KEY POINTS • Structured reporting is increasingly being used in radiology, especially in abdominal and neuroradiological CT and MRI reports. • SR can be subdivided into structured layout (SR level 1) and structured content (SR level 2), in which the first is defined as being a template in which the reporter has to report; the latter is an IT-based manner in which the content of the radiology report can be inserted and displayed into the report. • Despite the extensive amount of research on the subject of structured reporting, the level of evidence is low.
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Affiliation(s)
- J Martijn Nobel
- Department of Radiology, Maastricht University Medical Center+, Postbox 5800, 6202 AZ, Maastricht, the Netherlands.
- Department of Educational Development and Research and School of Health Professions Education, Maastricht University, Maastricht, the Netherlands.
| | - Koos van Geel
- Department of Educational Development and Research and School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
- Department of Medical Imaging of Zuyderland Medical Center, Heerlen, the Netherlands
| | - Simon G F Robben
- Department of Radiology, Maastricht University Medical Center+, Postbox 5800, 6202 AZ, Maastricht, the Netherlands
- Department of Educational Development and Research and School of Health Professions Education, Maastricht University, Maastricht, the Netherlands
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Malik RF, Hasanain A, Lafaro KJ, He J, Narang AK, Fishman EK, Zaheer A. Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning. Abdom Radiol (NY) 2022; 47:704-714. [PMID: 34800162 DOI: 10.1007/s00261-021-03353-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content. METHODS We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher's exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale. RESULTS The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons' rating of overall report quality was significantly higher for structured reports (p < 0.001). CONCLUSION Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.
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Radiologist Productivity Analytics: Factors Impacting Abdominal Pelvic CT Exam Reporting Times. J Digit Imaging 2022; 35:87-97. [PMID: 35013824 PMCID: PMC8921423 DOI: 10.1007/s10278-021-00548-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/29/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022] Open
Abstract
The purpose is to determine factors impacting radiologist abdominal pelvic CT exam reporting time. This study was Research Ethics Board approved. Between January 2019 and March 2020, consecutive abdominal pelvic CT exams were documented as structured or unstructured based on application of templates with separate sections for different organs or organ systems. Radiologist reporting location, patient class (inpatient, Emergency Department (ED) patient, outpatient), radiologist fellowship-training, report word count, and radiologist years of experience were documented. Median reporting times were compared using the Wilcoxon Rank-sum test, Kruskal-Wallis test, and regression analysis. Spearman's rank correlation was used to determine correlation between word count and radiologist experience with reporting time. P < 0.05 is defined statistical significance. A total of 3602 abdominal pelvic CT exam reports completed by 33 radiologists were reviewed, including 1150 outpatient and 2452 inpatient and Emergency Department (ED) cases. 1398 of all reports were structured. Median reporting time for structured and unstructured reports did not differ (P = 0.870). Reports dictated in-house were completed faster than reports dictated remotely (P < 0.001), and reports for inpatients/ED patients were completed faster than for outpatients (P < 0.001). Reporting time differences existed between radiologists (P < 0.001) that were not explained by fellowship training (P = 0.762). Median reporting time had a weak correlation with word count (ρ = 0.355) and almost no correlation with radiologist years of experience (ρ = 0.167), P < 0.001. Abdominal pelvic CT reporting is most efficient when dictations are completed in-house and for high-priority cases; the use of structured templates, radiologist fellowship training, and years of experience have no impact on reporting times.
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Kohli A, Castillo S, Thakur U, Chhabra A. Structured Reporting in Musculoskeletal Radiology. Semin Musculoskelet Radiol 2021; 25:641-645. [PMID: 34861708 DOI: 10.1055/s-0041-1736412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Musculoskeletal (MSK) radiologists are predominantly consultants in the service departments of health care. Unlike the manufacturing industry, quality controls are difficult to institute in a service industry and more variability is expected. Structured reporting is a unique way to institute quality standards, and by using the checklist approach with uniform terminology, it can lead to more homogeneity and consistency of reporting, concise lexicon use within and across practices, minimization of errors, enhancement of divisional and departmental branding, improvement of interdisciplinary communications, and future data mining. We share our experience from more than a decade of structured reporting in the domain of MSK radiology, our practice standards, and how reporting has evolved in our MSK practice. Further discussions include future directions aided by machine learning approaches with augmented reality and the possibility of virtual fellowship and training using consistent lexicons and structured reporting.
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Affiliation(s)
- Ajay Kohli
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas.,Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Samantha Castillo
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Uma Thakur
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas.,Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
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Lee JK, Bermel R, Bullen J, Ruggieri P, Jones SE. Structured Reporting in Multiple Sclerosis Reduces Interpretation Time. Acad Radiol 2021; 28:1733-1738. [PMID: 32868172 DOI: 10.1016/j.acra.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 02/01/2023]
Abstract
RATIONALE AND OBJECTIVES Previous studies have reported mixed results regarding whether the use of structured reporting (SR) leads to a change in interpretation times. The objective of this study was to quantify any change in interpretation times after the implementation of SR for multiple sclerosis (MS) follow-up magnetic resonance imaging (MRI) of the brain. MATERIALS AND METHODS Interpretation times before and after the transition to MS MRI SR were compared over a 5-year period. To control for changing practice patterns, a control group of non-MS (intracranial masses) reports not using SR was also assessed. In a secondary analysis, interpretation times for 2D and 3D MRI MS protocols after the initiation of SR were compared to determine whether increased image number with the 3D protocol affected interpretation times. RESULTS Mean and median interpretation times before the initiation of SR for MS MRI were 11.0 and 8.0 minutes versus 8.5 and 6.0 minutes after the implementation of SR (p < 0.001). Although non-MS MRI interpretation times also decreased, an interaction analysis demonstrated that the decrease in MS interpretation times was significantly higher (p < 0.001). Mean and median interpretation times using 3D protocols were slighter increased compared to interpretation times with 2D protocols (p = 0.036). CONCLUSION After the implementation of SR for MS follow-up MRI at our institution, interpretation times significantly decreased despite the increased number of images with some of the examinations due to the adoption of 3D protocols. The adoption of SR for MS MRI follow-up scans may improve radiologist efficiency.
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Affiliation(s)
- Jonathan K Lee
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195.
| | - Robert Bermel
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Bullen
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Paul Ruggieri
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
| | - Stephen E Jones
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195
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ENT Residents Benefit from a Structured Operation Planning Approach in the Training of Functional Endoscopic Sinus Surgery. MEDICINA-LITHUANIA 2021; 57:medicina57101062. [PMID: 34684099 PMCID: PMC8541081 DOI: 10.3390/medicina57101062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 01/11/2023]
Abstract
Background and Objectives: Preoperative planning utilizing computed tomographies (CT) is of utmost importance in functional endoscopic sinus surgery (FESS). Frequently, no uniform documentation and planning structures are available to residents in training. Consequently, overall completeness and quality of operation planning may vary greatly. The objective of the present study was to evaluate the impact of a structured operation planning (SOP) approach on the report quality and user convenience during a 4-day sinus surgery course. Materials and Methods: Fifteen participant were requested to plan a FESS procedure based on a CT scan of the paranasal sinuses that exhibited common pathological features, in a conventional manner, using a free text. Afterwards, the participants reevaluated the same scans by means of a specifically designed structured reporting template. Two experienced ENT surgeons assessed the collected conventional operation planning (COP) and SOP methods independently with regard to time requirements, overall quality, and legibility. User convenience data were collected by utilizing visual analogue scales. Results: A significantly greater time expenditure was associated with SOPs (183 s vs. 297 s, p = 0.0003). Yet, legibility (100% vs. 72%, p < 0.0001) and overall completeness (61.3% vs. 22.7%, p < 0.0001) of SOPs was significantly superior to COPs. Additionally, description of highly relevant variants in anatomy and pathologies were outlined in greater detail. User convenience data delineated a significant preference for SOPs (VAS 7.9 vs. 6.9, p = 0.0185). Conclusions: CT-based planning of FESS procedures by residents in training using a structured approach is more time-consuming while producing a superior report quality in terms of detailedness and readability. Consequently, SOP can be considered as a valuable tool in the process of preoperative evaluations, especially within residency.
