Tarik K. Alkasab

Incidence of Nephrogenic Systemic Fibrosis after Adoption of Restrictive Gadolinium-based Contrast Agent Guidelines

PURPOSE To retrospectively determine the incidence of nephrogenic systemic fibrosis (NSF) in a large academic medical center after the adoption of restrictive gadolinium-based contrast agent (GBCA) administration guidelines. MATERIALS AND METHODS For this retrospective HIPAA-compliant study, institutional review board approval was obtained and the requirement for informed consent was waived. Restrictive GBCA guidelines were adopted in May 2007. The guidelines (a) require a recent serum creatinine level measurement in any patient who is aged 60 years or older and/or at risk for renal disease, (b) limit the maximal weight-based GBCA dose administered to any patient with an estimated glomerular filtration rate (eGFR) lower than 60 mL/min/m(2) to 20 mL, and (c) prohibit the administration of any GBCA in patients who have an eGFR lower than 30 mL/min/m(2) and/or are undergoing chronic dialysis treatment (except in emergency situations). The electronic medical records were searched for all contrast material-enhanced magnetic resonance (MR) imaging examinations performed during the post-guidelines adoption period between January 2008 and March 2010 and the pre-guidelines adoption and transitional period between January 2002 and December 2007. Separate pathology records were searched for biopsy-confirmed cases of NSF during the same study periods. The incidences of NSF during the pre-guidelines adoption and transitional period and post-guidelines adoption period were compared by using the paired Z test. RESULTS A total of 52,954 contrast-enhanced MR examinations were performed during the post-guidelines adoption period. Of these 52,954 examinations, 46,464 (88%) were performed in adult patients with an eGFR of 60 mL/min/m(2) or higher or presumed normal renal function and 6454 (12%) were performed in patients with an eGFR of 30-59 mL/min/m(2). Thirty-six patients with an eGFR lower than 30 mL/min/m(2) underwent contrast-enhanced MR imaging for emergent indications. Review of the pathology records for January 2008 to September 2010 revealed no new cases of NSF resulting from GBCA exposure. CONCLUSION After restrictive guidelines regarding GBCA administration were instituted, no new cases of NSF were identified among 52,954 contrast-enhanced MR examinations, including those performed in patients with an eGFR lower than 60 mL/min/m(2).

Effects of a computerized provider order entry system on clinical histories provided in emergency department radiology requisitions.

PURPOSE The provided clinical history can affect the interpretation of radiologic examinations, especially in the emergency department context. The aim of this study was to evaluate the effects of computerizing the radiology requisition process on the information contained in provided clinical histories. METHODS Requests for abdominal computed tomographic examinations from the emergency department for 10-day periods before and after the switch from a paper-based to a computerized requisition system were examined. Requisitions were individually rated for information on signs and symptoms, prior diagnoses, abnormal test results, and clinical questions. Post hoc analysis of the lengths of provided histories was also performed. RESULTS Requests from the computerized system were significantly more likely than paper-based requests to contain clinical questions (52.6% vs 34.8%; P < .0001) or information on prior diagnoses (71.1% vs 51.1%; P = .0027). No significant difference was seen for information regarding signs and symptoms or abnormal test results. Computerized histories also tended to be longer then paper-based histories (71.2 vs 49.6 characters). CONCLUSIONS A computerized radiology requisition system can result in more clinical history information being provided. Radiologists should seek to further improve the interfaces with which referring physicians provide such information and test that these refinements are having the desired effect.

Cardiac Sarcoidosis Imitating Arrhythmogenic Right Ventricular Dysplasia

A 59-year-old male was admitted to Massachusetts General Hospital, Boston, Mass, with a 2-month history of exertional dyspnea (New York Heart Association class II to III). The patient denied dyspnea at rest, chest pain, palpitations, or syncope. There was no history of fevers or recent weight loss. An outpatient echocardiogram (Figure 1), performed as part of the workup of the patient’s dyspnea, demonstrated normal left ventricular size and function. The right ventricle (RV) was normal in size but diffusely hypokinetic. There was evidence of segmental RV dysfunction, with 2 discrete aneurysmal areas in the RV free wall at the base and apex, which measured 1.5 and 3.0 cm in width. Both areas appeared thinned and dyskinetic. The echocardiographic appearance was suggestive of arrhythmogenic RV dysplasia/cardiomyopathy (ARVD/C).1 A CT scan ruled out the presence of pulmonary embolism but was notable for marked mediastinal lymphadenopathy (Figure 2 …

