Recommendations for Additional Imaging on Head and Neck Imaging Examinations: Interradiologist Variation and Associated Factors.

BACKGROUND. A paucity of relevant guidelines may lead to pronounced variation among radiologists in issuing recommendations for additional imaging (RAI) for head and neck imaging. OBJECTIVE. The purpose of this article was to explore associations of RAI for head and neck imaging examinations with examination, patient, and radiologist factors and to assess the role of individual radiologist-specific behavior in issuing such RAI. METHODS. This retrospective study included 39,200 patients (median age, 58 years; 21,855 women, 17,315 men, 30 with missing sex information) who underwent 39,200 head and neck CT or MRI examinations, interpreted by 61 radiologists, from June 1, 2021, through May 31, 2022. A natural language processing (NLP) tool with manual review of NLP results was used to identify RAI in report impressions. Interradiologist variation in RAI rates was assessed. A generalized mixed-effects model was used to assess associations between RAI and examination, patient, and radiologist factors. RESULTS. A total of 2943 (7.5%) reports contained RAI. Individual radiologist RAI rates ranged from 0.8% to 22.0% (median, 7.1%; IQR, 5.2-10.2%), representing a 27.5-fold difference between minimum and a maximum values and 1.8-fold difference between 25th and 75th percentiles. In multivariable analysis, RAI likelihood was higher for CTA than for CT examinations (OR, 1.32), for examinations that included a trainee in report generation (OR, 1.23), and for patients with self-identified race of Black or African American versus White (OR, 1.25); was lower for male than female patients (OR, 0.90); and was associated with increasing patient age (OR, 1.09 per decade) and inversely associated with radiologist years since training (OR, 0.90 per 5 years). The model accounted for 10.9% of the likelihood of RAI. Of explainable likelihood of RAI, 25.7% was attributable to examination, patient, and radiologist factors; 74.3% was attributable to radiologist-specific behavior. CONCLUSION. Interradiologist variation in RAI rates for head and neck imaging was substantial. RAI appear to be more substantially associated with individual radiologist-specific behavior than with measurable systemic factors. CLINICAL IMPACT. Quality improvement initiatives, incorporating best practices for incidental findings management, may help reduce radiologist preference-sensitive decision-making in issuing RAI for head and neck imaging and associated care variation.

Risk of Malignancy in Incidentally Detected Lung Nodules in Patients Aged Younger Than 35 Years.

BACKGROUND: The risk of malignancy in pulmonary nodules incidentally detected on computed tomography (CT) in patients who are aged younger than 35 years is unclear. OBJECTIVE: The aim of this study was to evaluate the incidence of lung cancer in incidental pulmonary nodules in patients who are 15-34 years old. METHODS: This retrospective study included patients aged 15-34 years who had an incidental pulmonary nodule on chest CT from 2010 to 2018 at our hospital. Patients with prior, current, or suspected malignancy were excluded. A chart review identified patients with diagnosis of malignancy. Incidental pulmonary nodule was deemed benign if stable or resolved on a follow-up CT at least 2 years after initial or if there was a medical visit in our health care network at least 2 years after initial CT without diagnosis of malignancy.Receiver operating characteristic curve analysis was performed with nodule size. Association of categorical variables with lung cancer diagnosis was performed with Fisher exact test, and association of continuous variables was performed with logistic regression. RESULTS: Five thousand three hundred fifty-five chest CTs performed on patients aged 15-34 years between January 2010 and December 2018. After excluding patients without a reported pulmonary nodule and prior or current malignancy, there were a total of 779 patients. Of these, 690 (89%) had clinical or imaging follow-up after initial imaging. Of these, 545 (70% of total patients) patients had imaging or clinical follow-up greater than 2 years after their initial imaging.A malignant diagnosis was established in 2/779 patients (0.3%; 95% confidence interval, 0.1%-0.9%). Nodule size was strongly associated with malignancy (P = 0.007), with area under the receiver operating characteristic curve of 0.97. There were no malignant nodules that were less than 10 mm in size. Smoking history, number of nodules, and nodule density were not associated with malignancy. CONCLUSIONS: Risk of malignancy for incidentally detected pulmonary nodules in patients aged 15-34 years is extremely small (0.3%). There were no malignant nodules that were less than 10 mm in size. Routine follow-up of subcentimeter pulmonary nodules should be carefully weighed against the risks.

Predictors of Completion of Clinically Necessary Radiologist-Recommended Follow-Up Imaging: Assessment Using an Automated Closed-Loop Communication and Tracking Tool.