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Jorg T, Heckmann JC, Mildenberger P, Hahn F, Düber C, Mildenberger P, Kloeckner R, Jungmann F. Structured reporting of CT scans of patients with trauma leads to faster, more detailed diagnoses: An experimental study. Eur J Radiol 2021; 144:109954. [PMID: 34563796 DOI: 10.1016/j.ejrad.2021.109954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 08/13/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed to determine whether structured reports (SRs) reduce reporting time and/or increase the level of detail for trauma CT scans compared to free-text reports (FTRs). METHOD Eight radiology residents used SRs and FTRs to describe 14 whole-body CT scans of patients with polytrauma in a simulated emergency room setting. Each resident created both a brief report and a detailed report for each case using one of the two formats. We measured the time to complete the detailed reports and established a scoring system to objectively measure report completeness and the level of detail. Scoring sheets divided the CT findings into main and secondary criteria. Finally, the radiological residents completed a questionnaire on their opinions of the SRs and FTRs. RESULTS The detailed SRs were completed significantly faster than the detailed FTRs (mean 19 min vs. 25 min; p < 0.001). The maximum allowance of 25 min was used for 25% of SRs and 59% of FTRs. For brief reports, the SRs contained more secondary criteria than the FTRs (p = 0.001), but no significant differences were detected in main criteria. Study participants rated their own SRs as significantly more time-efficient, concise, and clearly structured compared to the FTRs. However, SRs and FTRs were rated similarly for quality, accuracy, and completeness. CONCLUSION We found that SRs for whole-body trauma CT add clinical value compared to FTRs because SRs reduce reporting time and increase the level of detail for trauma CT scans.
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Affiliation(s)
- Tobias Jorg
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Julia Caroline Heckmann
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Philipp Mildenberger
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Felix Hahn
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter Mildenberger
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Florian Jungmann
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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Nikolić O, Sousa FAE, Cunha TM, Nikolić MB, Otero-García MM, Gui B, Nougaret S, Leonhardt H. Vulvar cancer staging: guidelines of the European Society of Urogenital Radiology (ESUR). Insights Imaging 2021; 12:131. [PMID: 34550489 PMCID: PMC8458511 DOI: 10.1186/s13244-021-01075-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022] Open
Abstract
Objective The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging staging guidelines for vulvar cancer and to propose standardised MRI protocols and reporting. Methods The guidelines recommended from the ESUR in this article resulted from a questionnaire analysis regarding imaging staging of vulvar cancer that was answered by all members of the Female Pelvic Imaging Working Group. Only the answers with an agreement equal to or more than 80% were considered. Additionally, the literature was reviewed to complement and further support our conclusions. Results The critical review of the literature and consensus obtained among experts allows for recommendations regarding imaging staging guidelines, patient preparation, MRI protocol, and a structured MRI report. Conclusions Standardising image acquisition techniques and MRI interpretation reduces ambiguity and ultimately improves the contribution of radiology to the staging and management of patients with vulvar cancer. Moreover, structured reporting assists with the communication of clinically relevant information to the referring physician.
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Affiliation(s)
- Olivera Nikolić
- Center of Radiology, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 1-9, 21000, Novi Sad, Serbia
| | - Filipa Alves E Sousa
- Department of Radiology, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António Dos Capuchos, 1169-050, Lisboa, Portugal.
| | - Teresa Margarida Cunha
- Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, R. Prof. Lima Basto, 1099-023, Lisbon, Portugal
| | - Marijana Basta Nikolić
- Center of Radiology, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 1-9, 21000, Novi Sad, Serbia
| | | | - Benedetta Gui
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia Generale Ed Interventistica Generale, Area Diagnostica Per Immagini, Dipartimento Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Stephanie Nougaret
- Department of Radiology, Montpellier Cancer Institute, 15 INSERM, Montpellier Cancer Research Institute, U1194, University of Montpellier, 208 Avenue des Apothicaires, 34295, Montpellier, France
| | - Henrik Leonhardt
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Bruna straket 11B, 413 45, Gothenburg, Sweden
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Jungmann F, Arnhold G, Kämpgen B, Jorg T, Düber C, Mildenberger P, Kloeckner R. A Hybrid Reporting Platform for Extended RadLex Coding Combining Structured Reporting Templates and Natural Language Processing. J Digit Imaging 2021; 33:1026-1033. [PMID: 32318897 DOI: 10.1007/s10278-020-00342-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Structured reporting is a favorable and sustainable form of reporting in radiology. Among its advantages are better presentation, clearer nomenclature, and higher quality. By using MRRT-compliant templates, the content of the categorized items (e.g., select fields) can be automatically stored in a database, which allows further research and quality analytics based on established ontologies like RadLex® linked to the items. Additionally, it is relevant to provide free-text input for descriptions of findings and impressions in complex imaging studies or for the information included with the clinical referral. So far, however, this unstructured content cannot be categorized. We developed a solution to analyze and code these free-text parts of the templates in our MRRT-compliant reporting platform, using natural language processing (NLP) with RadLex® terms in addition to the already categorized items. The established hybrid reporting concept is working successfully. The NLP tool provides RadLex® codes with modifiers (affirmed, speculated, negated). Radiologists can confirm or reject codes provided by NLP before finalizing the structured report. Furthermore, users can suggest RadLex® codes from free text that is not correctly coded with NLP or can suggest to change the modifier. Analyzing free-text fields took 1.23 s on average. Hybrid reporting enables coding of free-text information in our MRRT-compliant templates and thus increases the amount of categorized data that can be stored in the database. This enhances the possibilities for further analyses, such as correlating clinical information with radiological findings or storing high-quality structured information for machine-learning approaches.
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Affiliation(s)
- Florian Jungmann
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany.
| | - G Arnhold
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - B Kämpgen
- Empolis Information Management GmbH, Kaiserslautern, Germany
| | - T Jorg
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - C Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - P Mildenberger
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
| | - R Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckst. 1, 55131, Mainz, Germany
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Structured Reporting of Computed Tomography Examinations in Post-Lung Transplantation Patients. J Comput Assist Tomogr 2021; 45:959-963. [PMID: 34347712 DOI: 10.1097/rct.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the benefits and potential of structured reports (SR) for chest computed tomography after lung transplantation. METHODS Free-text reports (FTR) and SR were generated for 49 computed tomography scans. Clinical routine reports were used as FTR. Two pulmonologists rated formal aspects, completeness, clinical utility, and overall quality. Wilcoxon and McNemar tests were used for statistical analysis. RESULTS Structured reports received significantly higher ratings for all formals aspects (P < 0.001, respectively). Completeness was higher in SR with regard to evaluation of bronchiectases, bronchial anastomoses, bronchiolitic and fibrotic changes (P < 0.001, respectively), and air trapping (P = 0.012), but not signs of pneumonia (P = 0.5). Clinical utility and overall quality were rated significantly higher for SR than FTR (P < 0.001, respectively). However, report type did not influence initiation of further diagnostic or therapeutic measures (P = 0.307 and 1.0). CONCLUSIONS Structured reports are superior to FTR with regard to formal aspects, completeness, clinical utility, and overall satisfaction of referring pulmonologists.
