Management-changing errors in the recall of radiologic results - a pilot study.

AIM: To evaluate the occurrence of alterations to diagnostic information from radiological studies, which are altered by person-to-person communication and/or faulty recall, and whether they affect patient management MATERIALS AND METHODS: A structured telephone survey was conducted at a large tertiary care medical centre of house staff managing inpatients who had undergone chest, abdominal, or pelvic computed tomography (CT) or magnetic resonance imaging (MRI) and remained in the hospital at least 2 days later. Fifty-six physicians were surveyed regarding 98 patient cases. Each physician was asked how he or she first became aware of the results of the study. Each was then asked to recall the substance of radiological interpretation and to compare it with the radiology report. Each was then asked to assess the level of difference between the interpretations and whether management was affected. Results were correlated with the route by which interviewees became aware of the report, the report length, and whether the managing service was medical or surgical. RESULTS: In nearly 15% (14/98) of cases, differences between the recalled and official results were such that patient management could have been (11.2%) or had already been affected (3.1%). There was no significant correlation between errors and either the route of report communication or the report length. CONCLUSION: There was a substantial rate of error in the recall and/or transmission of diagnostic radiological information, which was sufficiently severe to affect patient management.

Trends in the use of drug therapies in patients with acute myocardial infarction: 1988 to 1992.

OBJECTIVES: In this study, we investigated the use of thrombolytic agents and other cardiac drugs in a national cohort of patients with acute myocardial infarction and assessed the influence of large clinical studies on types of thrombolytic therapy prescribed. BACKGROUND: Information about usage patterns for these drugs is unavailable, and little is known about the impact of large clinical trials on their use. METHODS: We conducted a retrospective cohort study of 65,011 patients who were treated for acute myocardial infarction during fiscal years 1988 to 1992 (October 1, 1987 to September 30, 1992) in hospitals participating in the SMS Corporation's on-line data pool. RESULTS: The overall thrombolysis rate for patients with acute myocardial infarction increased from 11% in fiscal year 1988 to 18% in fiscal year 1990 and has remained approximately at that level since then. In mid-1989, tissue plasminogen activator was used in 90% of the patients receiving thrombolysis, whereas streptokinase was used in only 10%. Since 1991, tissue plasminogen activator has been used in 60% of patients and streptokinase in almost 30%. Much of this change came after presentation and publication of results of the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico (GISSI-2) and the Third International Study of Infarct Survival (ISIS-3) trials. Over these 5 years, use of beta-adrenergic blocking agents increased steadily, and use of calcium-channel blocking agents declined steadily. CONCLUSIONS: Current usage rates of thrombolytic therapy are lower than expected, but trends in usage rates for beta-blockers and calcium channel blockers reflect their increasing and decreasing approval, respectively. Presentation and publication of results from the Third International Study of Infarct Survival and the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico trials appear to have influenced the type of thrombolytic agent prescribed.

Some economics of mental health 'carve-outs'.

We discuss the rationale for benefit carve-out contracts in general and for mental health and substance abuse in particular. We focus on the control of adverse selection as a principal explanation and find that this is consistent with the wide-spread use of sole-source contracting with periodic rebidding. We also find that some degree of risk sharing is common; we interpret this as a method of balancing cost-containment incentives with incentives to maintain access and quality on unmeasured dimensions.

Phase I/II studies of docetaxel (Taxotere) combined with estramustine in men with hormone-refractory prostate cancer.

Evaluation of the combined regimen of estramustine and docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) in men with hormone-refractory prostate cancer is in its early stages. While this combination is promising in terms of efficacy, adverse events associated with estramustine are a concern. Estramustine has been associated with side effects such as nausea, vomiting, edema, and serious vascular events. Reported here are the results of phase I and phase II trials in which 280 mg estramustine was given three times daily on days I to 5 in 21-day treatment cycles with docetaxel at varying doses. Data from patients evaluable thus far support the efficacy of this combination, both in chemotherapeutically naive patients and in those who have had prior therapy. A survival benefit from this combination appears achievable from these early studies. As significant antitumor activity can be achieved with docetaxel alone, future studies need to define the minimal dose of estramustine for this combination.

Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trial.