BACKGROUND. Patients with adverse social determinants of health may be at increased risk of not completing clinically necessary follow-up imaging. OBJECTIVE. The purpose of this study was to use an automated closed-loop communication and tracking tool to identify patient-, referrer-, and imaging-related factors associated with lack of completion of radiologist-recommended follow-up imaging. METHODS. This retrospective study was performed at a single academic health system. A tool for automated communication and tracking of radiologist-recommended follow-up imaging was embedded in the PACS and electronic health record. The tool prompted referrers to record whether they deemed recommendations to be clinically necessary and assessed whether clinically necessary follow-up imaging was pursued. If imaging was not performed within 1 month after the intended completion date, the tool prompted a safety net team to conduct further patient and referrer follow-up. The study included patients for whom a follow-up imaging recommendation deemed clinically necessary by the referrer was entered with the tool from October 21, 2019, through June 30, 2021. The electronic health record was reviewed for documentation of eventual completion of the recommended imaging at the study institution or an outside institution. Multivariable logistic regression analysis was performed to identify factors associated with completion of follow-up imaging. RESULTS. Of 5856 recommendations entered during the study period, the referrer agreed with 4881 recommendations in 4599 patients (2929 women, 1670 men; mean age, 61.3 ± 15.6 years), who formed the study sample. Follow-up was completed for 74.8% (3651/4881) of recommendations. Independent predictors of lower likelihood of completing follow-up imaging included living in a socioeconomically disadvantaged neighborhood according to the area deprivation index (odds ratio [OR], 0.67 [95% CI, 0.54-0.84]), inpatient (OR, 0.25 [95% CI, 0.20-0.32]) or emergency department (OR, 0.09 [95% CI, 0.05-0.15]) care setting, and referrer surgical specialty (OR, 0.70 [95% CI, 0.58-0.84]). Patient age, race and ethnicity, primary language, and insurance status were not independent predictors of completing follow-up (p > .05). CONCLUSION. Socioeconomically disadvantaged patients are at increased risk of not completing recommended follow-up imaging that referrers deem clinically necessary. CLINICAL IMPACT. Initiatives for ensuring completion of follow-up imaging should be aimed at the identified patient groups to reduce disparities in missed and delayed diagnoses.

Development and External Validation of an Artificial Intelligence Model for Identifying Radiology Reports Containing Recommendations for Additional Imaging.

BACKGROUND. Reported rates of recommendations for additional imaging (RAIs) in radiology reports are low. Bidirectional encoder representations from transformers (BERT), a deep learning model pretrained to understand language context and ambiguity, has potential for identifying RAIs and thereby assisting large-scale quality improvement efforts. OBJECTIVE. The purpose of this study was to develop and externally validate an artificial intelligence (AI)-based model for identifying radiology reports containing RAIs. METHODS. This retrospective study was performed at a multisite health center. A total of 6300 radiology reports generated at one site from January 1, 2015, to June 30, 2021, were randomly selected and split by 4:1 ratio to create training (n = 5040) and test (n = 1260) sets. A total of 1260 reports generated at the center's other sites (including academic and community hospitals) from April 1 to April 30, 2022, were randomly selected as an external validation group. Referring practitioners and radiologists of varying sub-specialties manually reviewed report impressions for presence of RAIs. A BERT-based technique for identifying RAIs was developed by use of the training set. Performance of the BERT-based model and a previously developed traditional machine learning (TML) model was assessed in the test set. Finally, performance was assessed in the external validation set. The code for the BERT-based RAI model is publicly available. RESULTS. Among a total of 7419 unique patients (4133 women, 3286 men; mean age, 58.8 years), 10.0% of 7560 reports contained RAI. In the test set, the BERT-based model had 94.4% precision, 98.5% recall, and an F1 score of 96.4%. In the test set, the TML model had 69.0% precision, 65.4% recall, and an F1 score of 67.2%. In the test set, accuracy was greater for the BERT-based than for the TML model (99.2% vs 93.1%, p < .001). In the external validation set, the BERT-based model had 99.2% precision, 91.6% recall, an F1 score of 95.2%, and 99.0% accuracy. CONCLUSION. The BERT-based AI model accurately identified reports with RAIs, outperforming the TML model. High performance in the external validation set suggests the potential for other health systems to adapt the model without requiring institution-specific training. CLINICAL IMPACT. The model could potentially be used for real-time EHR monitoring for RAIs and other improvement initiatives to help ensure timely performance of clinically necessary recommended follow-up.

Electronic Health Record Order Entry-Based Interventions in Response to a Global Iodinated Contrast Media Shortage: Impact on Contrast-Enhanced CT Utilization.