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Mönch S, Andrisan T, Bernkopf K, Ikenberg B, Friedrich B, Zimmer C, Hedderich DM. Structured reporting of brain MRI following mechanical thrombectomy in acute ischemic stroke patients. BMC Med Imaging 2021; 21:91. [PMID: 34034677 PMCID: PMC8152045 DOI: 10.1186/s12880-021-00621-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany. .,Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
| | - Tiberiu Andrisan
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kathleen Bernkopf
- Department of Neurology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Dennis M Hedderich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
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Schnitzer ML, Sabel L, Schwarze V, Marschner C, Froelich MF, Nuhn P, Falck Y, Nuhn MM, Afat S, Staehler M, Rückel J, Clevert DA, Rübenthaler J, Geyer T. Structured Reporting in the Characterization of Renal Cysts by Contrast-Enhanced Ultrasound (CEUS) Using the Bosniak Classification System-Improvement of Report Quality and Interdisciplinary Communication. Diagnostics (Basel) 2021; 11:diagnostics11020313. [PMID: 33671991 PMCID: PMC7919270 DOI: 10.3390/diagnostics11020313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/29/2021] [Accepted: 02/11/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This study aims to evaluate the potential benefits of structured reporting (SR) compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) of cystic renal lesions, based on the Bosniak classification. METHODS Fifty patients with cystic renal lesions who underwent CEUS were included in this single-center study. FTR created in clinical routine were compared to SR retrospectively generated by using a structured reporting template. Two experienced urologists evaluated the reports regarding integrity, effort for information extraction, linguistic quality, and overall quality. RESULTS The required information could easily be extracted by the reviewers in 100% of SR vs. 82% of FTR (p < 0.001). The reviewers trusted the information given by SR significantly more with a mean of 5.99 vs. 5.52 for FTR (p < 0.001). SR significantly improved the linguistic quality (6.0 for SR vs. 5.68 for FTR (p < 0.001)) and the overall report quality (5.98 for SR vs. 5.58 for FTR (p < 0.001)). CONCLUSIONS SR significantly increases the quality of radiologic reports in CEUS examinations of cystic renal lesions compared to conventional FTR and represents a promising approach to facilitate interdisciplinary communication in the future.
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Affiliation(s)
- Moritz L. Schnitzer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Laura Sabel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Constantin Marschner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
| | - Philipp Nuhn
- Department of Urology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany;
| | - Yannick Falck
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Maria-Magdalena Nuhn
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Saif Afat
- Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany;
| | - Michael Staehler
- Department of Urology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany;
| | - Johannes Rückel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Dirk-André Clevert
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
| | - Thomas Geyer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.L.S.); (L.S.); (V.S.); (C.M.); (Y.F.); (M.-M.N.); (J.R.); (D.-A.C.); (J.R.)
- Correspondence: ; Tel.: +49-89440073620
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Geyer T, Rübenthaler J, Marschner C, von Hake M, Fabritius MP, Froelich MF, Huber T, Nörenberg D, Rückel J, Weniger M, Martens C, Sabel L, Clevert DA, Schwarze V. Structured Reporting Using CEUS LI-RADS for the Diagnosis of Hepatocellular Carcinoma (HCC)-Impact and Advantages on Report Integrity, Quality and Interdisciplinary Communication. Cancers (Basel) 2021; 13:cancers13030534. [PMID: 33572502 PMCID: PMC7866827 DOI: 10.3390/cancers13030534] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/28/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Contrast-enhanced ultrasound (CEUS) is an increasingly accepted imaging modality for visualizing hepatocellular carcinoma (HCC) and is recommended as a secondary imaging option by most leading hepatology societies. In recent years, the use of structured reporting (SR) has been recommended by several societies to standardize report content and improve report quality of various diagnostic modalities when compared to conventional free-text reports (FTR). Our single-center study aimed to evaluate the use of SR using a CEUS LI-RADS software template in CEUS examinations of 50 HCC patients. SR significantly increased report integrity, satisfaction of the referring physicians, linguistic quality and overall report quality compared to FTR. Therefore, the use of SR in CEUS examinations of HCC patients may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future. Abstract Background: Our retrospective single-center study aims to evaluate the impact of structured reporting (SR) using a CEUS LI-RADS template on report quality compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC). Methods: We included 50 patients who underwent CEUS for HCC staging. FTR created after these examinations were compared to SR retrospectively generated by using template-based online software with clickable decision trees. The reports were evaluated regarding report completeness, information extraction, linguistic quality and overall report quality by two readers specialized in internal medicine and visceral surgery. Results: SR significantly increased report completeness with at least one key feature missing in 31% of FTR vs. 2% of SR (p < 0.001). Information extraction was considered easy in 98% of SR vs. 86% of FTR (p = 0.004). The trust of referring physicians in the report was significantly increased by SR with a mean of 5.68 for SR vs. 4.96 for FTR (p < 0.001). SR received significantly higher ratings regarding linguistic quality (5.79 for SR vs. 4.83 for FTR (p < 0.001)) and overall report quality (5.75 for SR vs. 5.01 for FTR (p < 0.001)). Conclusions: Using SR instead of conventional FTR increases the overall quality of reports in CEUS examinations of HCC patients and may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.
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Affiliation(s)
- Thomas Geyer
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
- Correspondence: ; Tel.: +49-894-4007-3620
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Constantin Marschner
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Malte von Hake
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Matthias P. Fabritius
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, 68167 Mannheim, Germany; (M.F.F.); (T.H.); (D.N.)
| | - Thomas Huber
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, 68167 Mannheim, Germany; (M.F.F.); (T.H.); (D.N.)
| | - Dominik Nörenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, 68167 Mannheim, Germany; (M.F.F.); (T.H.); (D.N.)
| | - Johannes Rückel
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Maximilian Weniger
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Corinna Martens
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Laura Sabel
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Dirk-André Clevert
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (J.R.); (C.M.); (M.v.H.); (M.P.F.); (J.R.); (L.S.); (D.-A.C.); (V.S.)
