Does litigation influence medical practice? The influence of community radiologists' medical malpractice perceptions and experience on screening mammography

Pros and cons of reporting incidental findings in lung cancer screening

Incidental findings (IFs) are common in lung cancer screening (LCS). While the detection of some of these findings can lead to early diagnosis and treatment of clinically significant conditions, it also carries the risks of overdiagnosis and overtreatment, causing anxiety for patients and increased economic costs for health systems. Effective management of IFs requires a balanced approach guided by clear guidelines, standardized reporting, and participants-centered communication. As the field of LCS evolves, continued research and innovation will be essential in refining the strategies for managing IFs, ensuring that the benefits of screening are maximized while minimizing potential harm. Evidence-based guidelines on reporting and management of IFs, however, are still lacking. This narrative review explores the pros and cons of reporting IFs in LCS, focusing on key controversies. KEY POINTS: Reporting and managing incidental findings in lung cancer screening is largely debated. The detection of incidental findings can lead to early diagnosis of clinically significant conditions but carries the risks of overdiagnosis and overtreatment. A balance must be found to have a positive impact on the population while not placing a burden on healthcare systems.

Effect of malpractice claims on orthopedic and traumatology physicians in Turkey: A survey study

OBJECTIVE

This study aimed to investigate the malpractice claims experienced by orthopedic and traumatology physicians and to determine their effects on burnout, job satisfaction, and clinical practice.

METHODS

A questionnaire survey was conducted on orthopedic and traumatology specialists between May 2019 and February 2020. Data collection was carried out via e-survey at "turk-ortopedi" mail group, which is an electronic communication network of orthopedic and traumatology physicians. For data collection, sociodemographic data forms were used including the general characteristics, working conditions, and the malpractice claim events along with the Maslach Burnout Inventory scale to evaluate burnout and the Minnesota Satisfaction Questionnaire to investigate job satisfaction.

RESULTS

In total, 353 orthopedic and traumatology physicians (348 men, 5 women), including 37 professors, 41 associate professors, and 275 surgeons, completed the questionnaire. In total, 65.4% of the participants (231 physicians and 471 relevant dossiers) stated that they were currently facing a malpractice claim. Emotional burnout and hesitant behavior in medical practices were significantly higher among the physicians who had undergone an investigation/trial with the claim of malpractice (p<0.05), whereas intrinsic job satisfaction was significantly lower (p<0.05). It was determined that orthopedic and traumatology physicians dealing with arthroplasty, vertebral surgery, hand surgery, and foot/ankle surgeries had undergone significantly more trials (p<0.05). In the evaluation of the burnout levels and job satisfaction scores of the physicians according to the age, academic title, seniority, and institution, it was determined that burnout level decreased with age, those between the ages of 25 and 34 years were exhausted the most, and job satisfaction increased with age. It was also found that burnout level decreased and job satisfaction increased as the academic title became higher, and attending physicians were the most exhausted. Moreover, burnout level decreased as seniority increased, the most senior ones were the ones most exhausted, and job satisfaction increased with seniority.

CONCLUSION

Evidence from this study has revealed that malpractice claims cause emotional burnout, low intrinsic job satisfaction, and a hesitant behavior in medical practice for the orthopedic and traumatology physicians. The concept of malpractice alone may result in unnecessary analyses/examinations for patients.

LEVEL OF EVIDENCE

Level IV, Diagnostic Study.

Variation in Follow-up Imaging Recommendations in Radiology Reports: Patient, Modality, and Radiologist Predictors

Background Variation between radiologists when making recommendations for additional imaging and associated factors are, to the knowledge of the authors, unknown. Clear identification of factors that account for variation in follow-up recommendations might prevent unnecessary tests for incidental or ambiguous image findings. Purpose To determine incidence and identify factors associated with follow-up recommendations in radiology reports from multiple modalities, patient care settings, and imaging divisions. Materials and Methods This retrospective study analyzed 318 366 reports obtained from diagnostic imaging examinations performed at a large urban quaternary care hospital from January 1 to December 31, 2016, excluding breast and US reports. A subset of 1000 reports were randomly selected and manually annotated to train and validate a machine learning algorithm to predict whether a report included a follow-up imaging recommendation (training-and-validation set consisted of 850 reports and test set of 150 reports). The trained algorithm was used to classify 318 366 reports. Multivariable logistic regression was used to determine the likelihood of follow-up recommendation. Additional analysis by imaging subspecialty division was performed, and intradivision and interradiologist variability was quantified. Results The machine learning algorithm classified 38 745 of 318 366 (12.2%) reports as containing follow-up recommendations. Average patient age was 59 years ± 17 (standard deviation); 45.2% (143 767 of 318 366) of reports were from male patients. Among 65 radiologists, 57% (37 of 65) were men. At multivariable analysis, older patients had higher rates of follow-up recommendations (odds ratio [OR], 1.01 [95% confidence interval {CI}: 1.01, 1.01] for each additional year), male patients had lower rates of follow-up recommendations (OR, 0.9; 95% CI: 0.9, 1.0), and follow-up recommendations were most common among CT studies (OR, 4.2 [95% CI: 4.0, 4.4] compared with radiography). Radiologist sex (P = .54), presence of a trainee (P = .45), and years in practice (P = .49) were not significant predictors overall. A division-level analysis showed 2.8-fold to 6.7-fold interradiologist variation. Conclusion Substantial interradiologist variation exists in the probability of recommending a follow-up examination in a radiology report, after adjusting for patient, examination, and radiologist factors. © RSNA, 2019 See also the editorial by Russell in this issue.

Physicians as second victims after a malpractice claim: An important issue in need of attention

OBJECTIVE

Being sued for malpractice is extremely stressful and potentially traumatizing. We aim to identify claims' consequences on the physicians' well-being and medical practice.

MATERIAL AND METHODS

We administered a confidential telephonic survey to those physicians with a claim closed during 2014, among those insured by the main professional liability insurance company in the region. The questionnaire addressed several topics: symptoms and well-being changes, needs, impairments and practice changes. We used descriptive statistics as well as Chi-square and T-Student tests.

RESULTS

A total of 99 physicians responded to the questionnaire (response rate of 64.7%). Most of them (80.8%) acknowledged having suffered a significant emotional distress, no matter the claim's outcome (p=0.958) or the kind of procedure (p=0.928). Anger and mood cluster of symptoms were frequent, and the experience frequently affected their personal, family or social life and professional conduct. Practice changes correlated significantly and positively with the number of symptoms reported (p=0.010), but not with the outcome of the claim (p=0.338) or the kind of procedure (p=0.552).