BACKGROUND. Radiology informatics systems and clinical decision support tools in the electronic health record (EHR) can be leveraged to help impact ordering patterns in response to the ongoing global iodinated contrast media shortage. OBJECTIVE. The purpose of our study was to assess the impact of EHR order entry-based interventions, implemented as part of a health system's response to the global contrast media shortage, on contrast-enhanced CT utilization. METHODS. This retrospective study included 79,259 patients who underwent CT at a large multisite health system between April 1, 2022, and July 3, 2022. Two EHR-based interventions were implemented as part of the health system's response to the global contrast media shortage. A first EHR-based intervention on May 10, 2022, entailed creating an alert that appeared in a sidebar after any contrast-enhanced body CT orders, indicating the present shortage and recommending alternate imaging modalities. A second EHR-based intervention on May 16, 2022, required referrers to enter detailed clinical information for all contrast-enhanced body CT orders, which radiologists used when protocoling examinations. Data regarding CT orders and examinations performed were extracted from the electronic data warehouse. RESULTS. During the preintervention, first postintervention, and second postintervention periods, the mean number of patients who underwent contrast-enhanced CT per weekday was 726, 689, and 639, respectively (p for preintervention vs second postintervention periods, < .001). During the three periods, the mean number of patients who underwent CT per weekday was 1350, 1323, and 1314 (p < .001). During the three periods, the mean number of patients who underwent contrast-enhanced body CT per weekday was 561, 532, and 492 (p < .001). During the three periods, the mean number of orders for CT with IV contrast media per weekday was 154, 143, and 131 (p < .001). During the three periods, the mean number of orders for CT without IV contrast media per weekday was 196, 202, and 221 (p < .001). CONCLUSION. EHR order entry-based interventions implemented in response to the global contrast media shortage significantly reduced contrast-enhanced CT utilization in a large health system. CLINICAL IMPACT. The findings indicate the ability to rapidly achieve changes in ordering clinician behavior and subsequent clinical practice using systemwide EHR changes.

Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study.

OBJECTIVES: We explored the variations in use of imaging modalities for confirming pulmonary embolism (PE) according to the trimester of pregnancy. METHODS: We included all pregnant patients with confirmed acute PE from RIETE, a prospective registry of patients with PE (03/2001-02/2020). Imaging modalities included computed tomography pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scan, or presence of signs of acute PE along with imaging-confirmed proximal deep vein thrombosis (pDVT) without pulmonary vascular imaging. We compared the imaging modalities to postpartum patients with PE, and other non-pregnant women with PE. RESULTS: There were 157 pregnant patients (age: 32.7 ± 0.5), 228 postpartum patients (age: 33.9 ± 0.5), and 23,937 non-pregnant non-postpartum women (age: 69.5 ± 0.1). CTPA was the most common modality for confirming PE, from 55.7% in first trimester to 58.3% in second trimester, and 70.0% in third trimester. From first trimester to third trimester, V/Q scanning was used in 21.3%, 16.7%, and 18.3% of cases, respectively. Confirmed pDVT along with the presence of signs/symptoms of PE was the confirmatory modality for PE in 21.3% of patients in first trimester, 19.4% in second trimester, and 6.7% in third trimester. The proportion of postpartum patients confirmed with CTPA (85.5%) was comparable to that of non-pregnant non-postpartum women (83.2%). From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with PE diagnosed with CTPA (p = 0.039). CONCLUSION: CTPA was the primary modality for confirming PE in all trimesters of pregnancy, although its proportional use was higher in later stages of pregnancy. KEY POINTS: • Computed tomography pulmonary angiography (CTPA) was the primary modality of diagnosis in all trimesters of pregnancy among patients with confirmed pulmonary embolism, even in the first trimester. • From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with pulmonary embolism who were diagnosed based on CTPA. • In the postpartum period, use of CTPA as the modality to confirm pulmonary embolism was comparable to non-pregnant patients.

Utility of Patient-Reported Risk Factors for Identifying Advanced Chronic Kidney Disease Before Outpatient CT: Comparison With Recent ACR/NKF Consensus Criteria.

