Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning

Tunçyürek, Özüm; Garces-Descovich, Alejandro; Jaramillo-Cardoso, Adrian; Duran, Elena Esteban; Cataldo, Thomas E.; Poylin, Vitaliy; Gómez, Said Fettane; Cabrera, Atenea Morcillo; Hegazi, Tarek M.; Beker, Kevin; Mortelé, Koenraad J.

doi:10.1007/s00261-018-1858-8

Cited by 29 publications

(28 citation statements)

References 22 publications

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“…The group was also able to reach consensus regarding a “minimum dataset” of information that should be contained within the imaging report, although these were based exclusively on expert opinion since we identified no research that investigated these items directly. However, a research article published by a group member subsequent to our literature search found that structured imaging reports for patients with fistula-in-ano missed fewer key features than narrative reports, and had greater utility for the referring clinician [ 8 ]. A further article from another group member advised a minimum dataset of items necessary for an informative report [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…Evidence strength (Oxford Centre for Evidence Based medicine; reference [3]) shown in parentheses: V, expert opinion; IV, case control studies; III, inconsistent reference standard; II, cohort study with consistent reference standard; I, systematic review of level II studies and had greater utility for the referring clinician [8]. A further article from another group member advised a minimum dataset of items necessary for an informative report [9].…”

Section: Recent Developmentsmentioning

confidence: 99%

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ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

et al. 2020

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Objectives To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis. Methods An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed. Results In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented. Conclusion These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis. Key Points • Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis. • While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation. • In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.

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Section: Discussionmentioning

confidence: 99%

Section: Recent Developmentsmentioning

confidence: 99%

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

et al. 2020

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“…Structured radiology reports may result in improved understanding of radiographic findings and clinical utility compared with narrative reports. 2,6,[20][21][22] Furthermore, studies have shown that clinicians may prefer standardized reports to narrative find- ings. 6,20,21,23 In addition, important features are less likely to be missed on structured reports.…”

Section: Discussionmentioning

confidence: 99%

“…2,6,[20][21][22] Furthermore, studies have shown that clinicians may prefer standardized reports to narrative find- ings. 6,20,21,23 In addition, important features are less likely to be missed on structured reports. 20,21 Given our findings of overall poor reporting of IC, the higher percentage of reporting with generalized IC statements, and the literature regarding structured reporting, we propose including IC as a part of the standardized radiology report.…”

Section: Discussionmentioning

confidence: 99%

“…6,20,21,23 In addition, important features are less likely to be missed on structured reports. 20,21 Given our findings of overall poor reporting of IC, the higher percentage of reporting with generalized IC statements, and the literature regarding structured reporting, we propose including IC as a part of the standardized radiology report. An IC section should include options for overall no interval change, significant interval change as described in the report, or no comparable priors.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of Explicitly Stated Interval Change on Noncontrast Head CT Radiology Reports

Braileanu

Crawford

Key

et al. 2019

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Consistent and standardized reporting of interval change for certain diagnoses may improve the clinical utility of radiology reports. The purpose of this study was to assess explicitly stated interval change of various findings in noncontrast head CT reports. MATERIALS AND METHODS: A retrospective review was performed on successive noncontrast head CT radiology reports from the first 2 weeks of January 2014. Reports with at least 1 prior comparison CT scan were included. Reports with normal examination findings and those that made comparison with only other types of examinations (eg, MR imaging) were excluded. Descriptive and subgroup statistical analyses were performed. RESULTS: In total, 200 patients with 230 reports and 979 radiographic findings were identified. The average interval between reports was 344.9 Ϯ 695.9 days (range, 0-3556 days). Interval change was mentioned 67.3% (n ϭ 659) of the time for all findings (n ϭ 979). Explicitly stated interval change was significantly associated with nonremote findings (P Ͻ .001) and generalized statements of interval change (P Ͻ .001). The proportion of interval change reported ranged from 95.3% of the time for hemorrhagic to 36.4% for soft-tissue/osseous categorizations. CONCLUSIONS: Interval change reporting was variable, mentioned for 67.3% of noncontrast head CT report findings with a prior comparison CT scan. Structured radiology reports may improve the consistent and clear reporting of interval change for certain findings.

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Qualität in der Befundung von Kopf- und Halssonographien an Universitätskliniken – eine Stichprobe

Künzel

Bozzato

Ernst

et al. 2021

HNO

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Zusammenfassung Hintergrund Die Ultraschalldiagnostik gilt für den Radiologen, Hals-Nasen-Ohren-Arzt (HNO) oder Mund-Kiefer-Gesichts-Chirurgen als Standard in der Abklärung zahlreicher Pathologien. Es besteht ein Konsens, dass die digitale Dokumentation heute dringend notwendig ist, um die Qualität der sonographischen Dokumentationen zu verbessern und zu standardisieren. Es häufen sich Publikationen zur Implementierung standardisierter Befunddokumentation einschließlich der Kopf- und Halssonographie. Ziel der Arbeit Die vorliegende Arbeit zielt darauf ab, die Qualität von routinemäßig angefertigten Kopf- und Halssonographiebefunden nach Kriterien der Kassenärztlichen Vereinigung (KV) Bayern an einer Auswahl deutscher HNO-Universitätskliniken stichprobenartig zu ermitteln. Material und Methoden Insgesamt wurden retrospektiv 70 zufällig ausgewählte, anonymisierte schriftliche Befunde einschließlich Bildmaterial von insgesamt 7 HNO-Universitätskliniken stichprobenartig nach KV-Kriterien durch einen erfahrenen Prüfer der KV Bayern ausgewertet und deskriptiv analysiert. Ergebnisse Von 70 Befunden konnten 69 ausgewertet werden. Die Dokumentationsvollständigkeit lag im Mittel bei 80,6 %. Neun Befunde waren vollständig korrekt dokumentiert (13 %). Die Dokumentationsvollständigkeit der einzelnen Kliniken lag zwischen 68,1 % und 93 %. Mit 88,5 % vs. 75 % erbrachte eine strukturierte Befundung eine höhere Befundvollständigkeit. In 75 % der Fälle verfügten die Kliniken mit strukturiertem Befund auch über digitale Dokumentationslösungen. Schlussfolgerung Die Vollständigkeit und Qualität von routinemäßig angefertigten Kopf- und Halssonographiebefunden an einer Auswahl von HNO-Universitätskliniken ist insgesamt optimierbar. Die Implementierung strukturierter Befundmasken und die Umstellung der analogen Dokumentation auf digitale Lösungen sowie Vernetzung mit dem Klinikinformationssystem (KIS) und Bildarchivierungs- und Kommunikationssystem (PACS) sollte weiter vorangetrieben werden. Darüber hinaus sind leitende Ärzte dazu angehalten, die Befundqualität unerfahrener Kollegen regelmäßig zu prüfen und im Rahmen der Facharztausbildung auf die Erfüllung entsprechender Standards wie der KV-Ultraschallvereinbarung hinzuarbeiten.

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Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning

Cited by 29 publications

References 22 publications

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

Assessment of Explicitly Stated Interval Change on Noncontrast Head CT Radiology Reports

Qualität in der Befundung von Kopf- und Halssonographien an Universitätskliniken – eine Stichprobe

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