CONCLUSIONS

Most claimed physicians suffer a significant emotional distress after a malpractice claim, which affects their professional performance. According to our results, they should be assessed and assisted in order to minimize the negative consequences on their well-being and their praxis.

Patient, Radiologist, and Examination Characteristics Affecting Screening Mammography Recall Rates in a Large Academic Practice

OBJECTIVE

The aims of this study were to evaluate patient, radiologist, and examination characteristics affecting screening mammography recall rates in an academic breast imaging practice and to identify modifiable factors that could reduce recall variation.

METHODS

This institutional review board-approved retrospective study included screening mammographic examinations in female patients interpreted by 13 breast imaging specialists at an academic center and two outpatient centers from October 1, 2012, to May 31, 2015. Patient demographics were extracted via electronic medical record. Natural language processing captured breast density, BI-RADS assignment, and current and prior screening examination findings. Radiologists' annual screening volumes, clinical experience, and concentration in breast imaging were calculated. Risk aversion, stress from uncertainty, and malpractice concerns were derived via survey. Univariate and multivariate analyses assessed patient, radiologist, and examination characteristics associated with likelihood of mammography recall. The Pearson product-moment correlation coefficient was used to assess the relationship between cancer detection rate and recall rate.

RESULTS

Overall, 5,678 of 61,198 screening examinations (9.3%) were recalled. In multivariate analysis, patient and radiologist characteristics associated with higher odds of recall included patient's age < 50 years (P < .0001), prior mammographic findings (calcification [P < .0001], mass [P < .0001], higher density category [P < .0001]), baseline examination (P < .0001), annual reading volume < 1,250 examinations (P = .0282), and <10 years of experience (P = .0036). Radiologist's risk aversion, stress from uncertainty, malpractice concerns, and cancer detection rates were not associated with higher recall rates (r = -0.36, P = .23).

CONCLUSIONS

In addition to patient and examination factors, screening recall variations were associated with radiologists' annual reading volume and experience. Interventions targeting radiologist factors (screening volumes, second review of potential recalls) may help reduce unwarranted variation in screening recall.

Co-prescribing naloxone does not increase liability risk

The opioid overdose epidemic claims the lives of tens of thousands of Americans every year. Opioid overdose is reversible by the administration of naloxone, a pure antagonist now available in formulations specifically designed and labeled for layperson use. Despite broad support for layperson access to naloxone from professional organizations, health officials, and clinical experts, qualitative studies suggest that some providers have concerns about legal risks associated with naloxone prescribing, particularly co-prescribing naloxone to pain patients. Such concerns are unfounded. The legal risk associated with prescribing naloxone is no higher than that associated with any other medication and is lower than many. Additionally, laws in a majority of states provide explicit legal protections for providers who prescribe or dispense naloxone, in many cases extending this protection to prescriptions issued to friends, family members, and others. In this large and increasing number of states, the liability risk of prescribing or dispensing naloxone in good faith to a patient at risk of overdose (or, in states where such prescribing is permitted, to an associate of such a patient) is either extremely low or absent entirely. Where a prescriber determines, in his or her clinical judgment, that a patient is at risk of overdose, co-prescribing naloxone is a reasonable and prudent clinical and legal decision. No clinician should fail or refuse to issue such a prescription based on liability concerns.

Frequency and Determinants of a Short-Interval Follow-up Recommendation After an Abnormal Screening Mammogram

PURPOSE

After imaging assessment of an abnormal screening mammogram, a follow-up examination 6 months later is recommended to some women. Our aim was to identify which characteristics of lesions, women, and physicians are associated to such short-interval follow-up recommendation in the Quebec Breast Cancer Screening Program.

METHODS

Between 1998 and 2008, 1,839,396 screening mammograms were performed and a total of 114,781 abnormal screens were assessed by imaging only. Multivariate analysis was done with multilevel Poisson regression models with robust variance and generalized linear mixed models.

RESULTS

A short-interval follow-up was recommended in 26.7% of assessments with imaging only, representing 2.3% of all screens. Case-mix adjusted proportion of short-interval follow-up recommendations varied substantially across physicians (range: 4%-64%). Radiologists with high recall rates (≥15%) had a high proportion of short-interval follow-up recommendation (risk ratio: 1.82; 95% confidence interval: 1.35-2.45) compared to radiologists with low recall rates (<5%). The adjusted proportion of short-interval follow-up was high (22.8%) even when a previous mammogram was usually available.

CONCLUSIONS

Short-interval follow-up recommendation at assessment is frequent in this Canadian screening program, even when a previous mammogram is available. Characteristics related to radiologists appear to be key determinants of short-interval follow-up recommendation, rather than characteristics of lesions or patient mix. Given that it can cause anxiety to women and adds pressure on the health system, it appears important to record and report short-interval follow-up and to identify ways to reduce its frequency. Short-interval follow-up recommendations should be considered when assessing the burden of mammography screening.

Increasing Prevalence Expectation in Thoracic Radiology Leads to Overcall

RATIONALE AND OBJECTIVES

The aim of this study was to measure the effect of prevalence expectation as determined by clinical history on the diagnostic performance of radiologists during pulmonary nodule detection on adult chest radiographs.

MATERIALS AND METHODS

A multi-observer, counter-balanced study (having half the readers in each group read a different condition initially) was performed to assess the effect of abnormality expectation on experienced radiologists' performance. A total of 33 board-certified radiologists were divided into three groups and searched for evidence of malignancy on a single set of 47 postero-anterior (PA) chest radiographs, 10 of which contained a single pulmonary nodule. The radiologists were unaware of disease prevalence. Before each viewing of the same dataset, the radiologists were allocated to two of three conditions based on the differing clinical information (previous cancer, no history, visa applicant). Location sensitivity, specificity, and jack-knife free-response receiver operator characteristics figure of merit were used to compare radiologist performance between conditions.

RESULTS

A significant reduction in specificity was shown for the cancer compared to that for the visa condition (W = -41 P = 0.02). No other significant findings were demonstrated for this or the other condition comparisons. No significant difference in the performance of radiologists was noted when viewing images under the same conditions.

CONCLUSIONS

This study suggested that there is a reduction in specificity with high compared to low prevalence expectation following specific radiological contexts. A reduction in specificity can have important clinical consequences leading to unnecessary interventions. The results and their implications emphasize the caution that should be placed on providing accurate referral criteria.

Breast cancer screening in England and the United States: a comparison of provision and utilisation

OBJECTIVES

Comparing breast cancer screening across countries within the context of some of the benefits and harms offers the opportunity to improve effectiveness through mutual learning.

METHODS

This paper describes the provision of breast cancer screening in England and the United States. The various recommendations for accessing breast cancer screening in the two countries are set out and the organisation of services including quality assurance, incentives and performance mechanisms considered.