BACKGROUND. Practices vary for screening patients for risk of renal dysfunction before administration of iodinated contrast medium. A 2020 American College of Radiology/National Kidney Foundation (ACR/NKF) consensus statement provided streamlined screening criteria. OBJECTIVE. The purpose of this study was to assess the yield of patient-reported risk factors for identifying estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 before outpatient CT. METHODS. This retrospective study was performed at a health system that implemented an electronic screening form for patients to complete before outpatient CT encounters to report undergoing dialysis, taking cancer-treating medications, having kidney disease, undergoing prior kidney surgery, having diabetes mellitus treated with medication, having hypertension treated with medication, or having multiple myeloma. Patients with any risk factor were required to undergo eGFR testing before CT. Of 44,708 patients completing the form from June 1, 2020, through February 28, 2021, 10,256 patients (5315 men, 4941 women; mean age, 66.8 ± 11.9 [SD] years; range, 21-98 years) underwent eGFR testing on the day of CT. Multivariable regression analysis for predicting reduced eGFR was performed. Findings were compared with those from theoretic use of the ACR/NKF criteria. RESULTS. Same-day testing yielded eGFR less than 30 mL/min/1.73 m2 in 1.4% (144/10,256) of patients. The only significant independent predictors of low eGFR were dialysis (odds ratio [OR], 203.30], kidney disease (OR, 12.55), and diabetes mellitus treated with medication (OR, 2.44). If the ACR/NKF criteria (only kidney disease, defined as dialysis, kidney disease, or prior kidney surgery) had been followed as a trigger for eGFR testing, the number of patients needing testing would have decreased 89.7%, from 10,256 to 1059; yield would have increased to 7.2% (76/1059); and 47.2% (68/144) of patients with low eGFR would have been missed. If the ACR/NKF criteria had been followed but diabetes mellitus been considered a required rather than an optional criterion, the number of patients needing testing would have decreased 77.1%, to 2353; yield would have increased to 4.0% (95/2353); and 34.0% (49/144) of patients with low eGFR would have been missed. CONCLUSION. Using patient-reported risk factors resulted in frequent eGFR testing but low yield of low eGFR. Commonly applied risk factors were not independently associated with low eGFR. CLINICAL IMPACT. Application of ACR/NKF criteria would substantially reduce eGFR testing, but patients with renal dysfunction would be missed. The statement should consider omitting kidney surgery as a trigger for eGFR testing and including diabetes mellitus as a required trigger.

Patient Experience Scores for Radiologists: Comparison With Nonradiologist Physicians and Changes After Public Posting in an Institutional Online Provider Directory.

BACKGROUND. Patients are increasingly using online information regarding patient experiences to guide care decisions. OBJECTIVE. The purpose of our study was to compare patient experience scores between radiologists and nonradiologist physicians and to assess changes in scores after their public posting in an online physician directory. METHODS. This retrospective study included data collected from May 1, 2017, to November 30, 2018, at a single large academic medical center. After all institutional outpatient visits, patients were e-mailed the Press Ganey Medical Practice Survey, which included 10 questions (answered using a Likert scale and converted to 100-point range) relating to the patient's experience with the specific provider for the encounter. Surveys were distributed to patients after radiology encounters if involving an image-guided invasive procedure. Mean scores for each question and the mean weighted overall score were displayed on each physician's publicly available profile on the hospital's online physician directory and were updated monthly. Scores were compared between radiologists and nonradiologist physicians; temporal changes were assessed. RESULTS. The response rate was 18.0% (96,057/533,983). After exclusions (23,989 surveys completed without provider ratings; 183 surveys evaluating physician assistants), 71,885 physician surveys were evaluated: 2703 surveys for 65 radiologists, 49,403 surveys for 916 physicians in 17 nonsurgical specialties, and 19,779 surveys for 262 physicians in 13 surgical specialties. Over the study period, the mean overall score was 95.6 for radiologists and 95.9 for nonradiologists (94.6 for surgical specialties, 96.4 for nonsurgical specialties). For the 10 individual questions, scores ranged for radiologists from 94.6 (time spent with patient) to 96.8 (friendliness/courtesy) and for nonradiologists from 94.6 (time spent with patient) to 97.0 (friendliness/courtesy). The mean overall score increased from the first month to the final month for radiologists from 94.2 to 97.1 and for nonradiologists from 95.7 to 96.3. For radiologists, the largest improvement was for instructions regarding postprocedure follow-up care (increased from 91.4 to 97.4). CONCLUSION. Radiologists received high scores on patient experience surveys when evaluated on encounters involving invasive procedures, achieving scores similar to those for other physicians. Scores improved over time, possibly related to online posting of survey results. CLINICAL IMPACT. The findings support the utility of implementing patient experience surveys in radiology.

Liver tumor F-18 FDG-PET before and immediately after microwave ablation enables imaging and quantification of tumor tissue contraction.