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[Quality in the appraisal of head and neck sonography results in university hospitals-a random sample]. HNO 2021; 69:907-912. [PMID: 33439274 PMCID: PMC8545731 DOI: 10.1007/s00106-020-00989-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
Hintergrund Die Ultraschalldiagnostik gilt für den Radiologen, Hals-Nasen-Ohren-Arzt (HNO) oder Mund-Kiefer-Gesichts-Chirurgen als Standard in der Abklärung zahlreicher Pathologien. Es besteht ein Konsens, dass die digitale Dokumentation heute dringend notwendig ist, um die Qualität der sonographischen Dokumentationen zu verbessern und zu standardisieren. Es häufen sich Publikationen zur Implementierung standardisierter Befunddokumentation einschließlich der Kopf- und Halssonographie. Ziel der Arbeit Die vorliegende Arbeit zielt darauf ab, die Qualität von routinemäßig angefertigten Kopf- und Halssonographiebefunden nach Kriterien der Kassenärztlichen Vereinigung (KV) Bayern an einer Auswahl deutscher HNO-Universitätskliniken stichprobenartig zu ermitteln. Material und Methoden Insgesamt wurden retrospektiv 70 zufällig ausgewählte, anonymisierte schriftliche Befunde einschließlich Bildmaterial von insgesamt 7 HNO-Universitätskliniken stichprobenartig nach KV-Kriterien durch einen erfahrenen Prüfer der KV Bayern ausgewertet und deskriptiv analysiert. Ergebnisse Von 70 Befunden konnten 69 ausgewertet werden. Die Dokumentationsvollständigkeit lag im Mittel bei 80,6 %. Neun Befunde waren vollständig korrekt dokumentiert (13 %). Die Dokumentationsvollständigkeit der einzelnen Kliniken lag zwischen 68,1 % und 93 %. Mit 88,5 % vs. 75 % erbrachte eine strukturierte Befundung eine höhere Befundvollständigkeit. In 75 % der Fälle verfügten die Kliniken mit strukturiertem Befund auch über digitale Dokumentationslösungen. Schlussfolgerung Die Vollständigkeit und Qualität von routinemäßig angefertigten Kopf- und Halssonographiebefunden an einer Auswahl von HNO-Universitätskliniken ist insgesamt optimierbar. Die Implementierung strukturierter Befundmasken und die Umstellung der analogen Dokumentation auf digitale Lösungen sowie Vernetzung mit dem Klinikinformationssystem (KIS) und Bildarchivierungs- und Kommunikationssystem (PACS) sollte weiter vorangetrieben werden. Darüber hinaus sind leitende Ärzte dazu angehalten, die Befundqualität unerfahrener Kollegen regelmäßig zu prüfen und im Rahmen der Facharztausbildung auf die Erfüllung entsprechender Standards wie der KV-Ultraschallvereinbarung hinzuarbeiten.
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22
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Ernst BP, Reissig MR, Strieth S, Eckrich J, Hagemann JH, Döge J, Matthias C, Gouveris H, Rübenthaler J, Weiss R, Sommer WH, Nörenberg D, Huber T, Gonser P, Becker S, Froelich MF. The role of structured reporting and structured operation planning in functional endoscopic sinus surgery. PLoS One 2020; 15:e0242804. [PMID: 33253265 PMCID: PMC7703956 DOI: 10.1371/journal.pone.0242804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022] Open
Abstract
Computed tomography (CT) scans represent the gold standard in the planning of functional endoscopic sinus surgeries (FESS). Yet, radiologists and otolaryngologists have different perspectives on these scans. In general, residents often struggle with aspects involved in both reporting and operation planning. The aim of this study was to compare the completeness of structured reports (SR) of preoperative CT images and structured operation planning (SOP) to conventional reports (CR) and conventional operation planning (COP) to potentially improve future treatment decisions on an individual level. In total, 30 preoperative CT scans obtained for surgical planning of patients scheduled for FESS were evaluated using SR and CR by radiology residents. Subsequently, otolaryngology residents performed a COP using free texts and a SOP using a specific template. All radiology reports and operation plannings were evaluated by two experienced FESS surgeons regarding their completeness for surgical planning. User satisfaction of otolaryngology residents was assessed by using visual analogue scales. Overall radiology report completeness was significantly higher using SRs regarding surgically important structures compared to CRs (84.4 vs. 22.0%, p<0.001). SOPs produced significantly higher completeness ratings (97% vs. 39.4%, p<0.001) regarding pathologies and anatomical variances. Moreover, time efficiency was not significantly impaired by implementation of SR (148 s vs. 160 s, p = 0.61) and user satisfaction was significantly higher for SOP (VAS 8.1 vs. 4.1, p<0.001). Implementation of SR and SOP results in a significantly increased completeness of radiology reports and operation planning for FESS. Consequently, the combination of both facilitates surgical planning and may decrease potential risks during FESS.
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Affiliation(s)
- Benjamin Philipp Ernst
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
- * E-mail:
| | - Manuel René Reissig
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Sebastian Strieth
- Department of Otorhinolaryngology, University Hospital Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Jonas Eckrich
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Jan H. Hagemann
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Julia Döge
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Christoph Matthias
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Haralampos Gouveris
- Department of Otorhinolaryngology, University Medical Center Mainz, Mainz, Rhineland-Palatinate, Germany
| | | | - Roxanne Weiss
- Department of Otorhinolaryngology, University Hospital Frankfurt, Frankfurt, Hessen, Germany
| | - Wieland H. Sommer
- Department of Radiology, LMU University Hospital, Munich, Bavaria, Germany
| | - Dominik Nörenberg
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany
| | - Thomas Huber
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany
| | - Phillipp Gonser
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen Medical Center, Tübingen, Baden-Wuerttemberg, Germany
| | - Sven Becker
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen Medical Center, Tübingen, Baden-Wuerttemberg, Germany
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany
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Analysis of Different Levels of Structured Reporting in Knee Magnetic Resonance Imaging. Acad Radiol 2020; 27:1440-1446. [PMID: 32037259 DOI: 10.1016/j.acra.2019.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 11/20/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study is to investigate the most appropriate knee MRI report template that not only provides structure and consistency, but also allows enough narrative freedom for the logical organization of findings and improved communication with the orthopedic referral base. MATERIALS AND METHODS Three fictitious knee MRI reports were created using templates with different levels of structuring: unstructured free text (FT), structured with headers (SH), and highly structured and itemized (SI). These were then distributed to clinicians in the orthopedics department at all levels of training along with a survey with numerical scoring questions on report readability, usefulness, and quality. Statistical analysis was used to evaluate the data. RESULTS Fifty-three surveys were completed with responses from residents, attendings, and physician assistants. The structured format with headers had statistically significant (p value <0.001) higher mean rank score in readability, usefulness, and quality parameters compared to the unstructured FT and highly SI report templates. Most clinicians (83%) found the structured format with headers to be the most coherent report. Conversely, 53% found the unstructured FT and 43% found the highly SI templates to be the most disjointed. CONCLUSION Based on responses to surveys of knee MRI report templates, our results show that our orthopedic clinicians prefer some level of structure in the reports but not the rigorous itemization of anatomic tissues. A "middle ground" reporting structure which includes headers for different anatomic compartments and allows for grouping of relevant pathology, is shown to be the preferred format.
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Improving radiologic communication in oncology: a single-centre experience with structured reporting for cancer patients. Insights Imaging 2020; 11:106. [PMID: 32990824 PMCID: PMC7524991 DOI: 10.1186/s13244-020-00907-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022] Open
Abstract
Objectives Our aim was to develop a structured reporting concept (structured oncology report, SOR) for general follow-up assessment of cancer patients in clinical routine. Furthermore, we analysed the report quality of SOR compared to conventional reports (CR) as assessed by referring oncologists. Methods SOR was designed to provide standardised layout, tabulated tumour burden documentation and standardised conclusion using uniform terminology. A software application for reporting was programmed to ensure consistency of layout and vocabulary and to facilitate utilisation of SOR. Report quality was analysed for 25 SOR and 25 CR retrospectively by 6 medical oncologists using a 7-point scale (score 1 representing the best score) for 6 questionnaire items addressing different elements of report quality and overall satisfaction. A score of ≤ 3 was defined as a positive rating. Results In the first year after full implementation, 7471 imaging examinations were reported using SOR. The proportion of SOR in relation to all oncology reports increased from 49 to 95% within a few months. Report quality scores were better for SOR for each questionnaire item (p < 0.001 each). Averaged over all questionnaire item scores were 1.98 ± 1.22 for SOR and 3.05 ± 1.93 for CR (p < 0.001). The overall satisfaction score was 2.15 ± 1.32 for SOR and 3.39 ± 2.08 for CR (p < 0.001). The proportion of positive ratings was higher for SOR (89% versus 67%; p < 0.001). Conclusions Department-wide structured reporting for follow-up imaging performed for assessment of anticancer treatment efficacy is feasible using a dedicated software application. Satisfaction of referring oncologist with report quality is superior for structured reports.