RESULTS

In the United States, younger women are routinely screened; they are less likely to benefit and more likely to be harmed. The utilisation of breast cancer screening amongst eligible women is broadly comparable in the two countries. However, there are differences in technical performance; the reasons for these including radiological reading procedures and cultural factors are explored.

CONCLUSIONS

Despite a well-functioning screening programme, breast cancer mortality and survival in England are poor relative to other countries. Emphasis for American improvement should be on reducing false-positive recall rates, while the English NHS could supplement existing efforts to understand and improve comparatively poor survival and mortality.

Comparison of cumulative false-positive risk of screening mammography in the United States and Denmark

INTRODUCTION

In the United States (US), about one-half of women screened with annual mammography have at least one false-positive test after ten screens. The estimate for European women screened ten times biennially is much lower. We evaluate to what extent screening interval, mammogram type, and statistical methods, can explain the reported differences.

METHODS

We included all screens from women first screened at age 50-69 years in the US Breast Cancer Surveillance Consortium (BCSC) (n=99,455) between 1996-2010, and from two population-based mammography screening programs in Denmark (n=230,452 and n=400,204), between 1991-2012 and 1993-2013, respectively. Model-based cumulative false-positive risks were computed for the entire sample, using two statistical methods (Hubbard Njor) previously used to estimate false-positive risks in the US and Europe.

RESULTS

Empirical cumulative risk of at least one false-positive test after eight (annual or biennial) screens was 41.9% in BCSC, 16.1% in Copenhagen, and 7.4% in Funen. Variation in screening interval and mammogram type did not explain the differences by country. Using the Hubbard method, the model-based cumulative risks after eight screens was 45.1% in BCSC, 9.6% in Copenhagen, and 8.8% in Funen. Using the Njor method, these risks were estimated to be 43.6, 10.9 and 8.0%.

CONCLUSION

Choice of statistical method, screening interval and mammogram type does not explain the substantial differences in cumulative false-positive risk between the US and Europe.

Evolving paradigm for imaging, diagnosis, and management of DCIS

Our understanding of the biology of breast cancer has dramatically expanded over the past decade, revealing that breast cancer is a heterogeneous group of diseases. This new knowledge can generate insights to improve screening performance and the management of ductal carcinoma in situ. In this article, the authors review the current state of the science of breast cancer and tools that can be used to improve screening and risk assessment. They describe several opportunities to improve clinical screening: (1) radiologists interpreting mammograms should aim to differentiate between the risk for invasive cancer and ductal carcinoma in situ to better assess the time frame for disease progression and the need for and optimal timing of biopsy; (2) imaging features associated with low risk, slow-growing cancer versus high risk, fast-growing cancer should be better defined and taught; and (3) as we learn more about assessing an individual's risk for developing breast cancer, we should incorporate these factors into a strategy for personalized screening to maximize benefit and minimize harm.

Educational interventions to improve screening mammography interpretation: a randomized controlled trial

OBJECTIVE

The objective of our study was to conduct a randomized controlled trial of educational interventions that were created to improve performance of screening mammography interpretation.

MATERIALS AND METHODS

We randomly assigned physicians who interpret mammography to one of three groups: self-paced DVD, live expert-led educational seminar, or control. The DVD and seminar interventions used mammography cases of varying difficulty and provided associated teaching points. Interpretive performance was compared using a pretest-posttest design. Sensitivity, specificity, and positive predictive value (PPV) were calculated relative to two outcomes: cancer status and consensus of three experts about recall. The performance measures for each group were compared using logistic regression adjusting for pretest performance.

RESULTS

One hundred two radiologists completed all aspects of the trial. After adjustment for preintervention performance, the odds of improved sensitivity for correctly identifying a lesion relative to expert recall were 1.34 times higher for DVD participants than for control subjects (95% CI, 1.00-1.81; p = 0.050). The odds of an improved PPV for correctly identifying a lesion relative to both expert recall (odds ratio [OR] = 1.94; 95% CI, 1.24-3.05; p = 0.004) and cancer status (OR = 1.81; 95% CI, 1.01-3.23; p = 0.045) were significantly improved for DVD participants compared with control subjects, with no significant change in specificity. For the seminar group, specificity was significantly lower than the control group (OR relative to expert recall = 0.80; 95% CI, 0.64-1.00; p = 0.048; OR relative to cancer status = 0.79; 95% CI, 0.65-0.95; p = 0.015).

CONCLUSION

In this randomized controlled trial, the DVD educational intervention resulted in a significant improvement in screening mammography interpretive performance on a test set, which could translate into improved interpretative performance in clinical practice.

The cumulative risk of false-positive results in the Norwegian Breast Cancer Screening Program: updated results

BACKGROUND

Some false-positive results are inevitable in mammographic screening, but the impact of false-positive findings on the program and the participants is a disadvantage of screening. The objective of the current study was to estimate the cumulative risk of a false-positive result over 10 biennial screening examinations and the cumulative risk of undergoing an invasive procedure with a benign outcome in women screened between the ages of 50 years to 69 years.

METHODS

A retrospective cohort study was performed in 231,310 women aged 50 years to 51 years at the time of first mammography screening who underwent 715,311 screening mammograms in the Norwegian Breast Cancer Screening Program from 1996 through 2010. Generalized linear mixed models were used to estimate the probability of a false-positive screening result and to compute the cumulative false-positive risk for up to 10 biennial screening examinations.

RESULTS

The cumulative false-positive risk after 20 years of biennial screening for women who initiated screening aged 50 years to 51 years was 20.0% (95% confidence interval [95% CI], 19.7%-20.4%). The cumulative risk of undergoing an invasive procedure with a benign outcome for the same group of women was 4.1% (95% CI, 3.9%-4.3%). The cumulative risk of undergoing a fine-needle aspiration cytology, core needle biopsy, or open biopsy with a benign outcome was 1.4% (95% CI, 1.3%-1.5%), 2.0% (95% CI, 1.9%-2.1%), and 0.16% (95% CI, 0.13%-0.19%), respectively.

CONCLUSIONS

One in every 5 women will be recalled for further assessment with a negative outcome if they attend biennial mammographic screening between ages 50 years to 69 years. The risk of an invasive procedure with a benign outcome is approximately 4%. It is important to communicate the existence and extent of this risk to the target group and to reduce to a minimum the waiting times between screening and further assessment.

Association between physician supply, local practice norms, and outpatient visit rates

BACKGROUND

There is considerable regional variation in Medicare outpatient visit rates; such variations may be the consequence of patient health, race/ethnicity differences, patient preferences, or physician supply and beliefs about the efficacy of frequently scheduled visits.