PURPOSE: Poor liver tumor visibility after microwave ablation (MWA) limits direct tumor ablation margin assessments using contrast-enhanced CT or ultrasound (US). Positron emission tomography (PET) or PET/CT may offer improved intraprocedural assessment of liver tumor ablation margins versus current imaging techniques, as 18F-fluorodeoxyglucose (18F-FDG)-avid tumors remain visible on PET immediately following ablation. The purpose of this study was to assess intraprocedural 18F-FDG PET scans before and immediately after PET/CT-guided MWA for visualization and quantification of metabolic liver tumor tissue contraction resulting from MWA. METHODS: This retrospective study, conducted at a large academic medical center after Institutional Review Board approval, included 36 patients (20 men; mean age 63 [range 37-85]) who underwent PET/CT-guided MWA of 42 18F-FDG-avid liver tumors from May 2013 to March 2018. Tumor metabolic diameters (short/long axes) were measured for each tumor on pre- and post-ablation PET images. Tumor metabolic volumes were calculated using tumor diameter measurements and compared with automated volumes using an SUV threshold algorithm. A two-tailed paired t test was used for the analyses. RESULTS: Comparing intraprocedural pre- and post-ablation PET images, mean metabolic tumor short- and long-axis diameters decreased from 21.4 to 14.9 mm [- 29%, p < 0.001, standard deviation (SD) 18%] and from 24.0 to 18.0 mm (- 24%, p < 0.001, SD 16%), respectively. The mean calculated tumor metabolic volume decreased from 10.5 to 4.6 mm3 (- 55%, p < 0.001, SD 26%). The mean automated tumor metabolic volume decreased from 10.6 to 5.8 mm3 (- 45%, p < 0.001, SD 30%). CONCLUSION: Intraprocedural PET images of 18F-FDG-avid liver tumors allow visualization and quantification of MWA-induced metabolic tumor tissue contraction during 18F-FDG PET/CT-guided procedures. The ability to visualize contracted tumor immediately post-MWA may facilitate emerging intraprocedural PET and PET/CT imaging techniques that address a clinical gap in directly assessing the ablation margin.

Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria.

BACKGROUND: An upcoming national mandate will require consultation of appropriate use criteria (AUC) through a clinical decision support mechanism (CDSM) for advanced imaging. We aimed to evaluate our current ability to ascertain test appropriateness. METHODS: We prospectively collected data on 288 consecutive stress tests and coronary computed tomography angiography studies for medical inpatients. Study appropriateness was determined independently by two physicians using the 2013 Multimodality AUC. RESULTS: The median age of the study population was 66 years [interquartile range (IQR) 56, 75], 40.8% were female, and 52.8% had a history of coronary artery disease. Review of the electronic health record (EHR) alone was sufficient to deem appropriateness for 87.2% of cases. The most common reason it was insufficient was inability to determine if the patient could exercise (59.5%). After reviewing the EHR and pilot CDSM data together, appropriateness could be determined for 95.8% of the cases. The most common reason appropriateness could not be determined was that the exam indication was not addressed by an AUC criterion (83.3%). CONCLUSION: In preparing for the mandate, it will be important for future CDSM to obtain information on the patient's ability to exercise and for future AUC to include additional indications that are not currently addressed.

Screening Mammography Performance Metrics of 2D Digital Mammography Versus Digital Breast Tomosynthesis in Women With a Personal History of Breast Cancer.

BACKGROUND. Patients with a history of breast cancer are at higher risk of subsequent breast cancers and need close clinical and imaging follow-up. Limited data are available on screening of these patients with digital breast tomosynthesis (DBT) versus full-field digital mammography (FFDM). OBJECTIVE. The purpose of this study was to evaluate the screening mammography performance of DBT compared with FFDM among patients with a history of breast cancer undergoing imaging at a large academic oncology center. METHODS. This retrospective study included consecutively registered patients with a personal history of breast cancer treated with mastectomy or lumpectomy who underwent screening FFDM from October 2014 through September 2016 (5706 examinations of 4091 patients) or screening DBT from February 2017 through December 2018 (4440 examinations of 3647 patients). An institutional mammographic database was queried to obtain imaging type, breast density, history of mastectomy or lumpectomy, and BI-RADS category. An institutional breast cancer registry identified cancer diagnoses. Screening performance metrics were compared between FFDM and DBT groups. RESULTS. Recall rate was significantly lower with DBT than with FFDM (7.9% vs 10.1%; p < .001). DBT and FFDM did not differ in PPV1 (7.7% vs 6.1%; p = .36) or cancer detection rate (CDR) (6.1/1000 vs 6.0/1000; p = .97). Sensitivity was 96.4% for DBT and 71.4% for FFDM (p = .008). Specificity was 92.3% for DBT and 90.0% for FFDM (p < .001). With stratification by breast density, patients with nondense breast tissue had a lower recall rate with DBT than with FFDM (5.9% vs 8.8%; p < .001) and a nonsignificant increase in PPV1 (12.0% vs 6.4%; p = .05). The metrics were not otherwise different between DBT and FFDM among patients with nondense and those with dense breast tissue. Recall rates were lower with DBT than with FFDM among both patients who underwent mastectomy (7.8% vs 9.1%; p = .09) and those who underwent lumpectomy (7.9% vs 11.0%; p = .002). PPV1 and CDR were not different between DBT and FFDM among patients who underwent mastectomy and those who underwent lumpectomy. CONCLUSION. For patients with a personal history of breast cancer who have nondense breasts, the use of DBT as opposed to FFDM reduces recall rate and improves sensitivity and specificity. CDR and PPV1 remain unchanged. CLINICAL IMPACT. For women with a personal history of breast cancer and nondense breasts, DBT offers the potential to maintain the benefits of early cancer detection while reducing the potential harms of false-positive findings.

