Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

What is the current role of CT urography and MR urography in the evaluation of the urinary tract?

Technologic advances in both computed tomography (CT) and magnetic resonance (MR) imaging have resulted in the ability to image the urinary tract in ways that surpass the prior mainstay of urinary tract imaging, the intravenous urogram. In adults, for most, if not all, historical indications for intravenous urography, CT urography or MR urography is now the preferred examination. Although a variety of techniques for both examinations have been described, each test provides more diagnostic information than does intravenous urography. With the introduction of multidetector technology, CT urography, to date, has emerged as the initial heir apparent to intravenous urography; many years of experience have now clearly demonstrated that CT is the test of choice for many urologic problems, including urolithiasis, renal masses, urinary tract infection, trauma, and obstructive uropathy. CT urography provides a detailed anatomic depiction of each of the major portions of the urinary tract--the kidneys, intrarenal collecting systems, ureters, and bladder--and thus allows patients with hematuria to be evaluated comprehensively. MR urography can be used also to evaluate the urinary tract and has the advantage of not using ionizing radiation and the potential to provide more functional information than CT. However, MR urography is less established and less reliably results in diagnostic image quality relative to CT urography. Although both tests can be used to evaluate the urinary tract, several issues remain and include reaching a consensus on the optimal protocols and appropriate utilization in an era of cost containment and heightened concerns about radiation exposure.

Design and Validation of a Peer-Teacher-Based Musculoskeletal Ultrasound Curriculum.

RATIONALE AND OBJECTIVES: To design and validate a peer-teacher based musculoskeletal ultrasound curriculum for radiology residents. MATERIALS AND METHODS: A musculoskeletal ultrasound curriculum with hands-on scanning workshops was designed for radiology residents. Prior to the workshops, several residents received 3 hours of hands-on training in ultrasound scanning technique which was overseen by an attending musculoskeletal radiologist; these "peer teachers" then led small-group hands-on scanning during the workshops. Participants performed diagnostic ultrasound examinations at the conclusion of the workshops to assess skill acquisition and 2 months following the workshops to quantify skill retention. Participants also completed surveys to determine confidence in performing musculoskeletal ultrasound examinations. Median scores and interquartile range (25-75%) were calculated, and t test was used to compare results. RESULTS: Thirty seven residents from all years of training and six senior resident or fellow peer teachers participated in four workshops. Diagnostic ultrasound images were obtained in 100% at the conclusion of the workshop and in 79% 2 months later. Prior to the workshops, residents reported low level of musculoskeletal ultrasound knowledge (median 2, interquartile ranges 1-2), and low confidence in performing (1, 1-2) and interpreting (1, 1-2) musculoskeletal ultrasound examinations. There was a significant increase in knowledge (3, 3-4) and confidence performing (3, 3-4) and interpreting (3, 3-4) studies following the workshops (p < 0.001 for all comparisons). CONCLUSION: Hands-on musculoskeletal ultrasound workshops, utilizing a peer teacher led small group format is an effective method of teaching scanning skills to residents. There was excellent skill acquisition, good skill retention, and significant increase in confidence performing and interpreting these studies following completion of the curriculum.

Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach.

PURPOSE: To describe the successful implementation of a structured reporting initiative in a large urban academic radiology department. METHODS: We describe our process, compromises, and top 10 lessons learned in overhauling traditional reporting practices and comprehensively implementing structured reporting at our institution. To achieve our goals, we took deliberate steps toward consensus building, undertook multistep template refinement, and achieved close collaboration with the technical staff, department coders, and hospital information technologists. Following institutional review board exemption, we audited radiologist compliance by evaluating 100 consecutive cases of 12 common examination types. Fisher exact test was applied to determine significance of association between trainee initial report drafting and template compliance. RESULTS: We produced and implemented structured reporting templates for 95% of all departmental computed tomography, magnetic resonance, and ultrasound examinations. Structured templates include specialized reports adhering to the American College of Radiology's Reporting and Data Systems (ACR's RADS) recommendations (eg, Lung-RADS and Li-RADS). We attained 94% radiologist compliance within 2 years, without any financial incentives. CONCLUSIONS: We provide a blueprint of how to successfully achieve structured reporting using a collaborative multistep approach.