OBJECTIVE

The objective of the study was to test associations between varying regional Medicare outpatient visit rates and beneficiaries' health, race/ethnicity, preferences, and physician practice norms and supply.

METHODS

We used Medicare claims from 2006 and 2007 and data from national surveys of 3 different groups in 2005-Medicare beneficiaries, cardiologists, and primary care physicians. Regression analysis tested explanations for outpatient visit rates: patient health (self-reported and hierarchical condition category score), self-reported race/ethnicity, preferences for care, and local physician practice norms and supply in beneficiaries' Hospital Referral Regions (HRRs) of residence.

RESULTS

Beneficiaries in the highest quintile of the hierarchical condition category scores experienced 4.99 more visits than those in the lowest. Beneficiaries who were black experienced 2.14 fewer visits than others with similar health and preferences. Higher care-seeking preferences were marginally significantly associated with more visits, whereas education and poverty were insignificant. HRRs with high physician supply and high-frequency practice norms were associated with 2.04 additional visits per year, whereas HRRs with high supply but low-frequency norms were associated with 1.45 additional visits. Adjusting for all individual beneficiary covariates explained <20% of the original associations between visit rates and physician supply and practice norms.

CONCLUSIONS

Medicare beneficiaries' health status, race, and preferences help explain individual office visit frequency; in particular, African-American patients appear to experience lower access to care. Yet, these factors explain a small fraction of the observed regional differences associated with physician supply and beliefs about the appropriate frequency of office visits.

Malpractice claims related to musculoskeletal imaging. Incidence and anatomical location of lesions

PURPOSE

Failure to detect lesions of the musculoskeletal system is a frequent cause of malpractice claims against radiologists.

MATERIALS AND METHODS

We examined all the malpractice claims related to alleged errors in musculoskeletal imaging filed against Italian radiologists over a period of 14 years (1993-2006).

RESULTS

During the period considered, a total of 416 claims for alleged diagnostic errors relating to the musculoskeletal system were filed against radiologists; of these, 389 (93.5%) concerned failure to report fractures, and 15 (3.6%) failure to diagnose a tumour.

CONCLUSIONS

Incorrect interpretation of bone pathology is among the most common causes of litigation against radiologists; alone, it accounts for 36.4% of all malpractice claims filed during the observation period. Awareness of this risk should encourage extreme caution and diligence.

Medical malpractice in connecticut: defensive medicine, real problem or a red herring - example of assessment of quality outcomes variables

MATERIAL AND METHOD

Using the survey data obtained from doctors in Connecticut, we estimate the "true" costs of defensive medicine and medical malpractice awards via litigation in the overall aggregate picture of U.S. national annual health expenditures.

RESULTS AND DISCUSION

Progressives claim that these costs amount only to approximately 2% of total annual health expenditures, while conservatives claim that these costs are much higher, in the neighborhood of 10%. Conservatives want to reform the current medical malpractice system because the savings could be significant. Progressives claim that this issue is a "red herring" in the overall picture of health care reform and that other factors such as hospital costs, payments to physicians and pharmaceutical prices are the largest contributors to runaway health care costs, currently amounting to 18% of GDP. The health of the national economy, deficit reduction and future prosperity will depend upon the speed and quality of the cost reducing solutions.

CONCLUSION

An in-depth look into cost and profit structure of each provider's procedure and legislative push for price and quality transparency of the informed and educated constituents are recommended to improve this serious national, socio-economic problem.

Sensitivity and specificity of mammographic screening as practised in Vermont and Norway

OBJECTIVE

The aim of this study was to examine the sensitivity and specificity of screening mammography as performed in Vermont, USA, and Norway.

METHODS

Incident screening data from 1997 to 2003 for female patients aged 50-69 years from the Vermont Breast Cancer Surveillance System (116 996 subsequent screening examinations) and the Norwegian Breast Cancer Screening Program (360 872 subsequent screening examinations) were compared. Sensitivity and specificity estimates for the initial (based on screening mammogram only) and final (screening mammogram plus any further diagnostic imaging) interpretations were directly adjusted for age using 5-year age intervals for the combined Vermont and Norway population, and computed for 1 and 2 years of follow-up, which ended at the time of the next screening mammogram.

RESULTS

For the 1-year follow-up, sensitivities for initial assessments were 82.0%, 88.2% and 92.5% for 1-, 2- and >2-year screening intervals, respectively, in Vermont (p=0.022). For final assessments, the values were 73.6%, 83.3% and 81.2% (p=0.047), respectively. For Norway, sensitivities for initial assessments were 91.0% and 91.3% (p=0.529) for 2- and >2-year intervals, and 90.7% and 91.3%, respectively, for final assessments (p=0.630). Specificity was lower in Vermont than in Norway for each screening interval and for all screening intervals combined, for both initial (90.6% vs 97.8% for all intervals; p<0.001) and final (98.8% vs 99.5% for all intervals; p<0.001) assessments.

CONCLUSION

Our study showed higher sensitivity and specificity in a biennial screening programme with an independent double reading than in a predominantly annual screening program with a single reading.

ADVANCES IN KNOWLEDGE

This study demonstrates that higher recall rates and lower specificity are not always associated with higher sensitivity of screening mammography. Differences in the screening processes in Norway and Vermont suggest potential areas for improvement in the latter.

Impact of an educational intervention designed to reduce unnecessary recall during screening mammography

RATIONALE AND OBJECTIVES

The aim of this study was to describe the impact of a tailored Web-based educational program designed to reduce excessive screening mammography recall.

MATERIALS AND METHODS

Radiologists enrolled in one of four mammography registries in the United States were invited to take part and were randomly assigned to receive the intervention or to serve as controls. The controls were offered the intervention at the end of the study, and data collection included an assessment of their clinical practice as well. The intervention provided each radiologist with individual audit data for his or her sensitivity, specificity, recall rate, positive predictive value, and cancer detection rate compared to national benchmarks and peer comparisons for the same measures; profiled breast cancer risk in each radiologist's respective patient populations to illustrate how low breast cancer risk is in population-based settings; and evaluated the possible impact of medical malpractice concerns on recall rates. Participants' recall rates from actual practice were evaluated for three time periods: the 9 months before the intervention was delivered to the intervention group (baseline period), the 9 months between the intervention and control groups (T1), and the 9 months after completion of the intervention by the controls (T2). Logistic regression models examining the probability that a mammogram was recalled included indication of intervention versus control and time period (baseline, T1, and T2). Interactions between the groups and time period were also included to determine if the association between time period and the probability of a positive result differed across groups.

