Recommendations for additional imaging of abdominal imaging examinations:frequency, benefit, and cost

OBJECTIVES: To investigate the frequency, determinants, clinical implications, and costs of recommendations for additional imaging (RAIs) in secondary interpretations of abdominal imaging examinations. METHODS: This retrospective study included 2225 abdominal imaging examinations from outside institutions that were reinterpreted as part of standard clinical care at a tertiary care center in a one-year time frame. RESULTS: Two hundred forty-six RAIs were present in 231 of 2225 reports (10.4%) of secondary abdominal imaging interpretations. Patient age and experience of the radiologist who performed the secondary interpretation were independently significantly associated with the presence of an RAI (both p = 0.002), with odds ratios of 0.99 per year increase in patient age (95% confidence interval [CI], 0.98-1.00) and 1.06 per year increase in experience of the radiologist (95% CI, 1.02-1.10). If followed, RAIs changed clinical management in 31.2%. Total costs of all 246 RAIs, whether performed or not by the referring physicians, amounted to €71,032.21, thus resulting in €31.92 per secondary abdominal imaging interpretation. Total costs of the 140 RAIs that were actually performed by the referring physicians amounted to €42,683.08, resulting in €19.18 per secondary abdominal imaging interpretation. CONCLUSIONS: The frequency of RAIs in reports of secondary interpretations of abdominal imaging examinations (which appear to be affected by patients' age and radiologists' experience) and associated costs are non-negligible. However, RAIs not infrequently change clinical management. The presented data may be helpful to radiology departments and healthcare policy makers to make well-informed decisions on the value and facilitation of the practice of secondary interpretations. KEY POINTS: • Frequency of recommendations for additional imaging (RAIs) in secondary interpretations of abdominal imaging examinations at a tertiary care center is approximately 10.4%. • RAIs appear to be more frequently issued in younger patients and by more experienced radiologists, and if followed by referring clinicians, change clinical management in about one third of cases. • RAI costs per secondary interpretation in the Dutch Healthcare system are €31.92 (considering all RAIs) or €19.18 (considering only those RAIs that are actually performed)

Unread Second-Opinion Radiology Reports:A Potential Waste of Health Care Resources

OBJECTIVE. The purpose of this study was to investigate how frequently second-opinion radiology reports are not read by clinicians and to identify reasons why reports are not read. MATERIALS AND METHODS. This retrospective study included 4696 consecutive second-opinion reports of external imaging examinations that were authorized by subspecialty radiologists at a tertiary care institution over a 1-year period. RESULTS. Of 4696 second-opinion reports, 537 were not read by a clinician, corresponding to a frequency of 11.4% (95% CI, 10.6-12.3%). On multivariate logistic regression analysis, five variables were significantly and independently associated with the second-opinion report not being read: Inpatient status (odds ratio [OR], 163.26; p < 0.001), sonography as the imaging modality (OR, 5.07; p = 0.014), surgery (OR, 0.18; p < 0.001) or neurology (OR, 2.82; p < 0.001) as the requesting clinician's specialty, and interventional radiology as the subspecialty of the radiologist who authorized the second-opinion report (OR, 3.52; p = 0.047). We found no significant independent associations between the clinician not reading the secondopinion report and patient age, patient sex, or time between submission of the second-opinion request and finalization of the report. CONCLUSION. A considerable proportion of second-opinion reports are not read by clinicians, which represents an appreciable but potentially reversible waste of health care resources. The reasons why clinicians do not read reports need to be investigated in future studies. If subspecialty radiologists and clinicians take the proven determinants into account, the amount of second-opinion readings with limited additional clinical value may be reduced

Point-of-care ultrasonography:Downstream utilization of and diagnostic (dis)agreements with additional cross-sectional imaging

OBJECTIVES: Point-of-care ultrasonography (POCUS), defined as ultrasonography (US) performed and interpreted by the clinician, is increasingly performed. This study aimed to determine the frequency of and reasons why clinicians of the emergency department request cross-sectional imaging after POCUS and how often radiologists experience diagnostic (dis)agreements. METHODS: This retrospective study included a consecutive series of 503 patients who underwent POCUS at the emergency department of a tertiary care center. RESULTS: Downstream cross-sectional imaging was performed in 77 (15.3%) of 503 POCUS examinations. Reasons for additional cross-sectional imaging were, in order of decreasing frequency: suspicion of pathology that was not assessed with POCUS in 46 cases (59.7%), confirmation of conclusive POCUS findings in 21 cases (27.3%), inconclusive POCUS (i.e. insufficient visualization of the structure of interest to make a diagnosis, despite an attempt of the POCUS operator) in 7 cases (9.6%), a combination of inconclusive POCUS and suspicion of pathology that was not assessed with POCUS in 2 cases (2.6%), and clarification of incidental findings on POCUS in 1 case (1.3%). In the 21 cases that underwent additional cross-sectional imaging to confirm POCUS findings, POCUS agreed with additional cross-sectional imaging in 19 (90.5%) and disagreed in 2 (9.5%) cases. CONCLUSIONS: The use of POCUS appears to not cause any considerable downstream overutilization of cross-sectional imaging. In addition, radiologists experience few diagnostic disagreements when asked to perform second opinion cross-sectional imaging. Future studies with more homogeneous datasets in terms of POCUS operators are required to confirm our results

