Shared patient analysis: a method to assess the clinical benefits of patient referrals.

BACKGROUND: Referral to specialized physicians or institutions often is deemed necessary in clinical medicine, but no method exists to assess the clinical benefit of such referrals. OBJECTIVES: To describe a method, which is shared patient analysis, to measure the expected improvement in clinical management associated with referrals and to apply that method in the field of abdominal and pelvic oncological radiology. SUBJECTS: All patients referred, during a 4-year period, to surgical oncologists at four academic centers (the referral providers, or RPs) with radiographs performed before referral at a community site (the initial providers, or IPs). Patients (n = 396) for whom both the IP interpretation and a final diagnosis was available were eligible. All IP and RP readings were placed in random order and presented to surgical oncologists, who then recommended a treatment course. MEASUREMENTS: Diagnostic accuracy of the IP and RP readings and the proportion of patients who were assigned to an appropriate treatment by the oncologist were determined. RESULTS: When the indication for imaging was primary diagnosis or staging, the kappa for presence of cancer was 0.70. When the indication was cancer follow-up, the kappa for presence of recurrent/progressing cancer was 0.66. There were disagreements between the IP and RP radiologists over the interpretation of 162 films, with the RP radiologists being correct in 153 (94%). Had the patients been treated using IP readings, there would have been 19 more inappropriate surgeries and 19 more admissions (both P <0.05) than if the oncologists had based their recommendations on RP readings. CONCLUSIONS: The technique of shared patient analysis permits assessment of the clinical benefits associated with referrals.

Transjugular renal biopsy in patients with liver disease.

Although transjugular renal biopsy has been used extensively in Europe, experience with its use in the United States has been limited. We report 25 patients who underwent both transjugular liver and renal biopsies in the same sitting and 4 patients who underwent only a transjugular renal biopsy. All 29 patients had both liver disease and renal abnormalities. Each patient was also believed to have a relative or absolute contraindication to a percutaneous renal biopsy (usually in the form of a bleeding abnormality). Transjugular renal biopsy yielded a quantity of tissue sufficient for diagnosis in all but 1 patient. The mean number of glomeruli obtained per biopsy was 19.4 +/- 12.2 (SD). Pathological diagnoses found were tubular injury in 5 patients, membranoproliferative glomerulonephritis in 5 patients, nephrosclerosis in 3 patients, diabetic nephropathy in 2 patients, immunoglobulin A (IgA) nephropathy in 2 patients, minimal change disease in 2 patients, end-stage renal disease in 2 patients, nonspecific changes in 1 patient, early glomerulosclerosis in 1 patient, tubular atrophy only in 1 patient, and normal renal histological characteristics in 4 patients. One patient with suspected IgA nephropathy had no histological diagnosis established because of a lack of glomeruli in the biopsy specimen. There were no instances of major bleeding from the perirenal area; however, a small perirenal hematoma was identified in 3 patients by postbiopsy computed tomography or sonography. Thus, based on our experience, transjugular renal biopsy appears to be a safe and effective procedure for establishing a histological diagnosis and is an attractive alternative biopsy method for patients with advanced liver disease and contraindications to conventional percutaneous renal biopsy.

Assessing the resectability of pancreatic carcinoma: the value of reinterpreting abdominal CT performed at other institutions.

OBJECTIVE: The purpose of this study was to determine the value of reinterpreting abdominal CT performed at other institutions when assessing the resectability of pancreatic carcinoma. MATERIALS AND METHODS: Fifty-three patients (30 men, 23 women; mean age, 62 years) referred to our tertiary care institution with newly diagnosed pancreatic carcinoma had formally reinterpreted abdominal CT scans and available initial reports. CT was performed at community hospitals (n = 47), university hospitals (n = 4), an outpatient clinic (n = 1), and an imaging center (n = 1); reinterpretation was performed by university radiologists with subspecialty expertise in abdominal imaging. On the basis of the initial and reinterpretation reports, the patients were categorized as having resectable or nonresectable disease. Medicare reimbursement rates were assessed. RESULTS: The initial and reinterpretation reports agreed in 36 (68%) of the 53 patients, with the disease of 16 patients considered resectable and 20 unresectable by both reports. In 17 patients (32%), we found discrepancies between the initial and the reinterpretation reports. All discrepancies involved the initial report indicating resectability and the reinterpretation report consistent with nonresectable disease. Discrepancies were resolved by findings at surgery (n = 9), percutaneous biopsy (n = 3), dedicated pancreatic CT (n = 3), dedicated liver CT (n = 1), and follow-up abdominal CT (n = 1); the reinterpretation reports were correct in 16 (94%) of 17 patients. Reimbursement for outside CT reinterpretation, repeated abdominal CT, and an exploratory laparotomy were estimated at $46.45, $414.47, and $16,996.44, respectively. CONCLUSION: Reinterpretation of outside abdominal CT was valuable for determining pancreatic carcinoma resectability and inexpensive when compared with repeating the CT examination or performing an exploratory laparotomy.

Sonographic measurements of the neonatal thyroid gland.

The purpose of this study was to establish the normal dimensions of the thyroid gland in euthyroid neonates. Ultrasonographic evaluation of the thyroid gland was performed in the first week of life in 68 term neonates whose gestational ages at birth were 37 to 41 weeks and whose birth weights ranged from 2570 to 4790 g. Measurements of the thyroid lobes were done in transverse, anteroposterior, and longitudinal planes. All neonates had age-appropriate thyroid stimulating hormone levels at birth. Mean +/- 2 standard deviations for thyroid volume were 472 mm3 and 1430 mm3. The mean measurements for the sum of both lobes for transverse, anteroposterior, and longitudinal dimensions were 13.9 mm, 15.1 mm, and 34.6 mm, respectively. No significant correlation of these measurements was found for gestational age, birth weight, or thyroid-stimulating hormone levels. The correlation coefficient between these measurements and total volume was 0.64 or less. Term euthyroid neonates were found to have a thyroid gland volume ranging between 472 mm3 and 1430 mm3. In term neonates sonographic measurements of thyroid lobes should be obtained in all three planes for reliable assessment of thyroid volume.