RESULTS

Thirty-one radiologists who completed the continuing medical education intervention were included in the adjusted model comparing radiologists in the intervention group (n = 22) to radiologists who completed the intervention in the control group (n = 9). At T1, the intervention group had 12% higher odds of positive mammographic results compared to the controls, after controlling for baseline (odds ratio, 1.12; 95% confidence interval, 1.00-1.27; P = .0569). At T2, a similar association was found, but it was not statistically significant (odds ratio, 1.10; 95% confidence interval, 0.96 to 1.25). No associations were found among radiologists in the control group when comparing those who completed the continuing medical education intervention (n = 9) to those who did not (n = 10). In addition, no associations were found between time period and recall rate among radiologists who set realistic goals.

CONCLUSIONS

This study resulted in a null effect, which may indicate that a single 1-hour intervention is not adequate to change excessive recall among radiologists who undertook the intervention being tested.

Utilization of radionuclide myocardial perfusion imaging in two health care systems: assessment with the 2009 ACCF/ASNC/AHA appropriateness use criteria

BACKGROUND

Although differences in the rate of utilization of invasive cardiac procedures between Veterans Affairs (VA) hospitals and other health care systems are present, noninvasive cardiac imaging use pattern has not been well studied. We evaluated the ability of the updated appropriateness use criteria (AUC) to determine utilization patterns of myocardial perfusion imaging (MPI) and compare use between an academic practice and a VA.

METHODS

One-hundred fifty stress/rest MPI studies in an academic practice and 150 at a VA hospital were retrospectively reviewed using the hierarchical approach published in the 2009 AUC.

RESULTS

Less than 1% of studies were unclassified. A higher percentage of MPI were requested for inappropriate reason at the VA, although this difference was not statistically significant (P = .248). In the VA, non-physicians requested significantly more inappropriate studies than physicians (26.8% vs 20.1%; P < .048). Within the academic practice non-cardiologists referred more patients for inappropriate indications than cardiologists (23.9% vs 10.1%; P = .001). Five most common inappropriate indications accounted for the vast majority of inappropriately requested MPI (77%).

CONCLUSIONS

The revised 2009 AUC allow for near complete categorization of appropriateness in testing. Differences between institutions and provider types were noted and areas for improved utilization were identified.

Law and cancer at the end of life: the problem of nomoigenic harms and the five desiderata of death law

Good laws are a necessary, but not a sufficient, condition for the provision of good health care. At the end of life, there is a need for laws that foster and encourage the best possible outcomes for patients, their families and healthcare professionals. This article proposes five desiderata for laws at the end of life. It uses the emerging Australian jurisprudence of end-of-life decision making to test and examine the desiderata. The article also proposes that poorly drafted and confusing laws may have a deleterious effect on patient care. These nomoigenic (law-caused) harms can be avoided by adherence to the five desiderata of death law.

Surgical management of ulcerative colitis: a comparison of Canadian and American colorectal surgeons

BACKGROUND

Ileal pouch anal anastomosis (IPAA) to surgically manage ulcerative colitis may involve multiple separate surgical procedures, impacting treatment costs, length of stay in hospital, complication rates and patient outcomes, and there is currently no accepted standard of care regarding the number of stages that should be performed. The purpose of this study was to compare the practice patterns of Canadian and American colorectal surgeons regarding the surgical management of ulcerative colitis.

METHODS

A questionnaire was mailed to all practisng fellows of the American Society of Colon and Rectal Surgeons (ASCRS) in Canada and the United States. Surgeons were asked to describe their typical practices for 3 clinical scenarios.

RESULTS

Questionnaires were mailed to 40 Canadian and 873 American ASCRS fellows with response rates of 86% and 62%, respectively. In the case of a patient who has had a prior colectomy, who is not taking steroids and in whom a tension-free IPAA is possible, 44% of Canadian surgeons would perform IPAA alone and 56% would perform IPAA with a loop ileostomy. In contrast, only 26% of American surgeons would perform IPAA alone and 74% would perform IPAA with a loop ileostomy (p = 0.002). In the case of a patient who has not had previous surgery, who is taking 10 mg/day of prednisone and in whom a tension-free IPAA is possible, the majority of both Canadian and American surgeons would perform an IPAA with a loop ileostomy (93% and 89%, respectively, p = 0.06). In the case of a patient who has not had previous surgery, who is taking 40 mg/day of prednisone and in whom a tension-free IPAA is possible, 45% of Canadian surgeons would perform a subtotal colectomy with an end ileostomy compared with 14% of American surgeons (p < 0.001).

CONCLUSION

There are significant differences in the surgical management of ulcerative colitis between Canadian and American colorectal surgeons.

Physician liability: the next big thing for personalized medicine?

Liability is likely to be a major driver for the future direction and implementation of personalized medicine, spurring the adoption of genetic tests and other pharmacogenomic technologies, in some cases appropriately, and in other cases prematurely or as inefficient defensive medicine. While all entities in the personalized medicine chain will face liability risks, physicians will be at the greatest risk owing to their lack of defenses, limited experience in dealing with genetics and the growing disparities within the profession in implementing new medical technologies. The history of liability for genetic testing, primarily in the prenatal testing context, suggests that liability will often be both unpredictable and influential in changing medical practice. It is critical to anticipate and attempt to prevent such liability risks in a proactive manner so to minimize the disruptive impact that liability can cause.

Breast cancer screening with mammography

There has been a great deal of controversy regarding the change in breast cancer screening recommendations released by the US Preventive Services Task Force in November 2009. Despite limited new data, the Task Force changed their previous recommendations delaying initial screening of asymptomatic women from age 40 to age 50 and recommending biennial rather than annual breast cancer screening. It is important to fully understand the nuances of the analysis and modeling upon which the revisions were based in order to accurately inform patients of the risks and benefits of breast cancer screening. Several new studies as well as additional guidelines have also been released over the past year which further inform the debate, and a number of commentaries have helped to place the risks and benefit in clinical and societal context.

Using a tailored web-based intervention to set goals to reduce unnecessary recall

RATIONALE AND OBJECTIVES

To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall, can assist radiologists in setting goals for reducing unnecessary recall.

MATERIALS AND METHODS

In a multisite randomized controlled study, we used a tailored web-based intervention to assess radiologists' ability to set goals to improve interpretive performance. The intervention provided peer comparison audit data, profiled breast cancer risk in each radiologist's respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns.

RESULTS

Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1%, respectively). The majority of selected goals involved re-reviewing cases initially interpreted as Breast Imaging Reporting and Data System category 0. More than half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits.

CONCLUSIONS

Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.

Feasibility and satisfaction with a tailored web-based audit intervention for recalibrating radiologists' thresholds for conducting additional work-up

RATIONALE AND OBJECTIVES

To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up after a screening mammogram.

