Medico-legal issues in breast imaging

To image or not in noncyclic breast pain? A systematic review

PURPOSE OF REVIEW

Investigation of noncyclic mastalgia in women without signs or risk factors for cancer is controversial. An initial imaging strategy can diagnose breast cancer early, potentially leading to better treatment and survival. However, cancer diagnosis is very uncommon in these cases, and this approach can be harmful, as false positives or suspicion results will lead to unneeded interventions and follow-up. The purpose of this review is to analyse the trade-offs between desirable and undesirable consequences of initial imaging tests against clinical follow-up.

RECENT FINDINGS

We found seven relevant studies, all observational, with some methodological limitations and very low-quality evidence. They showed low breast cancer prevalence (around 1-2%, increasing with age), high sensitivity to rule out disease but moderate specificity to rule it in using mammography and echography, and lacked evidence on follow-up and final outcomes.

SUMMARY

There is a low prevalence of breast cancer in patients with painful breast with negative physical examination, and very little research to inform about the effect of performing or avoiding initial imaging test on outcomes of interest. With such limited evidence, only a weak recommendation to reinforce shared decision making about what should be done in the primary care setting can be made, with the backup of a specialized breast unit.

Investigating Errors in Medical Imaging: Lessons for Practice From Medicolegal Closed Claims

PURPOSE

Radiology has lagged behind other disciplines in using medicolegal data to improve patient safety. The aim of this study was to characterize a sample of closed claims files to inform radiology practice and identify opportunities for system change.

METHODS

A retrospective analysis of 443 medicolegal closed claims provided to the Radiology Events Register. Data were provided by 2 medical defense organizations that provide medical indemnity insurance to Australian private practitioners. We calculated a procedural risk ratio (prevalence in the closed claims dataset divided by prevalence among all diagnostic imaging procedures reimbursed by the Australian Government over the corresponding timeframe) for each modality (CT, ultrasound, radiography, MRI, nuclear medicine) and some procedures. For each closed claim, the incident type was determined, and a classification of 12 patient safety fields was conducted.

RESULTS

Misdiagnosis (delay or failure to correctly read imaging) accounted for 62% of error types. Modalities and procedures at higher risk of leading to a claim were: mammography (risk ratio [RR] = 4.0, 95% CI 2.9-5.5); breast ultrasound (RR = 2.8, 95% CI 1.7-4.7); total MRI (RR = 3.4, 95% CI 2.0-5.6); total CT (RR = 1.9, 95% CI 1.5-2.5), and obstetrics and gynecology ultrasound (RR = 1.9, 95% CI 1.4-2.4). Lower-risk modalities and procedures were: cardiac ultrasound (RR = 0.1, 95% CI 0.0-0.8); radiography extremities (RR = 0.7, 95% CI 0.5-0.9); and total radiography (RR = 0.8, 95% CI 0.7-0.9). Information to inform patient safety classification was limited, with a mean of 5.8 ± 1.8 (SD) fields available.

CONCLUSIONS

Despite its limitations, medicolegal data deserve further attention from patient safety analysts.