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.

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.

Associations between residual hyperarousal and insomnia symptoms in veterans following a 2-week intensive outpatient program for posttraumatic stress disorder.

Many returning military service members and veterans who were deployed following the September 11, 2001, terrorist attacks (9/11) suffer from posttraumatic stress disorder (PTSD) and insomnia. Although intensive treatment programs for PTSD have shown promise in the treatment of PTSD symptoms, recent research has demonstrated that sleep disturbance shows little improvement following intensive trauma-focused treatment. The aim of the present study was to evaluate changes in self-reported insomnia symptoms among veterans and service members following participation in a 2-week intensive program for PTSD. We further aimed to investigate if residual PTSD symptoms, specifically hyperarousal, were associated with residual insomnia symptoms. Participants (N = 326) completed self-report assessments of insomnia, PTSD symptoms, and depressive symptoms at pre- and posttreatment. At pretreatment, 73.9% of participants (n = 241) met the criteria for moderate or severe insomnia, whereas at posttreatment 67.7% of participants (n = 203) met the criteria. Results of paired t tests demonstrated statistically significant differences between pre- and posttreatment Insomnia Severity Index scores; however, the effect size was small, d = 0.34. Analyses revealed that posttreatment hyperarousal symptoms were associated with posttreatment insomnia. These findings suggest that although an intensive program for service members and veterans with PTSD may significantly reduce insomnia symptoms, clinically meaningful residual insomnia symptoms remain. Further research is warranted to elucidate the association between residual hyperarousal and insomnia symptoms following intensive trauma-focused treatment.

Actionability of Recommendations for Additional Imaging in Head and Neck Radiology.

PURPOSE: The aims of this study were to measure the actionability of recommendations for additional imaging (RAIs) in head and neck CT and MRI, for which there is a near complete absence of best practices or guidelines; to identify the most common recommendations; and to assess radiologist factors associated with actionability. METHODS: All head and neck CT and MRI radiology reports across a multi-institution, multipractice health care system from June 1, 2021, to May 31, 2022, were retrospectively reviewed. The actionability of RAIs was scored using a validated taxonomy. The most common RAIs were identified. Actionability association with radiologist factors (gender, years out of training, fellowship training, practice type) and with trainees was measured using a mixed-effects model. RESULTS: Two hundred nine radiologists generated 60,543 reports, of which 7.2% (n = 4,382) contained RAIs. Only 3.9% of RAIs (170 of 4,382) were actionable. More than 60% of RAIs were for eight examinations: thyroid ultrasound (14.1%), neck CT (12.6%), brain MRI (6.9%), chest CT (6.5%), neck CT angiography (5.5%), temporal bone CT (5.3%), temporal bone MRI (5.2%), and pituitary MRI (4.6%). Radiologists >23 years out of training (odds ratio, 0.39; 95% confidence interval, 0.15-1.02; P = .05) and community radiologists (odds ratio, 0.53; 95% confidence interval, 0.22-1.31; P = .17) had substantially lower estimated odds of making actionable RAIs than radiologists <7 years out of training and academic radiologists, respectively. CONCLUSIONS: The studied radiologists rarely made actionable RAIs, which makes it difficult to identify and track clinically necessary RAIs to timely performance. Multifaceted quality improvement initiatives including peer comparisons, clinical decision support at the time of reporting, and the development of evidence-based best practices, may help improve tracking and timely performance of clinically necessary RAIs.

Patient and System Factors Associated With Completed Follow-Up of Probably Benign (BI-RADS 3) Breast Imaging Findings.

OBJECTIVE: Evaluate patient factors and health system test ordering and scheduling processes associated with completed BI-RADS 3 breast imaging follow-up. METHODS: Retrospective review of reports from January 1, 2021, to July 31, 2021, identified BI-RADS 3 findings corresponding to unique patient encounters (index examinations). The electronic health record was queried for patient, examination, and health system ordering or scheduling data including follow-up order status (order placed, performed; order placed, scheduled, but not performed; order placed, unscheduled; no order placed); ordering provider specialty and health system affiliation (primary care versus other, internal versus external to health system); and ordering department (radiology staff versus referring physician staff). Patient home addresses were categorized by area deprivation index (University of Wisconsin's Neighborhood Atlas). Univariable and multivariable analysis identified patient, examination, and ordering or scheduling factors associated with completed follow-up imaging within 15 months of BI-RADS 3 assessment. RESULTS: There were 3,104 unique BI-RADS 3 assessments, 2,561 (82.5%) with completed BI-RADS 3 follow-up within 15 months of study examination. In multivariable analysis, factors associated with incomplete follow-up included ultrasound (odds ratio [OR] 0.48; 95% confidence interval [95% CI] 0.38-0.60; P < .001) and MRI (OR 0.71; 95% CI 0.50-1.00; P = .049) versus mammogram; patients living in the highest disadvantaged neighborhoods (OR 0.70; 95% CI 0.50-0.98; P = .04); patients <40 years (OR 0.14; 95% CI 0.11-0.19; P < .001); Asian race (OR 0.55; 95% CI 0.37-0.81; P = .003); order placement >3 months (OR, 0.05; 95% CI 0.02-0.16; P < .001) after index examination or scheduling >6 months after order placement (OR, 0.35; 95% CI 0.14-0.87; P = .02); order placement by breast oncology or breast surgery departments (OR 0.35; 95% CI 0.17-0.73; P = .01) versus radiology department. DISCUSSION: Incomplete BI-RADS 3 follow-up is associated with ultrasound or MRI, most socioeconomically disadvantaged patients, younger patients, Asian race, delayed order entry, and follow-up examination ordering and scheduling by non-radiology departments.