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25
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Farmer CI, Bourne AM, O'Connor D, Jarvik JG, Buchbinder R. Enhancing clinician and patient understanding of radiology reports: a scoping review of international guidelines. Insights Imaging 2020; 11:62. [PMID: 32372369 PMCID: PMC7200955 DOI: 10.1186/s13244-020-00864-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
Imaging reports are the primary method of communicating diagnostic imaging findings between the radiologist and the referring clinician. Guidelines produced by professional bodies provide guidance on content and format of imaging reports, but the extent to which they consider comprehensibility for referring clinicians and their patients is unclear. The objective of this review was to determine the extent to which radiology reporting guidelines consider comprehensibility of imaging reports for referring clinicians and patients.We performed a scoping review of English-language diagnostic imaging reporting guidelines. We searched electronic databases (OVID MEDLINE, Embase) and websites of radiological professional organisations to identify guidelines. The extent to which the guidelines recommended essential report features such as technical information, content, format and language, as well as features to enhance comprehensibility, such as lay language summaries, was recorded.Six guidelines from professional bodies representing radiologists from the USA, Canada, Australia and New Zealand, Hong Kong, the UK and Europe were identified from the search. Inconsistencies exist between guidelines in their recommendations, and they rarely consider that patients may read the report. No guideline made recommendations about the reporting of results considering the clinical context, and none recommended features preferred by patients such as lay language summaries. This review identifies an opportunity for future radiology reporting guidelines to give greater consideration to referring clinician and patient preferences.
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Affiliation(s)
- Caitlin I Farmer
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale St, Malvern, VIC, 3144, Australia. .,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Allison M Bourne
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale St, Malvern, VIC, 3144, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Denise O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale St, Malvern, VIC, 3144, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jeffrey G Jarvik
- Departments of Radiology, Neurological Surgery, School of Medicine and Health Services, School of Public Health, University of Washington, Seattle, WA, USA.,Departments of Pharmacy and Orthopaedic & Sports Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale St, Malvern, VIC, 3144, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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26
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Kim SH, Sobez LM, Spiro JE, Curta A, Ceelen F, Kampmann E, Goepfert M, Bodensohn R, Meinel FG, Sommer WH, Sommer NN, Galiè F. Structured reporting has the potential to reduce reporting times of dual-energy x-ray absorptiometry exams. BMC Musculoskelet Disord 2020; 21:248. [PMID: 32299400 PMCID: PMC7164197 DOI: 10.1186/s12891-020-03200-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND In recent years, structured reporting has been shown to be beneficial with regard to report completeness and clinical decision-making as compared to free-text reports (FTR). However, the impact of structured reporting on reporting efficiency has not been thoroughly evaluted yet. The aim of this study was to compare reporting times and report quality of structured reports (SR) to conventional free-text reports of dual-energy x-ray absorptiometry exams (DXA). METHODS FTRs and SRs of DXA were retrospectively generated by 2 radiology residents and 2 final-year medical students. Time was measured from the first view of the exam until the report was saved. A random sample of DXA reports was selected and sent to 2 referring physicians for further evaluation of report quality. RESULTS A total of 104 DXA reports (both FTRs and SRs) were generated and 48 randomly selected reports were evaluated by referring physicians. Reporting times were shorter for SRs in both radiology residents and medical students with median reporting times of 2.7 min (residents: 2.7, medical students: 2.7) for SRs and 6.1 min (residents: 5.0, medical students: 7.5) for FTRs. Information extraction was perceived to be significantly easier from SRs vs FTRs (P < 0.001). SRs were rated to answer the clinical question significantly better than FTRs (P < 0.007). Overall report quality was rated significantly higher for SRs compared to FTRs (P < 0.001) with 96% of SRs vs 79% of FTRs receiving high or very high-quality ratings. All readers except for one resident preferred structured reporting over free-text reporting and both referring clinicians preferred SRs over FTRs for DXA. CONCLUSIONS Template-based structured reporting of DXA might lead to shorter reporting times and increased report quality.
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Affiliation(s)
- Su Hwan Kim
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Lara M Sobez
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Judith E Spiro
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Adrian Curta
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Felix Ceelen
- Munich Transplant Center, University Hospital, LMU Munich, Munich, Germany
| | - Eric Kampmann
- Department of Internal Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Martin Goepfert
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Raphael Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Felix G Meinel
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Wieland H Sommer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nora N Sommer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Franziska Galiè
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
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Evidence of the benefits, advantages and potentialities of the structured radiological report: An integrative review. Artif Intell Med 2019; 102:101770. [PMID: 31980107 DOI: 10.1016/j.artmed.2019.101770] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 12/27/2022]
Abstract
The structured report is a new trend for the preparation and manipulation of radiological examination reports. The structuring of the radiological report data can bring many benefits and advantages over other existing methodologies. Research and studies about the structured radiological report are highly relevant in clinical and academic subjects, improving medical practice, reducing unobserved problems by radiologists, improving reporting practices and medical diagnoses. Exposing the benefits, advantages and potential of the structured radiological report is important in encouraging the acceptance and implementation of this method by radiology professionals who are still somewhat resistant. The present review highlights the factors that contribute to the consolidation of adopting the structured radiology report methodology, addressing a variety of studies focused on the structuring of the radiological report. This integrative review of the literature is proposed by searching publications and journals databases (CAPES - Coordination of Improvement of Higher-Level Personnel, SciELO - Scientific Electronic Library Online, and PubMed - Publisher Medline) to develop a complete and unified understanding of the subject, so that it becomes a major part of evidence-based initiatives.
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The use of structured reporting of head and neck ultrasound ensures time-efficiency and report quality during residency. Eur Arch Otorhinolaryngol 2019; 277:269-276. [PMID: 31612337 DOI: 10.1007/s00405-019-05679-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Free text reports (FTR) of head and neck ultrasound studies are currently deployed in most departments. Because of a lack of composition and language, these reports vary greatly in terms of quality and reliability. This may impair the learning process during residency. The purpose of the study was to analyze the longitudinal effects of using structured reports (SR) of head and neck ultrasound studies during residency. METHODS Attending residents (n = 24) of a tripartite course on head and neck ultrasound, accredited by the German Society for Ultrasound in Medicine (DEGUM), were randomly allocated to pictures of common diseases. Both SRs and FTRs were compiled. All reports were analyzed concerning completeness, acquired time and legibility. Overall user contentment was evaluated by a questionnaire. RESULTS SRs achieved significantly higher ratings regarding completeness (95.6% vs. 26.4%, p < 0.001), description of pathologies (72.2% vs. 58.9%, p < 0.001) and legibility (100% vs. 52.4%, p < 0.001) with a very high inter-rater reliability (Fleiss' kappa 0.9). Reports were finalized significantly faster (99.1 s vs. 115.0 s, p < 0.001) and user contentment was significantly better when using SRs (8.3 vs. 6.3, p < 0.001). In particular, only SRs showed a longitudinally increasing time efficiency (- 20.1 s, p = 0.036) while maintaining consistent completeness ratings. CONCLUSIONS The use of SRs of head and neck ultrasound studies results in an increased longitudinal time-efficiency while upholding the report quality at the same time. This may indicate an additive learning effect of structured reporting. Superior outcomes in terms of comprehensiveness, legibility and time-efficiency can be observed immediately after implementation.