MATERIALS AND METHODS

We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a 9-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium.

RESULTS

Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1-14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% preintervention to 17.8% after intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). More than 75% of radiologists answered the postintervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the United States is 9%. The mean self-reported recall rates were 13.0 for radiologists spending <40% time in breast imaging and 14.9% for those spending >40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; P < .001).

CONCLUSIONS

Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, although only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.

Perceived practice change in Australian doctors as a result of medicolegal concerns

OBJECTIVES

To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not.

DESIGN AND SETTING

Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company.

PARTICIPANTS

2999 respondents of 8360 who were sent the survey.

MAIN OUTCOME MEASURES

Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients.

RESULTS

Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not.

CONCLUSIONS

This Australian study, like international studies, confirms that doctors' concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Health and life insurance as an alternative to malpractice tort law

Background

Tort law has legitimate social purposes of deterrence, punishment and compensation, but medical tort law does none of these well. Tort law could be counterproductive in medicine, encouraging costly defensive practices that harm some patients, restricting access to care in some settings and discouraging innovation.

Discussion

Patients might be better served by purchasing combined health and life insurance policies and waiving their right to pursue malpractice claims. The combined policy should encourage the insurer to profit by inexpensively delaying policyholders' deaths. A health and life insurer would attempt to minimize mortal risks to policyholders from any cause, including medical mistakes and could therefore pursue systematic quality improvement efforts. If policyholders trust the insurer to seek, develop and reward genuinely effective care; identify, deter and remediate poor care; and compensate survivors through the no-fault process of paying life insurance benefits, then tort law is largely redundant and the right to sue may be waived. If expensive defensive medicine can be avoided, that savings alone could pay for fairly large life insurance policies.

Summary

Insurers are maligned largely because of their logical response to incentives that are misaligned with the interests of patients and physicians in the United States. Patient, provider and insurer incentives could be realigned by combining health and life insurance, allowing the insurer to use its considerable information access and analytic power to improve patient care. This arrangement would address the social goals of malpractice torts, so that policyholders could rationally waive their right to sue.

The future of mammography: radiology residents' experiences, attitudes, and opinions

OBJECTIVE

The objective of our study was to assess the experiences and preferences of radiology residents with respect to breast imaging.

MATERIALS AND METHODS

We surveyed radiology residents at 26 programs in New York and New Jersey. Survey topics included plans for subspecialty training, beliefs, and attitudes toward breast imaging and breast cancer screening and the likelihood of interpreting mammography in the future.

RESULTS

Three hundred forty-four residents completed the survey (response rate, 62%). The length of time spent training in breast imaging varied from no dedicated time (37%) to 1-8 weeks (40%) to more than 9 weeks (23%). Most respondents (97%) agreed that mammography is important to women's health. More than 85% of residents believed that mammography should be interpreted by breast imaging specialists. Respondents shared negative views about mammography, agreeing with statements that the field was associated with a high risk of malpractice (99%), stress (94%), and low reimbursement (68%). Respondents endorsed several positive attributes of mammography, including job availability (97%), flexible work schedules (94%), and few calls or emergencies (93%). Most radiology residents (93%) said that they were likely to pursue subspecialty training, and 7% expressed interest in breast imaging fellowships.

CONCLUSION

Radiology residents' negative and positive views about mammography seem to be independent of time spent training in mammography and of future plans to pursue fellowship training in breast imaging. Systematic assessment of the plans and preferences of radiology residents can facilitate the development of strategies to attract trainees to careers in breast imaging.

Time trends in radiologists' interpretive performance at screening mammography from the community-based Breast Cancer Surveillance Consortium, 1996-2004

PURPOSE

To examine time trends in radiologists' interpretive performance at screening mammography between 1996 and 2004.

MATERIALS AND METHODS

All study procedures were institutional review board approved and HIPAA compliant. Data were collected on subsequent screening mammograms obtained from 1996 to 2004 in women aged 40-79 years who were followed up for 1 year for breast cancer. Recall rate, sensitivity, and specificity were examined annually. Generalized estimating equation (GEE) and random-effects models were used to test for linear trend. The area under the receiver operating characteristic curve (AUC), tumor histologic findings, and size of the largest dimension or diameter of the tumor were also examined.

RESULTS

Data on 2,542,049 subsequent screening mammograms and 12,498 cancers diagnosed in the follow-up period were included in this study. Recall rate increased from 6.7% to 8.6%, sensitivity increased from 71.4% to 83.8%, and specificity decreased from 93.6% to 91.7%. In GEE models, adjusted odds ratios per calendar year were 1.04 (95% confidence interval [CI]: 1.02, 1.05) for recall rate, 1.09 (95% CI: 1.07. 1.12) for sensitivity, and 0.96 (95% CI: 0.95, 0.98) for specificity (P < .001 for all). Random-effects model results were similar. The AUC increased over time: 0.869 (95% CI: 0.861, 0.877) for 1996-1998, 0.884 (95% CI: 0.879, 0.890) for 1999-2001, and 0.891 (95% CI: 0.885, 0.896) for 2002-2004 (P < .001). Tumor histologic findings and size remained constant.

CONCLUSION

Recall rate and sensitivity for screening mammograms increased, whereas specificity decreased from 1996 to 2004 among women with a prior mammogram. This trend remained after accounting for risk factors. The net effect was an improvement in overall discrimination, a measure of the probability that a mammogram with cancer in the follow-up period has a higher Breast Imaging Reporting and Data System assessment category than does a mammogram without cancer in the follow-up period.

Radiologic malpractice litigation risk in Italy: an observational study over a 14-year period

OBJECTIVE

The purpose of this study is to assess the risk of medical malpractice litigation for Italian radiologists, compared with the corresponding data in the literature.

MATERIALS AND METHODS

The insurance claims of Italian radiologists over the 1993-2006 period were anonymously assessed and classified according to the cause of the claim.

RESULTS

A total of 1,424 claims were filed during the examined period, with most claims being filed at a considerable time interval after the event (up to 10 years). The resulting incidence may be estimated as 44.2 cases per 1,000, meaning that 44% of Italian radiologists have received, or will receive, summons regarding their professional activity during the past 10 years.

CONCLUSION

The risk of medical malpractice litigation for Italian radiologists is by now comparable to that for American radiologists. Comparison with previous data concerning the same study population shows that the diagnostic errors category has surpassed all other error categories (nondiagnostic errors) and that, within the diagnostic errors category, claims for allegedly missed cancer have surpassed claims for allegedly missed bone abnormalities. Among missed diagnosis claims, the maximum increase concerned mammograms. Strict adherence to radiologic standards and radiotherapy protocols may be a means of reducing the risk of legal action and obviating litigation.