Health care expenditures of 1,136 children whose families participated in a randomized trial, The Rand Health Insurance Experiment, are reported. Children whose families were assigned to receive 100% reimbursement for health costs spent one third more per capita than children whose families paid 95% of medical expenses up to a family maximum. Outpatient use decreased as cost-sharing rose for a variety of use measures: the probability of seeing a doctor, annual expenditures, number of visits per year, and numbers of outpatient treatment episodes. Hospital expenditures did not vary significantly among children insured with varying levels of cost-sharing. Episodes of treatment for preventive care were as responsive to cost-sharing as episodes for acute or chronic illness. The results give no reason not to insure preventive care as liberally as care for acute illness.

Prepaid group practice effects on the utilization of medical services and health outcomes for children: results from a controlled trial.

A total of 693 children between the ages of 0 and 13 years were randomly assigned to either a staff model HMO or to one of several fee-for-service insurance plans in Seattle to evaluate differences in medical expenditures and health outcomes. Although the fee-for-service plans varied the amount of cost sharing (0% to 95%), all children were covered for the same medical services, for either 3 or 5 years. No differences in imputed total expenditures were observed for children assigned to the HMO or any of the fee-for-service plans. Children with cost-sharing fee-for-service plans, however, had fewer medical contacts and received fewer preventive services than those assigned to the HMO. Nonetheless, children with the cost-sharing fee-for-service plans were perceived (by their mothers) to be in better health overall than those assigned to the HMO. No significant differences regarding physiological outcomes (eg, visual acuity, hemoglobin level) were observed between the two groups. The results of this experiment neither strongly support nor indict fee-for-service or prepaid care for children.

Consequences of cost-sharing for children's health.

Do children whose families bear a percentage of their health care costs reduce their use of ambulatory care compared with those families who receive free care? If so, does the reduction affect their health? To answer these questions, 1,844 children aged 0 to 13 years were randomly assigned (for a period of 3 or 5 years) to one of 14 insurance plans. The plans differed in the percentage of their medical bills that families paid. One plan provided free care. The others required up to 95% coinsurance subject to a +1,000 maximum. Children whose families paid a percentage of costs reduced use by up to one third. For the typical child in the study, this reduction caused no significant difference in either parental perceptions of their child's health or in physiologic measures of health. Confidence intervals are sufficiently narrow for most measures to rule out the possibility that large true differences went undetected. Nor were statistically significant differences observed for children at risk of disease. Wider confidence intervals for these comparisons, however, mean that clinically meaningful differences, if present, could have been undetected in certain subgroups.

Fluid compartment distribution of intravenous iothalamate in the dog.

The distribution of 125I iothalamate between the intravascular and extravascular fluid compartments was determined after intravenous injection in dogs. Simultaneous measurements of total blood volume, blood iothalamate concentrations and urinary iothalamate excretion were made and permitted calculation of extravascular iothalamate. The drug diffused very rapidly to the extravascular space: more than half had reached the extravascular space one minute after injection. The ratio of extravascular to intravascular iothalamate rose to a plateau of 6.8. We conclude that the contrast material responsible for tissue opacification during radiography is primarily extravascular and that the levels of contrast in plasma during urography are affected less by renal excretion than by distribution between fluid compartments.

Efficacy and safety of iopromide for excretory urography.

RATIONALE AND OBJECTIVES: Iopromide is a nonionic monomeric contrast agent. Initial laboratory and clinical data have shown that it is relatively safe. Efficacy for excretory urography has been shown to be good, comparable with other low-osmolality agents. The authors attempted to confirm these impressions in a randomized, double-blind comparison with equivalent doses of ioversol and iopamidol. METHODS: Two hundred adult patients undergoing excretory urography were studied. One hundred received iopromide, 40 received ioversol, and 60 received iopamidol (300 mg I/kg) as an intravenous bolus. Urographic films (obtained 1, 5, 15, and 20 minutes after the bolus, and postvoid) were interpreted by an observer blinded to contrast type. Visualization of renal parenchyma, pelvis and calyces, ureters, and bladder was independently assessed as excellent, good, poor, or nonvisualized. Vital signs were recorded before, 30 to 60 minutes after, and 24 hours after injection. Adverse reactions were sought, physical examinations were performed, and standard hematology and serum chemistry values were measured before and 1 day after injection; a 72-hour serum creatinine level was also measured. RESULTS: Ninety-eight percent of visualization scores were good or excellent; no significant differences among iopromide, iopamidol, and ioversol were found, nor were there any significant differences among groups in vital signs. Only one patient experienced a contrast-related physical examination change (subcutaneous extravasation). No significant changes with regard to hematology or serum chemistry values were observed; there was no contrast-induced nephropathy. Mild adverse reactions were experienced by 10% of patients; there were no significant differences in reaction rates among contrast agents. CONCLUSIONS: Iopromide at a dose of approximately 300 mg I/kg is safe and effective as an excretory urographic agent and is comparable in performance with ioversol and iopamidol.