Evaluating an Image Gently and Image Wisely Campaign in a Multihospital Health Care System.

PURPOSE: The efficacy of an Image Gently(®)/Image Wisely(®) radiology departmental campaign consisting of the optimization of CT protocols to reduce dose while maintaining quality, and an educational effort to alter the ordering patterns of referring physicians at a multihospital academic center, was evaluated. METHODS: The numbers of CT, MR, and ultrasound studies performed at inpatient, outpatient, and emergency facilities in the hospital system before and after the initiation of the departmental campaign (2010) were obtained for a 10-year period (2004-2014) using a radiology information system. For the same time period, dose per scan (volumetric CT dose index) was obtained through the Dose Index Registry(®)/National Radiology Data Registry for frequently performed studies. Descriptive statistics were used to analyze temporal trends in radiation dose and utilization across differing age groups: <20, 20 to 39, and 40 to 59 years. RESULTS: The radiology information system yielded 865,879 imaging examinations and 4,508,030 patients. Although patient and imaging volume grew annually over the study period (by 6.8% and 4.9%, respectively), CT utilization as a percentage of total imaging decreased, compensated for by an increase in ultrasound use. This was most marked in the youngest age group. MR use as a percentage of total imaging was unchanged. The median volumetric CT dose index for each study protocol was reduced or stabilized. CONCLUSIONS: The campaign resulted in a reduction in CT utilization, a reduction in radiation dose per study, and a compensatory rise in ultrasound use. An interactive aggressive educational campaign directed toward referring providers combined with protocol dose reduction efforts can be successful in reducing patient exposure from medical radiation.

Intraoperative radiography for evaluation of surgical miscounts.

PURPOSE: Retained surgical items result in substantial morbidity, health care-related expense, and legal liability. This study determines the performance of a protocol for locating surgical items after a miscount, in which intraoperative radiography included a radiograph of the unaccounted for item. METHODS: Institutional review board approval was obtained. In 20,820 operations performed between January 1, 2011 and April 1, 2013, a total of 183 consecutive surgical miscounts occurred, involving 180 patients (97 male, 83 female; median age: 55 years). Departmental protocol mandated that a radiograph of an example of the potentially retained item be taken simultaneously with each patient intraoperative radiograph. Three board-certified radiologists retrospectively reviewed these radiographs and follow-up imaging, achieving consensus on interpretation. Adherence to institutional protocol was assessed. Demographic data, surgical documentation, and clinical follow-up data were recorded. RESULTS: The incidence of surgical miscounts was 0.9% (183 of 20,820). Only 9% (17 of 183) were resolved by discovery: outside the patient (8 cases); on intraoperative radiographs (5 cases); incidentally on follow-up radiographs (2 cases); and on retrospective review (2 cases). The false-negative rate was 44% (4 of 9). Neither of the 2 retained needles discovered postoperatively was removed. The procedures most prone to miscounts were: esophagogastrectomy (33%; 2 of 6); liver transplant (18%; 12 of 66); and Whipple procedure (16%; 7 of 44). Needles (65%) and sponges (9%) were the items that were overlooked most often. Adherence to the protocol of imaging an example of a potentially retained item was 91% (167 of 183). CONCLUSIONS: Despite good adherence to a protocol of imaging the potentially retained items, small needles often were not visualized on intraoperative radiographs and were not subsequently removed, without known adverse events. This finding suggests that intraoperative radiography for small needles may be unnecessary, but further study is required.

A guide to the external review of an academic radiology department.

External reviews are used to evaluate a department on a routine basis or prior to reappointment or recruitment of a department chair. The Society of Chairs of Academic Radiology Departments (SCARD) developed a template that outlines important components of an external review report and a table that outlines the objective information that can be requested from the institution/department prior to the reviewer's site visit. The template is meant to facilitate a high-quality review and serve as a guide to a chair who is preparing for his/her first review, chairs who serve as external consultants, and institutional officials seeking review of a radiology department.

Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.