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Spandorfer A, Branch C, Sharma P, Sahbaee P, Schoepf UJ, Ravenel JG, Nance JW. Deep learning to convert unstructured CT pulmonary angiography reports into structured reports. Eur Radiol Exp 2019; 3:37. [PMID: 31549323 PMCID: PMC6757071 DOI: 10.1186/s41747-019-0118-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 07/24/2019] [Indexed: 01/29/2023] Open
Abstract
Background Structured reports have been shown to improve communication between radiologists and providers. However, some radiologists are concerned about resultant decreased workflow efficiency. We tested a machine learning-based algorithm designed to convert unstructured computed tomography pulmonary angiography (CTPA) reports into structured reports. Methods A self-supervised convolutional neural network-based algorithm was trained on a dataset of 475 manually structured CTPA reports. Labels for individual statements included “pulmonary arteries,” “lungs and airways,” “pleura,” “mediastinum and lymph nodes,” “cardiovascular,” “soft tissues and bones,” “upper abdomen,” and “lines/tubes.” The algorithm was applied to a test set of 400 unstructured CTPA reports, generating a predicted label for each statement, which was evaluated by two independent observers. Per-statement accuracy was calculated based on strict criteria (algorithm label counted as correct if the statement unequivocally contained content only related to that particular label) and a modified criteria, accounting for problematic statements, including typographical errors, statements that did not fit well into the classification scheme, statements containing content for multiple labels, etc. Results Of the 4,157 statements, 3,806 (91.6%) and 3,986 (95.9%) were correctly labeled by the algorithm using strict and modified criteria, respectively, while 274 (6.6%) were problematic for the manual observers to label, the majority of which (n = 173) were due to more than one section being included in one statement. Conclusion This algorithm showed high accuracy in converting free-text findings into structured reports, which could improve communication between radiologists and clinicians without loss of productivity and provide more structured data for research/data mining applications.
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Affiliation(s)
- Adam Spandorfer
- Department of Radiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Cody Branch
- Department of Radiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Puneet Sharma
- Siemens Medical Solutions USA, Inc., 40 Liberty Boulevard, Malvern, PA, 19355, USA
| | - Pooyan Sahbaee
- Siemens Medical Solutions USA, Inc., 40 Liberty Boulevard, Malvern, PA, 19355, USA
| | - U Joseph Schoepf
- Department of Radiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - James G Ravenel
- Department of Radiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - John W Nance
- Department of Radiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA.
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Wetterauer C, Winkel DJ, Federer-Gsponer JR, Leboutte F, Horn T, Schnyder P, Dugas SG, Zahiti L, Engesser C, Halla A, Seifert HH, Boll DT, Ebbing J. Novices in MRI-targeted prostate biopsy benefit from structured reporting of MRI findings. World J Urol 2019; 38:1729-1734. [PMID: 31522235 DOI: 10.1007/s00345-019-02953-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/07/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE The aim of this study was to investigate whether structured reports (SRs) of prostate MRI results are more suitable than non-structured reports (NSRs) for promoting the more accurate assessment of the location of a single prostate cancer lesion by novices in MRI-targeted biopsy. METHODS 50 NSRs and 50 SRs describing a single prostatic lesion were presented to 5 novices in MRI-targeted biopsy. The participants were asked to plot the tumor location in a two-dimensional prostate diagram and to answer a questionnaire on the quality of the reports. The accuracy of the plotted tumor position was evaluated with a validated 30-point scoring system that distinguished between "major" and "minor" mistakes. RESULTS The overall mean score for the accuracy of the tumor plotting was significantly higher for SRs than for NSRs (26.4 vs. 20.7, p < 0.01). The mean numbers of major (1.4 vs. 0.48, p < 0.01) and minor (3.05 vs. 1.15, p < 0.01) mistakes were significantly higher for NSRs than for SRs. Compared with NSRs, SRs received significantly higher ratings for the perceived quality of the summary (4.0 vs. 2.4, p < 0.01) as well as for the overall satisfaction with the report (4.1 vs. 2.1, p < 0.01). CONCLUSION Novices in MRI-targeted biopsy prefer structured reporting of prostate MRI as an information tool. SRs allow for a more accurate assessment of the location of single prostate cancer lesions. Therefore, structured reporting of prostate MRI may help to foster the learning process of novices in MRI-targeted biopsy.
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Affiliation(s)
- Christian Wetterauer
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - David Jean Winkel
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
| | - Joel R Federer-Gsponer
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Francois Leboutte
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Tobias Horn
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Petra Schnyder
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Sarah G Dugas
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Leutrim Zahiti
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Christian Engesser
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Armin Halla
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Hans-Helge Seifert
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
| | - Daniel T Boll
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Jan Ebbing
- Department of Urology, University Hospital Basel, Spitalstr.21, 4031, Basel, Switzerland
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Creating high-quality radiology reports in foreign languages through multilingual structured reporting. Eur Radiol 2019; 29:6038-6048. [PMID: 31028444 DOI: 10.1007/s00330-019-06206-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/19/2019] [Accepted: 03/26/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Globalization and migration are increasing the demand for reports in different languages. We aimed to examine if structured reports created by non-German-speaking radiologists with multilingual templates show significant differences in quality to structured reports and free-text reports by German native speakers. METHODS We used structured templates that allow radiologists to report in their mother tongue and then switch the report language to German or English automatically using proprietary software. German- and English-speaking radiology residents created structured reports in both German and English with these templates. Reports for three different exam types were created (intensive care chest x-ray, shoulder x-ray specifically for degenerative processes, and CT pulmonary angiogram for pulmonary embolism). The report quality of automatically translated German structured reports by English-speaking radiologists and German structured reports by German radiologists was then evaluated by German clinicians with a standardized questionnaire. The questionnaire was designed to assess attributes including content, comprehensibility, clinical consequences, and overall quality. RESULTS Structured reports by English-speaking radiologists that were automatically translated into German and German structured reports by German radiologists both received very high or high overall quality ratings in the majority of cases, showing no significant differences in quality. Likewise, no significant differences were observed between the two report types regarding comprehensibility and clinical consequences. Structured reports by German radiologists received significantly better ratings for overall quality and comprehensibility compared to free-text reports by German radiologists. CONCLUSIONS Multilingual structured reporting templates may serve as a feasible tool for creating high-quality radiology reports in foreign languages. KEY POINTS • Multilingualism in structured reporting templates can be a useful tool for creating high-quality radiology reports in foreign languages. • German reports created with multilingual structured reporting templates by English-speaking radiologists and German structured reports by German radiologists exhibit no significant differences in overall report quality. • Multilingual structured reporting templates can help radiologists overcome communication barriers and facilitate teleradiology.