Mn (III) hematoporphyrin. A potential MR contrast agent.

Manganese (III) hematoporphyrin (MnHP), a new and stable complex, was prepared, and its toxicity and magnetic resonance (MR) imaging properties were evaluated. In tests of acute and subacute toxicity, no deaths resulted from bolus intravenous injections of 13 or 19 mumols/kg of MnHP, but there was a 33% mortality when the dose was 38 mumols/kg. Laboratory results were normal in the surviving rats. Ultraviolet- visible spectroscopy of the urine and serum of two rats injected 24 hours previously with 38 mumols/kg MnHP revealed no free HP, suggesting in vivo stability of MnHP. Finally, using a standardized imaging protocol, there was a mean increase of 37% in the liver-to-muscle intensity ratios in four rats injected 24 hours previously with 25 mumols/kg MnHP when compared to paired controls (P less than .005). In addition, obvious visual increase in the signal intensity of the liver on T1-weighted images was seen in animals tested with 13 and 19 mumols/kg of MnHP. The results suggest that further evaluation of MnHP as an MR contrast agent for the liver is warranted.

Quadtree-based data compression of abdominal CT images.

An ROC study was performed to evaluate the effect of quadtree-based data compression on the diagnostic yield of CT images. Seventy images were selected from a series of consecutive abdominal/pelvic CT scans. Following the application of quadtree-based compression, all images were reviewed independently by three radiologists. The images were analyzed at six decreasing irreversible compression ratios (30.6:1 to 7.4:1), as well as after reversible compression (2.9:1). ROC curves reveal a gradual decrease in clinical accuracy with increasing compression ratios. At a compression ratio of 7.4:1, sensitivity for all major abnormalities was 99% with a specificity of 93%. As the compression ratio was increased to 30.6:1, sensitivity and specificity dropped to 75% and 83% respectively. Execution times for compression and decompression of the CT images with a PC-AT based digital radiography system varied from 24.7 to 18.5 seconds and from 16.2 to 5.1 seconds respectively, decreasing with higher levels of compression. We conclude that quadtree-based compression of abdominal CT images may have practical applications for a PC based digital radiography system.

Application of region of interest definition to quadtree-based compression of CT images.

A quadtree-based data compression algorithm can provide different levels of compression within and outside of regions of interest (ROIs). The current study shows whether ROI compression can provide greater compression or diagnostic accuracy than uniform quadtree compression. In 75 single CT images from 75 consecutive abdominal examinations, 43 abnormalities were identified and surrounded by ROIs. Three radiologists interpreted the images following (1) 50:1 compression of the entire image; (2) ROI compression at five decreasing compression ratios (with 50:1 compression outside the ROI); and (3) reversible (lossless) compression of the entire image. Reversible compression (compression ratio 3:1) yielded a sensitivity of 96%. ROI compression of 15:1 was achieved with no loss of sensitivity; ROI compression of 28:1 yielded a sensitivity of 91% (not significantly different). At any given compression ratio, diagnostic sensitivity was greater with ROI compression than with uniform quadtree compression. For purposes of image archiving, quadtree-based ROI compression is superior to uniform compression of CT images.

Ultrasound placental site in relation to bloody taps in midtrimester amniocentesis.

In an unselected, consecutive series of 137 midtrimester amniocenteses for prenatal genetic diagnosis, it was found that the incidence of blood contamination of amniotic fluid samples was similar regardless of placental site as determined by ultrasound localization. Three (5.8%) patients with anterior placental location versus 5 (9.1%) patients with posterior placentas had gross blood in the amniotic fluid by visual inspection. These results support the view that placental penetration during amniocentesis is not the major cause of bloody taps. Ultrasound studies done prior to midtrimester amniocentesis should, perhaps, be more specifically evaluated in relation to pregnancy information obtained rather than solely as an aid to improve technical performance of amniocentesis.

Polycystic kidneys without radiologic enlargement.

Polycystic kidneys in adults usually appear in the middle years and are described as large kidneys with most of their parenchyma displaced by a large number of cysts. Often the diagnosis is excluded if the intravenous pyelogram reveals kidneys of normal size. This report describes a patient with normal sized polycystic kidneys discovered at an advanced age.