Decision Support for Radiologist Report Recommendations

THE CLINICAL PROBLEM The past 2 decades have seen a remarkable increase in the capabilities, utilization, and cost burden of medical imaging [1-6]. This increase in demand for diagnostic imaging has put imaging in the spotlight as a target for cuts in reimbursement [1-7]. Much of the growth in imaging utilization is clearly beneficial to medical practice and increased quality of care [8]. However, we are also facing a challenge from some referring physicians who regard recommendations for additional imaging made by radiologists in their official reports as a form of “self-referral” [9]. Also, some physicians challenge radiologist recommendations on the grounds that they feel that such recommendations increase their risk for medical liability if they go unheeded [10]. Specialists often feel they know better than radiologists about what to do next and resent being pressured to act through the recommendation process. To promote the optimal use of imaging, the ACR established a program in 1992 to develop the ACR Appropriateness Criteria [11]. These riteria are designed to help referring hysicians select the right imaging xaminations for their patients: the roverbial goal of right patient, right est, right reason, and right protocol. e now argue here that a similar set f appropriateness criteria should be eveloped to guide radiologists as hey make recommendations for aditional imaging. They should be obective, evidence based, and consenus driven—including input from onradiologists—just as the original CR Appropriateness Criteria are. hey need to be presented to radiol-

Consensus-oriented group peer review: a new process to review radiologist work output.

The Joint Commission and other regulatory bodies have mandated that health care organizations implement processes for ongoing physician performance review. Software solutions, such as RADPEER™, have been created to meet this need efficiently. However, the authors believe that available systems are not optimally designed to produce changes in practice and overlook many important aspects of quality by excessive focus on diagnosis. The authors present a new model of peer review known as consensus-oriented group review, which is based on group discussion of cases in a conference setting and places greater emphasis on feedback than traditional systems of radiology peer review. By focusing on the process of peer review, consensus-oriented group review is intended to optimize performance improvement and foster group standards of practice. The authors also describe the software tool developed to implement this process of enriched peer review.

Radiologist Peer Review by Group Consensus

PURPOSE The objective of this study was to evaluate the feasibility of the consensus-oriented group review (COGR) method of radiologist peer review within a large subspecialty imaging department. METHODS This study was institutional review board approved and HIPAA compliant. Radiologist interpretations of CT, MRI, and ultrasound examinations at a large academic radiology department were subject to peer review using the COGR method from October 2011 through September 2013. Discordance rates and sources of discordance were evaluated on the basis of modality and division, with group differences compared using a χ(2) test. Potential associations between peer review outcomes and the time after the initiation of peer review or the number of radiologists participating in peer review were tested by linear regression analysis and the t test, respectively. RESULTS A total of 11,222 studies reported by 83 radiologists were peer reviewed using COGR during the two-year study period. The average radiologist participated in 112 peer review conferences and had 3.3% of his or her available CT, MRI and ultrasound studies peer reviewed. The rate of discordance was 2.7% (95% confidence interval [CI], 2.4%-3.0%), with significant differences in discordance rates on the basis of division and modality. Discordance rates were highest for MR (3.4%; 95% CI, 2.8%-4.1%), followed by ultrasound (2.7%; 95% CI, 2.0%-3.4%) and CT (2.4%; 95% CI, 2.0%-2.8%). Missed findings were the most common overall cause for discordance (43.8%; 95% CI, 38.2%-49.4%), followed by interpretive errors (23.5%; 95% CI, 18.8%-28.3%), dictation errors (19.0%; 95% CI, 14.6%-23.4%), and recommendation (10.8%; 95% CI, 7.3%-14.3%). Discordant cases, compared with concordant cases, were associated with a significantly greater number of radiologists participating in the peer review process (5.9 vs 4.7 participating radiologists, P < .001) and were significantly more likely to lead to an addendum (62.9% vs 2.7%, P < .0001). CONCLUSIONS COGR permits departments to collect highly contextualized peer review data to better elucidate sources of error in diagnostic imaging reports, while reviewing a sufficient case volume to comply with external standards for ongoing performance review.

Non-Research-Related Physician-Industry Relationships of Radiologists in the United States

PURPOSE To evaluate non-research-related, physician-industry financial relationships in the United States, in 2013, as reported pursuant to the Physician Payments Sunshine Act (a provision of the Affordable Care Act). METHODS In September 2014, CMS released the first five months (August 2013 to December 2013) of data disclosing physician-industry financial relationships. The frequency and value of non-research-related transfers in radiology were calculated and compared with those for 19 other specialties. Subanalyses of the frequency and value of such transfers in radiology were performed, based on state of licensure, radiologic subspecialty, nature of payment, manufacturer identity, and drug or device involved. RESULTS A total of 7.4% (2,654 of 35,768) of radiologists from the United States had reportable non-research-related financial relationship(s) with industry during the 5-month period, the second-lowest level among the medical specialties evaluated. The average value of non-research-related transfers of value to radiologists, excluding royalties and licenses, was low (

Creation of an Open Framework for Point-of-Care Computer-Assisted Reporting and Decision Support Tools for Radiologists

438.71; SD:

Outcome of Recommendations for Radiographic Follow-Up of Pneumonia on Outpatient Chest Radiography

2,912.15; median:

A Case Tracking System with Electronic Medical Record Integration to Automate Outcome Tracking for Radiologists

43.85), with <4% of radiologists receiving >