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Ernst BP, Katzer F, Künzel J, Hodeib M, Strieth S, Eckrich J, Tattermusch A, Froelich MF, Matthias C, Sommer WH, Becker S. Impact of structured reporting on developing head and neck ultrasound skills. BMC MEDICAL EDUCATION 2019; 19:102. [PMID: 30971248 PMCID: PMC6458758 DOI: 10.1186/s12909-019-1538-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/31/2019] [Indexed: 05/06/2023]
Abstract
BACKGROUND Reports of head and neck ultrasound examinations are frequently written by hand as free texts. This is a serious obstacle to the learning process of the modality due to a missing report structure and terminology. Therefore, there is a great inter-observer variability in overall report quality. Aim of the present study was to evaluate the impact of structured reporting on the learning process as indicated by the overall report quality of head and neck ultrasound examinations within medical school education. METHODS Following an immersion course on head and neck ultrasound, previously documented images of three common pathologies were handed out to 58 medical students who asked to create both standard free text reports (FTR) and structured reports (SR). A template for structured reporting of head and neck ultrasound examinations was created using a web-based approach. FTRs and SRs were evaluated with regard to overall quality, completeness, required time to completion and readability by two independent raters (Paired Wilcoxon test, 95% CI). Ratings were assessed for inter-rater reliability (Fleiss' kappa). Additionally, a questionnaire was utilized to evaluate user satisfaction. RESULTS SRs received significantly better ratings in terms of report completeness (97.7% vs. 53.5%, p < 0.001) regarding all items. In addition, pathologies were described in more detail using SRs (70% vs. 51.1%, p < 0.001). Readability was significantly higher in all SRs when compared to FTRs (100% vs. 54.4%, p < 0.001). Mean time to complete was significantly lower (79.6 vs. 205.4 s, p < 0.001) and user satisfaction was significantly higher when using SRs (8.5 vs. 4.1, p < 0.001). Also, inter-rater reliability was very high (Fleiss' kappa 0.93). CONCLUSIONS SRs of head and neck ultrasound examinations provide more detailed information with a better readability in a time-saving manner within medical education. Also, medical students may benefit from SRs in their learning process due to the structured approach and standardized terminology.
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Affiliation(s)
- Benjamin P. Ernst
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Fabian Katzer
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Julian Künzel
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Mohamed Hodeib
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Sebastian Strieth
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Jonas Eckrich
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | | | - Matthias F. Froelich
- Institute of Clinical Radiology and Nuclear Medicine, Institute of Clinical Radiology and Nuclear Medicine, Faculty Mannheim-Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph Matthias
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Wieland H. Sommer
- Department of Radiology, LMU University Hospital, Marchioninistraße 15, 81377 Munich, Germany
| | - Sven Becker
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
- Department of Otolaryngology, Head and Neck Surgery, University of Tübingen, Elfriede-Aulhorn-Straße 5, 72076 Tübingen, Germany
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Ernst BP, Hodeib M, Strieth S, Künzel J, Bischof F, Hackenberg B, Huppertz T, Weber V, Bahr K, Eckrich J, Hagemann J, Engelbarts M, Froelich MF, Solbach P, Linke R, Matthias C, Sommer WH, Becker S. Structured reporting of head and neck ultrasound examinations. BMC Med Imaging 2019; 19:25. [PMID: 30917796 PMCID: PMC6437950 DOI: 10.1186/s12880-019-0325-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/11/2019] [Indexed: 12/25/2022] Open
Abstract
Background Reports of head and neck ultrasound examinations are frequently written by hand as free texts. Naturally, quality and structure of free text reports is variable, depending on the examiner’s individual level of experience. Aim of the present study was to compare the quality of free text reports (FTR) and structured reports (SR) of head and neck ultrasound examinations. Methods Both standard FTRs and SRs of head and neck ultrasound examinations of 43 patients were acquired by nine independent examiners with comparable levels of experience. A template for structured reporting of head and neck ultrasound examinations was created using a web-based approach. FTRs and SRs were evaluated with regard to overall quality, completeness, required time to completion, and readability by four independent raters with different specializations (Paired Wilcoxon test, 95% CI) and inter-rater reliability was assessed (Fleiss’ kappa). A questionnaire was used to compare FTRs vs. SRs with respect to user satisfaction (Mann-Whitney U test, 95% CI). Results By comparison, completeness scores of SRs were significantly higher than FTRs’ completeness scores (94.4% vs. 45.6%, p < 0.001), and pathologies were described in more detail (91.1% vs. 54.5%, p < 0.001). Readability was significantly higher in all SRs when compared to FTRs (100% vs. 47.1%, p < 0.001). The mean time to complete a report, however, was significantly higher in SRs (176.5 vs. 107.3 s, p < 0.001). SRs achieved significantly higher user satisfaction ratings (VAS 8.87 vs. 1.41, p < 0.001) and a very high inter-rater reliability (Fleiss’ kappa 0.92). Conclusions As compared to FTRs, SRs of head and neck ultrasound examinations are more comprehensive and easier to understand. On the balance, the additional time needed for completing a SR is negligible. Also, SRs yield high inter-rater reliability and may be used for high-quality scientific data analyses.
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Affiliation(s)
- Benjamin P Ernst
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Mohamed Hodeib
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Sebastian Strieth
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Julian Künzel
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Fabian Bischof
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Berit Hackenberg
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Tilmann Huppertz
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Veronika Weber
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Katharina Bahr
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jonas Eckrich
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jan Hagemann
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Matthias Engelbarts
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Matthias F Froelich
- Department of Radiology, LMU University Hospital, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp Solbach
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Richard Linke
- Department of General and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Christoph Matthias
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Wieland H Sommer
- Department of Radiology, LMU University Hospital, Marchioninistraße 15, 81377, Munich, Germany
| | - Sven Becker
- Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Alessandrino F, Cristiano L, Cinnante CM, Tartaglione T, Gerevini S, Verdolotti T, Colafati GS, Ghione E, Vitale R, Peverelli L, Brogna C, Berardinelli A, Moggio M, Mercuri EM, Pichiecchio A. Value of structured reporting in neuromuscular disorders. Radiol Med 2019; 124:628-635. [DOI: 10.1007/s11547-019-01012-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 11/27/2022]
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Tuncyurek O, Garces-Descovich A, Jaramillo-Cardoso A, Durán EE, Cataldo TE, Poylin VY, Gómez SF, Cabrera AM, Hegazi T, Beker K, Mortele KJ. Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning. Abdom Radiol (NY) 2019; 44:811-820. [PMID: 30519819 DOI: 10.1007/s00261-018-1858-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons. MATERIALS AND METHODS In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning. RESULTS Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports. CONCLUSION Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.
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Wetterauer C, Winkel DJ, Federer-Gsponer JR, Halla A, Subotic S, Deckart A, Seifert HH, Boll DT, Ebbing J. Structured reporting of prostate magnetic resonance imaging has the potential to improve interdisciplinary communication. PLoS One 2019; 14:e0212444. [PMID: 30779810 PMCID: PMC6380587 DOI: 10.1371/journal.pone.0212444] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/01/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective interdisciplinary communication of imaging findings is vital for patient care, as referring physicians depend on the contained information for the decision-making and subsequent treatment. Traditional radiology reports contain non-structured free text and potentially tangled information in narrative language, which can hamper the information transfer and diminish the clarity of the report. Therefore, this study investigates whether newly developed structured reports (SRs) of prostate magnetic resonance imaging (MRI) can improve interdisciplinary communication, as compared to non-structured reports (NSRs). METHODS 50 NSRs and 50 SRs describing a single prostatic lesion were presented to four urologists with expert level experience in prostate cancer surgery or targeted MRI TRUS fusion biopsy. They were subsequently asked to plot the tumor location in a 2-dimensional prostate diagram and to answer a questionnaire focusing on information on clinically relevant key features as well as the perceived structure of the report. A validated scoring system that distinguishes between "major" and "minor" mistakes was used to evaluate the accuracy of the plotting of the tumor position in the prostate diagram. RESULTS The mean total score for accuracy for SRs was significantly higher than for NSRs (28.46 [range 13.33-30.0] vs. 21.75 [range 0.0-30.0], p < 0.01). The overall rates of major mistakes (54% vs. 10%) and minor mistakes (74% vs. 22%) were significantly higher (p < 0.01) for NSRs than for SRs. The rate of radiologist re-consultations was significantly lower (p < 0.01) for SRs than for NSRs (19% vs. 85%). Furthermore, SRs were rated as significantly superior to NSRs in regard to determining the clinical tumor stage (p < 0.01), the quality of the summary (4.4 vs. 2.5; p < 0.01), and overall satisfaction with the report (4.5 vs. 2.3; p < 0.01), and as more valuable for further clinical decision-making and surgical planning (p < 0.01). CONCLUSIONS Structured reporting of prostate MRI has the potential to improve interdisciplinary communication. Through SRs, expert urologists were able to more accurately assess the exact location of single prostate cancer lesions, which can facilitate surgical planning. Furthermore, structured reporting of prostate MRI leads to a higher satisfaction level of the referring physician.