Development and Assessment of an Information Technology Intervention to Improve the Clarity of Radiologist Follow-up Recommendations.

Importance: It is challenging to ensure timely performance of radiologist-recommended additional imaging when radiologist recommendation language is incomplete or ambiguous. Objective: To evaluate whether voluntary use of an information technology tool with forced structured entry of recommendation attributes was associated with improved completeness of recommendations for additional imaging over time. Design, Setting, and Participants: This cohort study of imaging report data was performed at an academic quaternary care center in Boston, Massachusetts, and included consecutive adults with radiology examinations performed from September 12 to 13, 2019 (taxonomy validation), October 14 to 17, 2019 (before intervention), April 5 to 7, 2021 (1 week after intervention), and April 4 to 7, 2022 (1 year after intervention), with reports containing recommendations for additional imaging. A radiologist scored the 3 groups (preintervention group, 1-week postintervention group, and 1-year postintervention group) of 336 consecutive radiology reports (n = 1008) with recommendations for additional imaging. Intervention: Final implementation on March 27, 2021, of a voluntary closed-loop communication tool embedded in radiologist clinical workflow that required structured entry of recommendation attributes. Main Outcomes and Measures: The a priori primary outcome was completeness of recommendations for additional imaging, defined in a taxonomy created by a multidisciplinary expert panel. To validate the taxonomy, 2 radiologists independently reviewed and scored language attributes as present or absent in 247 consecutive radiology reports containing recommendations for additional imaging. Agreement was assessed with Cohen κ. Recommendation completeness over time was compared with with 1-sided Fisher exact tests and significance set at P < .05. Results: Radiology-related information for consecutive radiology reports from the 4 time periods was collected from the radiology department data warehouse, which does not include data on patient demographic characteristics or other nonimaging patient medical information. The panel defined 5 recommendation language attributes: complete (contains imaging modality, time frame, and rationale), ambiguous (equivocal, vague language), conditional (qualifying language), multiplicity (multiple options), and alternate (language favoring a different examination to that ordered). Two radiologists had more than 90% agreement (κ > 0.8) for these attributes. Completeness with use of the tool increased more than 3-fold, from 14% (46 of 336) before the intervention to 46% (153 of 336) (P < .001) 1 year after intervention; completeness in the corresponding free-text report language increased from 14% (46 of 336) before the intervention to 25% (85 of 336) (P < .001) 1 year after the intervention. Conclusions and Relevance: This study suggests that supplementing free-text dictation with voluntary use of a structured entry tool was associated with improved completeness of radiologist recommendations for additional imaging as assessed by an internally validated taxonomy. Future research is needed to assess the association with timely performance of clinically necessary recommendations and diagnostic errors. The taxonomy can be used to evaluate and build interventions to modify radiologist reporting behaviors.

Financial Impact of a Radiology Safety Net Program for Resolution of Clinically Necessary Follow-up Imaging Recommendations.

OBJECTIVE: Health care safety net (SN) programs can potentially improve patient safety and decrease risk associated with missed or delayed follow-up care, although they require financial resources. This study aimed to assess whether the revenue generated from completion of clinically necessary recommendations for additional imaging (RAI) made possible by an IT-enabled SN program could fund the required additional labor resources. METHODS: Clinically necessary RAI generated October 21, 2019, to September 24, 2021, were tracked to resolution as of April 13, 2023. A new radiology SN team worked with existing schedulers and care coordinators, performing chart review and patient and provider outreach to ensure RAI resolution. We applied relevant Current Procedural Terminology, version 4 codes of the completed imaging examinations to estimate total revenue. Coprimary outcomes included revenue generated by total performed examinations and estimated revenue attributed to SN involvement. We used Student's t test to compare the secondary outcome, RAI time interval, for higher versus lower revenue-generating modalities. RESULTS: In all, 24% (3,243) of eligible follow-up recommendations (13,670) required SN involvement. Total estimated revenue generated by performed recommended examinations was $6,116,871, with $980,628 attributed to SN. Net SN-generated revenue per 1.0 full-time equivalent was an estimated $349,768. Greatest proportion of performed examinations were cross-sectional modalities (CT, MRI, PET/CT), which were higher revenue-generating than non-cross-sectional modalities (x-ray, ultrasound, mammography), and had shorter recommendation time frames (153 versus 180 days, P < .001). DISCUSSION: The revenue generated from completion of RAI facilitated by an IT-enabled quality and safety program supplemented by an SN team can fund the required additional labor resources to improve patient safety. Realizing early revenue may require 5 to 6 months postimplementation.