Geographic access and the use of screening mammography

BACKGROUND

Screening mammography rates vary geographically and have recently declined. Inadequate mammography resources in some areas may impair access to this technology. We assessed the relationship between availability of mammography machines and the use of screening.

METHODS

The location and number of all mammography machines in the United States were identified from US Food and Drug Administration records of certified facilities. Inadequate capacity was defined as <1.2 mammography machines per 10,000 women age 40 or older, the threshold required to meet the Healthy People 2010 target screening rate. The impact of capacity on utilization was evaluated in 2 cohorts: female respondents age 40 or older to the 2006 Behavioral Risk Factor Surveillance System survey (BRFSS) and a 5% nationwide sample of female Medicare beneficiaries age 65 or older in 2004-2005.

RESULTS

About 9% of women in the BRFSS cohort and 13% of women in the Medicare cohort lived in counties with <1.2 mammography machines per 10,000 women age 40 or older. In both cohorts, residence in a county with inadequate mammography capacity was associated with lower odds of a recent mammogram (adjusted odds ratio in BRFSS: 0.89, 95% CI: 0.80-0.98, P < 0.05; adjusted odds ratio in Medicare: 0.86, 95% CI: 0.85-0.87, P < 0.05), controlling for demographic and health care characteristics.

CONCLUSION

In counties with few or no mammography machines, limited availability of imaging resources may be a barrier to screening. Efforts to increase the number of machines in low-capacity areas may improve mammography rates and reduce geographic disparities in breast cancer screening.

Variability in interpretive performance at screening mammography and radiologists' characteristics associated with accuracy

PURPOSE

To identify radiologists' characteristics associated with interpretive performance in screening mammography.

MATERIALS AND METHODS

The study was approved by institutional review boards of University of Washington (Seattle, Wash) and institutions at seven Breast Cancer Surveillance Consortium sites, informed consent was obtained, and procedures were HIPAA compliant. Radiologists who interpreted mammograms in seven U.S. regions completed a self-administered mailed survey; information on demographics, practice type, and experience in and perceptions of general radiology and breast imaging was collected. Survey data were linked to data on screening mammograms the radiologists interpreted between January 1, 1998, and December 31, 2005, and included patient risk factors, Breast Imaging Reporting and Data System assessment, and follow-up breast cancer data. The survey was returned by 71% (257 of 364) of radiologists; in 56% (205 of 364) of the eligible radiologists, complete data on screening mammograms during the study period were provided; these data were used in the final analysis. An evaluation of whether the radiologists' characteristics were associated with recall rate, false-positive rate, sensitivity, or positive predictive value of recall (PPV(1)) of the screening examinations was performed with logistic regression models that were adjusted for patients' characteristics and radiologist-specific random effects.

RESULTS

Study radiologists interpreted 1 036 155 screening mammograms; 4961 breast cancers were detected. Median percentages and interquartile ranges, respectively, were as follows: recall rate, 9.3% and 6.3%-13.2%; false-positive rate, 8.9% and 5.9%-12.8%; sensitivity, 83.8% and 74.5%-92.3%; and PPV(1), 4.0% and 2.6%-5.9%. Wide variability in sensitivity was noted, even among radiologists with similar false-positive rates. In adjusted regression models, female radiologists or fellowship-trained radiologists had significantly higher recall and false-positive rates (P < .05, all). Fellowship training in breast imaging was the only characteristic significantly associated with improved sensitivity (odds ratio, 2.32; 95% confidence interval: 1.42, 3.80; P < .001) and the overall accuracy parameter (odds ratio, 1.61; 95% confidence interval: 1.05, 2.45; P = .028).

CONCLUSION

Fellowship training in breast imaging may lead to improved cancer detection, but it is associated with higher false-positive rates.

Variability of interpretive accuracy among diagnostic mammography facilities

BACKGROUND

Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied.

METHODS

Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided.

RESULTS

Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P < .001; and PPV2, P < .001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses.

CONCLUSIONS

Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.

Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007

OBJECTIVES

The objectives were to determine current practice among emergency physicians (EPs) regarding the initiation and termination of cardiopulmonary resuscitative (CPR) efforts and to compare responses to those from a similar study performed in 1996.

METHODS

This anonymous self-administered survey was mailed to 4,991 randomly selected EPs. Main outcome measures included responses regarding current practices related to advance directives and initiation and termination of resuscitative attempts. Results from 1995 and 2007 surveys were compared, using 95% confidence intervals (CIs) of the difference between groups.

RESULTS

Among 928 respondents (18% response rate), most (86%) honor legal advance directives, an increase over 78% reported in 1996 (8% increase, 95% CI = 5% to 11%). Few honor unofficial documents (7%) or verbal reports (12%) of advance directives. Many (58%) make decisions regarding resuscitation because of fear of litigation or criticism. Most respondents (62%) attempt resuscitation in 10% or more of cases of cardiac arrest. A majority (56%) have attempted more than 10 resuscitations in the past 3 years, despite expectations that such efforts would be futile. Factors reported to be "very important" in making resuscitation decisions were advance directives (78%), witnessed arrest (77%), downtime (73%), family wishes (40%), presenting rhythm (38%), age (28%), and prearrest state of health (25%). A significant majority of respondents (80%) indicated that ideally, legal concerns should not influence physician practices regarding resuscitation, but that in the current environment, legal concerns do influence practice (92%). Other than the increase in respondents who honor legal advance directives, these results do not differ substantially from responses in 1996.

CONCLUSIONS

Most EPs attempt to resuscitate patients in cardiopulmonary arrest regardless of poor outcomes, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than professional judgment of medical benefit. Most results did not differ significantly from the previous study of 1995, although more physicians honor legal advance directives than previously noted.

Radiologists' performance and their enjoyment of interpreting screening mammograms

OBJECTIVE

One might speculate that radiologists who enjoy mammography may exhibit better performance than radiologists who do not.

MATERIALS AND METHODS

One hundred thirty-one radiologists at three Breast Cancer Surveillance Consortium (BCSC) registries completed a survey about their characteristics, clinical practices, and attitudes related to screening mammography. Survey results were linked with BCSC performance data for 662,084 screening and 33,977 diagnostic mammograms. Using logistic regression, we modeled the odds of an abnormal interpretation, cancer detection, sensitivity, and specificity among radiologists who reported they enjoy interpreting screening mammograms compared with those who do not.