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Affiliation(s)
- C. Wetterauer
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - D. J. Winkel
- Department of Radiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
| | - J. R. Federer-Gsponer
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - A. Halla
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - S. Subotic
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - A. Deckart
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - H. H. Seifert
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
| | - D. T. Boll
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - J. Ebbing
- University Hospital Basel, Urological University Clinic Basel-Liestal, Basel, Switzerland
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The Effect of Computer-Assisted Reporting on Interreader Variability of Lumbar Spine MRI Degenerative Findings: Five Readers With 30 Disc Levels. J Am Coll Radiol 2018; 15:1613-1619. [DOI: 10.1016/j.jacr.2017.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/07/2017] [Accepted: 12/15/2017] [Indexed: 11/24/2022]
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Structured reporting in petrous bone MRI examinations: impact on report completeness and quality. Int J Comput Assist Radiol Surg 2018; 13:1971-1980. [DOI: 10.1007/s11548-018-1828-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/16/2018] [Indexed: 12/16/2022]
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Pool FJ, Siemienowicz ML. New RANZCR clinical radiology written report guidelines. J Med Imaging Radiat Oncol 2018; 63:7-14. [PMID: 30019848 DOI: 10.1111/1754-9485.12756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/21/2018] [Indexed: 12/17/2022]
Abstract
The Royal Australian and New Zealand College of Radiologists (RANZCR) Radiology Written Report Guideline was first issued in 2011. A survey-based consultation of clinical radiology members of the college in 2015 found that the vast majority of 235 respondents supported all components of the guideline. Since the original guideline was developed, considerable new research has been published about radiology reporting, particularly regarding structured/template reports. In 2016/17 a RANZCR working group used the consultation results, stakeholder feedback and recent research to develop revised guidelines. This article outlines the consultation survey results and guideline revision process as well as some of the supporting evidence from the literature.
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Affiliation(s)
- Felicity Jane Pool
- Department of Diagnostic Imaging, National University Hospital, Singapore
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Nougaret S, Horta M, Sala E, Lakhman Y, Thomassin-Naggara I, Kido A, Masselli G, Bharwani N, Sadowski E, Ertmer A, Otero-Garcia M, Kubik-Huch RA, Cunha TM, Rockall A, Forstner R. Endometrial Cancer MRI staging: Updated Guidelines of the European Society of Urogenital Radiology. Eur Radiol 2018; 29:792-805. [DOI: 10.1007/s00330-018-5515-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/18/2018] [Accepted: 04/26/2018] [Indexed: 12/21/2022]
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Schoeppe F, Sommer WH, Nörenberg D, Verbeek M, Bogner C, Westphalen CB, Dreyling M, Rummeny EJ, Fingerle AA. Structured reporting adds clinical value in primary CT staging of diffuse large B-cell lymphoma. Eur Radiol 2018; 28:3702-3709. [PMID: 29600475 DOI: 10.1007/s00330-018-5340-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/11/2018] [Accepted: 01/17/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate whether template-based structured reports (SRs) add clinical value to primary CT staging in patients with diffuse large B-cell lymphoma (DLBCL) compared to free-text reports (FTRs). METHODS In this two-centre study SRs and FTRs were acquired for 16 CT examinations. Thirty-two reports were independently scored by four haematologists using a questionnaire addressing completeness of information, structure, guidance for patient management and overall quality. The questionnaire included yes-no, 10-point Likert scale and 5-point scale questions. Altogether 128 completed questionnaires were evaluated. Non-parametric Wilcoxon signed-rank test and McNemar's test were used for statistical analysis. RESULTS SRs contained information on affected organs more often than FTRs (95 % vs. 66 %). More SRs commented on extranodal involvement (91 % vs. 62 %). Sufficient information for Ann-Arbor classification was included in more SRs (89 % vs. 64 %). Information extraction was quicker from SRs (median rating on 10-point Likert scale=9 vs. 6; 7-10 vs. 4-8 interquartile range). SRs had better comprehensibility (9 vs. 7; 8-10 vs. 5-8). Contribution of SRs to clinical decision-making was higher (9 vs. 6; 6-10 vs. 3-8). SRs were of higher quality (p < 0.001). All haematologists preferred SRs over FTRs. CONCLUSIONS Structured reporting of CT examinations for primary staging in patients with DLBCL adds clinical value compared to FTRs by increasing completeness of reports, facilitating information extraction and improving patient management. KEY POINTS • Structured reporting in CT helps clinicians to assess patients with lymphoma. • This two-centre study showed that structured reporting improves information content and extraction. • Patient management may be improved by structured reporting. • Clinicians preferred structured reports over free-text reports.
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Affiliation(s)
- Franziska Schoeppe
- Department of Radiology, University Hospital, LMU Munich, Marchionistr. 15, 81377, Munich, Germany.
| | - Wieland H Sommer
- Department of Radiology, University Hospital, LMU Munich, Marchionistr. 15, 81377, Munich, Germany
| | - Dominik Nörenberg
- Department of Radiology, University Hospital, LMU Munich, Marchionistr. 15, 81377, Munich, Germany
| | - Mareike Verbeek
- III. Department of Internal Medicine and Comprehensive Cancer Center, Technical University of Munich (TUM), Munich, Germany
| | - Christian Bogner
- III. Department of Internal Medicine and Comprehensive Cancer Center, Technical University of Munich (TUM), Munich, Germany
| | - C Benedikt Westphalen
- Department of Internal Medicine III and Comprehensive Cancer Center, University Hospital Grosshadern, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
| | - Martin Dreyling
- Department of Internal Medicine III and Comprehensive Cancer Center, University Hospital Grosshadern, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
| | - Ernst J Rummeny
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich (TUM), Munich, Germany
| | - Alexander A Fingerle
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich (TUM), Munich, Germany
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Szilveszter B, Kolossváry M, Karády J, Jermendy ÁL, Károlyi M, Panajotu A, Bagyura Z, Vecsey-Nagy M, Cury RC, Leipsic JA, Merkely B, Maurovich-Horvat P. Structured reporting platform improves CAD-RADS assessment. J Cardiovasc Comput Tomogr 2017; 11:449-454. [DOI: 10.1016/j.jcct.2017.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/14/2017] [Accepted: 09/13/2017] [Indexed: 12/17/2022]
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