Radiologic follow-up of patients with T1-3a,b,c or T4N+M0 renal cell carcinoma after radical nephrectomy.

OBJECTIVES: To determine the pattern of disease recurrence after radical nephrectomy in patients with node-positive renal cell carcinoma (RCC) in order to design a schedule for subsequent radiologic evaluation. METHODS: We reviewed the postoperative radiologic studies of 45 patients with T1-3a,b,c or T4N+M0 RCC enrolled in a prospective trial of adjuvant autolymphocyte therapy (ALT) after radical nephrectomy for node-positive disease. Chest radiograph and abdominal computed tomography (CT) were performed quarterly, and bone scan and head CT were performed every 6 months until disease recurrence, or earlier if clinically indicated. Time from surgery to recurrence and sites of recurrence were analyzed. RESULTS: Twenty-nine patients (64%) had disease progression, with a mean time to progression of 14.9 months. Mean follow-up of patients without progression was 39 months. The sites of recurrence were retroperitoneal lymph nodes (n=14), lung (n=11), liver (n=5), bone (n=5), mediastinal lymph nodes (n=4), renal fossa (n=3), pelvis (n=2), brain (n=2), contralateral kidney (n=1), retrocecum (n=1), and skin (n=1). Fourteen patients had recurrence at more than one site. Of the patients whose disease progressed, 59% did so by 12 months, 83% by 24 months, and 93% by 36 months. Mean time to progression in the ALT group was delayed compared with the observation group, but the sites of disease recurrence were not different between the two groups. Abdominal CT alone detected recurrent lesions in 79% of patients with progression, and the combination of abdominal CT and chest radiograph detected lesions in 100% of patients with progression. CONCLUSIONS: Abdominal CT with chest radiograph detects recurrence in all patients with T1-3a,b,c or T4N+M0 RCC whose disease progresses, and more than 90% of recurrences occur within the first 3 years after surgery. We recommend abdominal CT and chest radiograph every 6 months for at least 3 years and yearly thereafter in this high-risk group of patients.

Angiographic features of benign renal adenoma.

Five cases of beign renal adenoma were studied angiographically. The findings are presented along with a review of the literature. There were 4 males and 1 female ranging in age from forty-two to sixty-three years. Each presented with a mass on excretory urography, and 1 contained calcification. The largest two lesions showed circumferentially distributed vascular supply. Two lesions showed a faint homogenous blush on the nephrogram phase of the angiogram, and the firth lesion, which arose in the wall of a cyst, was angiographically silent.

Giant multilocular cystadenoma of the prostate.

Giant multilocular prostatic cystadenoma is a rare clinicopathologic entity characterized by benign histology and the ability to enlarge massively. The lesion may arise from the prostate gland either in continuity with the prostatic urethra or separate from it, or it may arise as a lesion distinct from the prostate gland. Obstructive voiding symptoms occur in all reported cases. The use of preoperative radiographic evaluation, such as magnetic resonance imaging, effectively defines the lesion's benign nature and aids in planning surgical extirpation.

Renal angiomyolipoma in adult-type polycystic disease.

Two adults with renal angiomyolipomas and polycystic disease are presented with emphasis on the angiographic manifestations of the coexisting lesions. One patient had multiple episodes of gross hematuria and a perinephric abscess which resulted in bilateral nephrectomies; the second presented with hypertension and underwent unilateral nephrectomy to treat a hypervascular tumor. The clinical and radiographic diagnoses of the combined lesions are discussed and suggestions for management offered.

An iconoclastic view of health cost containment.

Calls for medical care cost containment are all around us. Although the evidence that costs are too high is strong, the evidence that they are rising too quickly is much weaker. The principal cause of increasing costs appears to be the increased capabilities of medicine; the scant evidence available suggests that to date the public has wanted to pay for most of these capabilities. Effective global budgets would address the rising opportunity costs of health care. However, they would threaten ongoing innovation and probably would increase distortions from pricing errors.

Economists, policy entrepreneurs, and health care reform.

Economists would have formulated several aspects of the health care reform debate differently than policy entrepreneurs did. Economists would have questioned whether health care costs must be contained and whether either competition or global budgets were a "magic bullet" for doing so. They also would have emphasized the distortive costs of subsidies and taxes necessary to reach universal coverage, as well as the shakiness of the arguments about international competitiveness and excess insurance industry profits.