RESULTS

Overall, 44.3% of radiologists reported not enjoying interpreting screening mammograms. Radiologists who reported enjoying interpreting screening mammograms were more likely to be women, spend at least 20% of their time in breast imaging, have a primary academic affiliation, read more than 2,000 mammograms per year, and be salaried. Enjoyment was not associated with screening mammography performance. Among diagnostic mammograms, there was a significant increase in sensitivity among radiologists who reported enjoyment (85.2%) compared with those who did not (78.2%). In models adjusting for radiologist characteristics, similar trends were found; however, no statistically significant associations remained.

CONCLUSION

Almost one half of radiologists actively interpreting mammograms do not enjoy that part of their job. Once we adjusted for radiologist and patient characteristics, we found that reported enjoyment was not related to performance in our study, although suggestive trends were noted.

Predictors of radiologists' perceived risk of malpractice lawsuits in breast imaging

OBJECTIVE

The shortage of radiologists in breast imaging may be related to heightened malpractice lawsuit concerns. Our objective was to examine radiologists' reported experiences and perceptions of future lawsuit risk and explore personal and professional factors that may be associated with elevated perceptions of risk.

MATERIALS AND METHODS

Radiologists who routinely interpret mammography examinations in diverse regions of the United States (Washington, Colorado, and New Hampshire) completed a mailed survey in 2002 and 2006, including questions on demographics, practice characteristics, and medicolegal experience and perceptions as well as a validated scale measuring reactions to uncertainty in clinical situations. A survey assessing the radiologists' work facilities was also completed in 2002.

RESULTS

Participation by eligible radiologists was 77% (139 of 181) in 2002 and 71% (84 of 118) in 2006. The percentage of radiologists reporting malpractice claims related to mammography in the previous 5 years was 8% on the 2002 survey and 10% on the 2006 survey. Radiologists' mean estimate of the probability of being sued for malpractice in the next 5 years (41% in 2002 and 35% in 2006) was markedly higher than the actual reported risk. Radiologists' age, sex, clinical experience, and workload were not associated with a higher perceived risk of being sued. Radiologists who reported higher perceived risk of lawsuits were more likely to have experienced a prior malpractice claim, to report knowing colleagues with prior lawsuits, and to score higher on a scale measuring anxiety caused by uncertainty in clinical situations. Radiologists working at facilities that did not use double reading reported higher perceived risk, but the difference was not statistically significant.

CONCLUSION

Radiologists working in breast imaging substantially overestimate their risk of a future malpractice lawsuit. Radiologists with higher risk perceptions show more negative reactions to uncertainty in a clinical setting. Understanding that their actual risk of malpractice lawsuits may be substantially lower than anticipated may help reduce radiologists' fears and alleviate the manpower shortage in mammography. Programs to address the shortage of breast imagers could be targeted toward radiologists with heightened malpractice lawsuit concerns.

Comparing screening mammography for early breast cancer detection in Vermont and Norway

BACKGROUND

Most screening mammography in the United States differs from that in countries with formal screening programs by having a shorter screening interval and interpretation by a single reader vs independent double reading. We examined how these differences affect early detection of breast cancer by comparing performance measures and histopathologic outcomes in women undergoing opportunistic screening in Vermont and organized screening in Norway.

METHODS

We evaluated recall, screen detection, and interval cancer rates and prognostic tumor characteristics for women aged 50-69 years who underwent screening mammography in Vermont (n = 45 050) and in Norway (n = 194 430) from 1997 through 2003. Rates were directly adjusted for age by weighting the rates within 5-year age intervals to reflect the age distribution in the combined data and were compared using two-sided Z tests.

RESULTS

The age-adjusted recall rate was 9.8% in Vermont and 2.7% in Norway (P < .001). The age-adjusted screen detection rate per 1000 woman-years after 2 years of follow-up was 2.77 in Vermont and 2.57 in Norway (P = .12), whereas the interval cancer rate per 1000 woman-years was 1.24 and 0.86, respectively (P < .001). Larger proportions of invasive interval cancers in Vermont than in Norway were 15 mm or smaller (55.9% vs 38.2%, P < .001) and had no lymph node involvement (67.5% vs 57%, P = .01). The prognostic characteristics of all invasive cancers (screen-detected and interval cancer) were similar in Vermont and Norway.

CONCLUSION

Screening mammography detected cancer at about the same rate and at the same prognostic stage in Norway and Vermont, with a statistically significantly lower recall rate in Norway. The interval cancer rate was higher in Vermont than in Norway, but tumors that were diagnosed in the Vermont women tended to be at an earlier stage than those diagnosed in the Norwegian women.

Mammography facility characteristics associated with interpretive accuracy of screening mammography

Background

Although interpretive performance varies substantially among radiologists, such variation has not been examined among mammography facilities. Understanding sources of facility variation could become a foundation for improving interpretive performance.

Methods

In this cross-sectional study conducted between 1996 and 2002, we surveyed 53 facilities to evaluate associations between facility structure, interpretive process characteristics, and interpretive performance of screening mammography (ie, sensitivity, specificity, positive predictive value [PPV1], and the likelihood of cancer among women who were referred for biopsy [PPV2]). Measures of interpretive performance were ascertained prospectively from mammography interpretations and cancer data collected by the Breast Cancer Surveillance Consortium. Logistic regression and receiver operating characteristic (ROC) curve analyses estimated the association between facility characteristics and mammography interpretive performance or accuracy (area under the ROC curve [AUC]). All P values were two-sided.

Results

Of the 53 eligible facilities, data on 44 could be analyzed. These 44 facilities accounted for 484 463 screening mammograms performed on 237 669 women, of whom 2686 were diagnosed with breast cancer during follow-up. Among the 44 facilities, mean sensitivity was 79.6% (95% confidence interval [CI] = 74.3% to 84.9%), mean specificity was 90.2% (95% CI = 88.3% to 92.0%), mean PPV1 was 4.1% (95% CI = 3.5% to 4.7%), and mean PPV2 was 38.8% (95% CI = 32.6% to 45.0%). The facilities varied statistically significantly in specificity (P < .001), PPV1 (P < .001), and PPV2 (P = .002) but not in sensitivity (P = .99). AUC was higher among facilities that offered screening mammograms alone vs those that offered screening and diagnostic mammograms (0.943 vs 0.911, P = .006), had a breast imaging specialist interpreting mammograms vs not (0.932 vs 0.905, P = .004), did not perform double reading vs independent double reading vs consensus double reading (0.925 vs 0.915 vs 0.887, P = .034), or conducted audit reviews two or more times per year vs annually vs at an unknown frequency (0.929 vs 0.904 vs 0.900, P = .018).

Conclusion

Mammography interpretive performance varies statistically significantly by facility.

The legal implications of error in radiology

Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.

Discretionary decision making by primary care physicians and the cost of U.S. Health care

Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.