Discrepancy rate between preliminary and official reports

of emergency radiology studies:

A performance indicator and quality improvement method

M Itania, B Taslakiana, N. Batleyb, M. Salibab, E. Hittib, F El-Merhia

Departments of Radiologya and Emergency Medicineb American University of Beirut Medical Center. Beirut, Lebanon

VR1

Imaging studies are an essential tool in emergency department (ED).

In many academic institutions, the radiology resident provides preliminary reading for emergency department.

The attending radiologist issues final reports for these studies, and it might be concordant or discordant.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April 2012 2

Introduction

The discrepancy between the preliminary reading by radiology resident and the final reading by the attending radiologist, concerning studies requested by the emergency department, vary in frequency and severity. They may also vary between imaging modalities, body parts, or resident level.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Introduction (continued)

The aim of this paper is to estimate the rate of discrepancy, study variable factors associated with these discrepancies, and benchmark it to other teaching institutions.

This has an implication on patient management, performance of the hospital according to international standards, and the radiology residency training program.

This might also point out deficiencies and thus allow for improvement.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Introduction (continued)

All imaging studies from emergency department are requested electronically, and all images are sent to the picture archiving and communication system (PACS) after acquisition.

The medical staff in the emergency department will be notified when a preliminary or final report of the study has been entered to the system.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods

The radiology resident sends a preliminary reading to emergency department, then attending radiologist checks the imaging studies. If there is a discrepancy in the interpretation of the images, then two actions will be taken:

1- The radiology resident will contact the emergency department staff and notify them of the discrepant finding. This will be entered into a log book in the emergency department.2- The study will be labeled by a keyword “A”.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods (continued)

We reviewed the imaging studies performed during a specific time period of 6 months (June 1, 2011 to November 30, 2011).

We collected the total number of studies performed on patients referred from the emergency department. This was categorized into plain radiography, ultrasound, and CT.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods (continued)

We then analyzed the discrepant studies, collected from the emergency department log book and the PACS system.

Each month, the discrepancy cases were studied in a conjoint conference between radiology and emergency departments staff, and severity scale was assigned to each case.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods (continued)

The severity score was assigned values of 1, 2 or 3 depending on how the discrepancy affected the patient management, as follows:

1- major discrepancies that necessitated an acute change in management and immediate callback for the patient2- significant findings that do not need urgent intervention (can wait up to one day)3- minor discrepancies that do not affect management or outcome related to the emergency presentation

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods (continued)

The cases were analyzed based on the severity scores, the type of the exam (musckuloskeletal x-rays, other plain radiographs, ultrasound, CT), and according to the level of the radiology resident in- training.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Methods (continued)

Graph 1: Total number of studies requested from emergency department per month

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results

June July August September October November0

200

400

600

800

1000

1200

1400

1600

1800

XRAY CT

US

Graph 2: Number of discrepancies as percentage of total studies requested from emergency department

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

171 exam-inations 1.38%

1226398.62%

Number of discrepancies

Total Number of ED radiology reports

Graph 3: Number of studies requested through emergency department 12263 divided as follows

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

8561 69.96%

3242 26.49%

343.55%

XRAYCTUS

Graph 4: Percentages of discrepancies according to imaging modality

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

47.95%

17.54%

33.92%

0.58%

X-ray MSKX-ray Non-MSKCTUS

Graph 5: Discrepancy rate per resident level

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

R1 R2 R3 R40.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1.80%

2.00%

Graph 6: Discrepancy rate per modality of imaging

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

X-ray CT US0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1.80%

Graph 7: Number of discrepancies for each severity score

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Results (continued)

1 2 30

10

20

30

40

50

60

70

Severity Score

Num

ber

of

dis

cre

pancie

s

Studies comparing resident-to-attending discrepancy had values of 4.3% from Northwestern University Feinberg School of Medicine, 2.6 % from Monmouth Medical Center, and 3.8% from Robert Wood Johnson University Hospital.

The total discrepancy rate was1.38% , which is below the international standards.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Discussion

According to RADPEER data published in 2009 by the American College of Radiology for attending-to-attending variability in interpretations, the total disagreement rate was 2.91%

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Discussion (continued)

It is expected to have higher discrepancy rate in CT and X-ray than ultrasound since ultrasound is operator dependent.

Having lower discrepancy rate for lower level residents may be related to the fact that more difficult or controversial studies are being interpreted by more senior residents.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Discussion (continued)

The discrepancy rate of radiology reports for emergency department should be monitored for performance evaluation and improvement of systems for clinical and academic accreditation purposes.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Conclusion

We give an example of a discrepancy monitoring system and display the results in a leading academic medical institution in the Middle East. We hope that this “Performance Indicator (PI)” becomes more systematically integrated in other Arab Academic Institutions.

Discrepancy rate between preliminary and official reports of emergency radiology studies. Itani et al. ARC5 - April

2012

Conclusion (continued)