Peer Learning in Radiology: Effect of a Pay-for-Performance Initiative on Clinical Impact and Usage.

OBJECTIVE. The purpose of this article is to assess the effects of a pay-for-performance (PFP) initiative on clinical impact and usage of a radiology peer learning tool. MATERIALS AND METHODS. This retrospective study was performed at a large academic hospital. On May 1, 2017, a peer learning tool was implemented to facilitate radiologist peer feedback including clinical follow-up, positive feedback, and consultation. Subsequently, PFP target numbers for peer learning tool alerts by subspecialty divisions (October 1, 2017) and individual radiologists (October 1, 2018) were set. The primary outcome was report addendum rate (percent of clinical follow-up alerts with addenda), which was a proxy for peer learning tool clinical impact. Secondary outcomes were peer learning tool usage rate (number of peer learning tool alerts per 1000 radiology reports) and proportion of clinical follow-up alerts (percent of clinical follow-ups among all peer learning tool alerts). Outcomes were assessed biweekly using ANOVA and statistical process control analyses. RESULTS. Among 1,265,839 radiology reports from May 1, 2017, to September 29, 2019, a total of 20,902 peer learning tool alerts were generated. The clinical follow-up alert addendum rate was not significantly different between the period before the PFP initiative (9.9%) and the periods including division-wide (8.3%) and individual (7.9%) PFP initiatives (p = .55; ANOVA). Peer learning tool usage increased from 2.2 alerts per 1000 reports before the PFP initiative to 12.6 per 1000 during the division-wide PFP period (5.7-fold increase; 12.6/2.2), to 25.2 in the individual PFP period (11.5-fold increase vs before PFP; twofold increase vs division-wide) (p < .001). The clinical follow-up alert proportion decreased from 37.5% before the PFP initiative, to 34.4% in the division-wide period, to 31.3% in the individual PFP period. CONCLUSION. A PFP initiative improved radiologist engagement in peer learning by marked increase in peer learning tool usage rate without a change in report addendum rate as a proxy for clinical impact.

Prevalence of imaging findings of acute pancreatitis in emergency department patients with elevated serum lipase.

PURPOSE: To assess the association of imaging features of acute pancreatitis (AP) with the magnitude of lipase elevation in Emergency Department (ED) patients. METHODS: This Institutional Review Board-approved retrospective study included 509 consecutive patients presenting from 9/1/13-8/31/15 to a large academic ED with serum lipase levels ≥3× the upper limit of normal (ULN) (≥180 U/L). Patients were excluded if they did not have imaging (n = 131) or had a history of trauma, abdominal metastases, altered mental status, or transfer from an outside hospital (n = 190); the final study population was 188 patients. Imaging exams were retrospectively evaluated, and a consensus opinion of two subspecialty-trained abdominal radiologists was used to diagnose AP. Primary outcome was presence of imaging features of AP stratified by lipase level (≥3×-10× ULN and > 10× ULN). Secondary outcome was rate of discordant consensus evaluation compared to original radiologist's report. RESULTS: 25.0% of patients (47/188) had imaging features of AP. When lipase was >10× ULN (n = 94), patients were more likely to have imaging features of AP (34%) vs. those with mild elevation (16%) (p = 0.0042). There was moderately strong correlation between lipase level and presence of imaging features of AP (r = 0.48, p < 0.0001). Consensus review of CT and MRI images was discordant with the original report in 14.9% (28/188) of cases. CONCLUSION: Prevalence of imaging signs of AP in an ED population with lipase ≥3× ULN undergoing imaging is low. However, the probability of imaging features of AP increases as lipase value increases.

Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis.

Background The overall rate of hip fractures not identified on radiographs but that require surgery (ie, surgical hip fractures) remains unclear in elderly patients who are suspected to have such fractures based on clinical findings. Moreover, the importance of advanced imaging in these patients has not been comprehensively assessed. Purpose To estimate the frequency of radiographically occult hip fracture in elderly patients, to define the higher-risk subpopulation, and to determine the diagnostic performance of CT and bone scanning in the detection of occult fractures by using MRI as the reference standard. Materials and Methods A literature search was performed to identify English-language observational studies published from inception to September 27, 2018. Studies were included if patients were clinically suspected to have hip fracture but there was no radiographic evidence of surgical hip fracture (including absence of any definite fracture or only presence of isolated greater trochanter [GT] fracture). The rate of surgical hip fracture was reported in each study in which MRI was used as the reference standard. The pooled rate of occult fracture, diagnostic performance of CT and bone scanning, and strength of evidence (SOE) were assessed. Results Thirty-five studies were identified (2992 patients; mean age, 76.8 years ± 6.0 [standard deviation]; 66% female). The frequency of radiographically occult surgical hip fracture was 39% (1110 of 2835 patients; 95% confidence interval [CI]: 35%, 43%) in studies of patients with no definite radiographic fracture and 92% (134 of 157 patients; 95% CI: 83%, 98%) in studies of patients with radiographic evidence of isolated GT fracture (moderate SOE). The frequency of occult fracture was higher in patients aged at least 80 years (44%, 529 of 1184), those with an equivocal radiographic report (58%, 71 of 126), and those with a history of trauma (41%, 977 of 2370) (moderate SOE). CT and bone scanning yielded comparable diagnostic performance in the detection of radiographically occult hip fracture (P = .67), with a sensitivity of 79% and 87%, respectively (low SOE). Conclusion Elderly patients with acute hip pain and negative or equivocal findings at initial radiography have a high frequency of occult hip fractures. Therefore, the performance of advanced imaging (preferably MRI) may be clinically appropriate in all such patients. © RSNA, 2020 Online supplemental material is available for this article.

Effect of a Report Template-Enabled Quality Improvement Initiative on Use of Preferred Phrases for Communicating Normal Findings in Structured Abdominal CT and MRI Reports.

OBJECTIVE. The objective of this study was to assess impact of a report template quality improvement (QI) initiative on use of preferred phrases for communicating normal findings in structured abdominal CT and MRI reports. SUBJECTS AND METHODS. This prospective QI initiative, designed to decrease use of equivocal phrases and increase use of preferred and acceptable phrases (defined by multidisciplinary experts including patient advocates) in radiology reports, was performed in an academic medical center with over 800,000 annual radiologic examinations and was exempt from institutional review board approval. The intervention populated the preferred term "normal" (default) and acceptable specified pertinent negative phrases (pick-list option) when describing abdominal organ subheadings (liver, pancreas, spleen, adrenal glands, kidneys) within the "Findings" heading of abdominal CT and MRI report templates. We tabulated frequencies of the term "normal", specified pertinent negatives, and equivocal phrases in 21,629 reports before (June 1, 2017, to February 28, 2018) and 23,051 reports after (April 1, 2018, to December 31, 2018) the intervention using natural language processing and recorded trainee participation in report generation. We assessed intervention impact using statistical process control (SPC) charts and the Fisher exact test. RESULTS. Equivocal phrases were used less frequently in abdominal CT and MRI reports for both attending radiologists and trainees after the intervention (p < 0.05, SPC). Use of the term "normal" increased for reports generated by attending radiologists alone but decreased for reports created with trainee participation (p < 0.05, SPC). Frequency of pertinent negatives increased for reports with trainee participation (p < 0.05, SPC). CONCLUSION. A QI intervention decreased use of equivocal terms and increased use of preferred and acceptable phrases when communicating normal findings in abdominal CT and MRI reports.

Comparing Tumor Characteristics and Rates of Breast Cancers Detected by Screening Digital Breast Tomosynthesis and Full-Field Digital Mammography.

OBJECTIVE. The purpose of this study was to compare the cancer detection rates (CDRs), tumor types, and characteristics between screening digital breast tomosynthesis (DBT) and screening full-field digital mammography (FFDM) in a matched patient population in a large academic breast imaging practice with mixed DBT and FFDM technology. MATERIALS AND METHODS. In this retrospective study, we reviewed consecutive screening FFDM and DBT examinations performed between October 2012 and September 2014. To control for nonrandomized selection of FFDM versus DBT examinations, we applied propensity score matching on the basis of patient age, imaging site, and prior imaging findings. An institutional breast cancer registry identified cancer diagnoses. CDR and tumor type, grade, receptor, nodal status, and size were compared between matched FFDM and DBT groups. RESULTS. Sixty-one cancers were detected in the matched screening cohort of DBT (n = 9817) and FFDM (n = 14,180) examinations. CDR was higher with DBT than with FFDM for invasive cancers (2.8 vs 1.3, p = 0.01), minimal cancers (2.4 vs 1.2, p = 0.03), estrogen receptor-positive invasive cancers (2.6 vs 1.1, p = 0.01), and node-negative invasive cancers (2.3 vs 1.1, p = 0.02.), respectively. The ratio of screen-detected invasive cancers to ductal carcinoma in situ on DBT (3.0) was not significantly different from that on FFDM (2.6) (p = 0.79). CONCLUSION. DBT results in an overall increase in CDR irrespective of the tumor type, size, or grade of cancer.

What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria.

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.

Improving Patient Experience in Radiology: Impact of a Multifaceted Intervention on National Ranking.

Purpose To assess the impact of a patient experience improvement program on national ranking in patient experience in a large academic radiology department. Materials and Methods This Health Insurance Portability and Accountability Act-compliant study was exempted from institutional review board approval. After initiating an electronic patient experience survey, 26 210 surveys and 22 213 comments were received from May 2017 to April 2018. During the study period, a multifaceted quality improvement initiative was instituted, focused on improving patient experience in the radiology department. The primary outcome was national percentile ranking as measured with the survey. Secondary outcome was the change in departmental percentile ranking compared with the overall hospital ranking for patient experience measured with a similar survey. Results The overall raw score for the department increased from 92.8 to 93.6 of 100 (P < .001), and the national ranking improved from the 35th to 50th percentile (P = .001). Improvements in raw scores related to personnel were primarily responsible for the increase in overall raw score and ranking. Of the 22 213 comments received, 3458 (15.6%) were negative. The percentage of negative comments was highly correlated with lower monthly percentile ranking (Pearson correlation coefficient of -0.69; P = .01). Conclusion It is feasible to develop a large-scale electronic survey to assess patient experience in the radiology department, to identify improvement opportunities, and to measurably improve patient experience. Changes in the percentage of negative comments were correlated with changes in a practice's national percentile rank in patient experience. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Kruskal and Sarwar in this issue.

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.

Improving Radiology Peer Learning: Comparing a Novel Electronic Peer Learning Tool and a Traditional Score-Based Peer Review System.

OBJECTIVE: The purpose of this study was to compare the yields of peer learning between a radiology electronic peer learning tool (PLT) and a score-based peer review (SBPR) system. MATERIALS AND METHODS: This retrospective study was performed from May 1, 2017, through October 31, 2017, at a 776-bed academic hospital performing more than 620,000 radiology examinations annually. Use of a PLT that generates alerts facilitating closed-loop feedback was initiated on March 1, 2017. Functions included providing peers with the following: clinical follow-up after review of prior reports, positive feedback, and consultation to solicit second opinions. In the same period, an SBPR system yielded the following scores: 1, agree with original interpretation; 2, minor discrepancy; 3, moderate discrepancy; and 4, major discrepancy. Potential learning opportunities were defined as cases receiving a clinical follow-up alert (PLT system) and reports scored 3 or 4 (SBPR system). Primary outcome was clinically significant feedback per total reports reviewed, measured as radiology report addendum rate (number with addenda divided by number of reports reviewed monthly for each system). The secondary outcome was potential learning opportunity rate (number of clinical follow-up alerts or reports scored 3 or 4 divided by the total number of radiology reports reviewed monthly). A paired t test was used for statistical analysis. RESULTS: The overall PLT report addendum rate was 11.2% (23 addenda/206 reports) versus 0.27% (13 addenda/4861 reports) for SBPR (p = 0.03), a 41-fold difference (11.2/0.27). The potential learning opportunity rate for PLT was 50.0% (206 clinical follow-up alerts among 412 total alerts) versus 0.53% (26 scored 3 or 4 among 4861 reports reviewed) for SBPR (p = 0.00003), a 94-fold difference (50/0.53). CONCLUSION: A PLT improves radiology peer learning with a significantly higher yield of clinically significant feedback and potential learning opportunities compared with a traditional SBPR system.