Extensions of some differential inequalities for fractional integro-differential equations via upper and lower solutions

This paper deals with some differential inequalities for generalized fractional integro-differential equations by using the technique of upper and lower solutions. The fractional differential operator is taken in Caputo’s sense and the nonlinear term divided into two parts depends on the fractional integrals of an unknown function with two different fractional orders. The results are studied by employing a variety of coupled upper and lower solutions. These theorems have some potential for extending the iterative techniques to fractional order integro-differential equations and to coupled systems of integro-differential fractional equations to obtain the existence of solutions as well as approximate solutions for the considered problem

Radiologist-patient consultation of imaging findings after neck ultrasonography:An opportunity to practice value-based radiology

Objective: To investigate how patients experience a radiologist-patient consultation of imaging findings directly after neck ultrasonography (US), and how much time this consumes. Materials and methods: This prospective randomized study included 109 consecutive patients who underwent neck US, of whom 44 had a radiologist-patient consultation of US results directly after the examination, and 65 who had not. Results: The median ratings of all healthcare quality metrics (friendliness of the radiologist, explanation of the radiologist, skill of the radiologist, radiologist's concern for comfort during the examination, radiologist's concern for patient questions/worries, overall rating of the examination, and likelihood of recommending the examination) were either good/high or very good/very high, without any significant differences between both patient groups. Patients who did not discuss the US results with the radiologist, were significantly more worried during the examination (P = 0.040) and had significantly higher anxiety levels after completion of the US examination (P = 0.027) than patients who discussed the US results with the radiologist. Fifty-one out of 55 responding patients (92.7%) indicated a radiologist-patient consultation of US results to be important. The median duration of US examinations that included a radiologist-patient consultation of US results was 7.57 min (range: 5.15-12.10 min), while the median duration of US examinations without a radiologist-patient consultation of US results was 7.34 min (range: 3.45-14.32 min), without any significant difference (P = 0.637). Conclusion: A radiologist-patient consultation of imaging findings after neck US decreases patient anxiety, is desired by most patients, and does not significantly prolong total examination time

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases.

OBJECTIVE: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial fibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. METHODS: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. CONCLUSION: This expert consensus of cardiologists aimed to define management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions

Requests for radiologic imaging:Prevalence and determinants of inadequate quality according to RI-RADS

PURPOSE: To determine the prevalence and determinants of radiologic imaging requests that are of inadequate quality according to the Reason for exam Imaging Reporting and Data System (RI-RADS). METHODS: This study included a random sample of 673 radiologic examinations performed at a tertiary care center. The quality of each imaging request was graded according to RI-RADS. Ordinal regression analysis was performed to determine the association of RI-RADS grade with patient age, gender, and hospital status, indication for imaging, requesting specialty, imaging modality, body region, time of examination, and relationship with previous imaging within the past one year. RESULTS: RI-RADS grades A (adequate request), B (barely adequate request), C (considerably limited request), and D (deficient request) were assigned to 159 (23.6 %), 166 (24.7 %), 214 (31.8 %), and 134 (19.9 %) of cases, respectively. Indication for imaging, requesting specialty, and body region were independently significantly associated with RI-RADS grades. Specifically, routine preoperative imaging (odds ratio [OR]: 3.422, P = 0.030) and transplantation imaging requests (OR: 8.710, P = 0.000) had a higher risk of poorer RI-RADS grades, whereas infection/inflammation as indication for imaging (OR: 0.411, P = 0.002), pediatrics as requesting specialty (OR: 0.400, P = 0.007), and head (OR: 0.384, P = 0.017), spine (OR: 0.346, P = 0.016), and upper extremity (OR: 0.208, P = 0.000) as body regions had a lower risk of poorer RI-RADS grades. CONCLUSION: The quality of radiologic imaging requests is inadequate in >75 % of cases, and is affected by several factors. The data from this study can be used as a baseline and benchmark for further investigation and improvement

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

OBJECTIVE: To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST. METHODS: This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST. RESULTS: FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038). CONCLUSION: Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available

Diagnostic errors in clinical FDG-PET/CT

Purpose: To determine the frequency, types, and determinants of diagnostic errors in clinical FDG-PET/CT, based on addenda to the original report. Materials and Methods: This retrospective study included 4,099 consecutive clinical FDG-PET/CT scans with corresponding reports that were made at a tertiary care center in an 18-month period. FDG-PET/CT reports were scrutinized for the presence of an addendum enclosing a diagnostic error. Results: 90 of 4,099 FDG-PET/CT reports (2.2%) contained an addendum enclosing a diagnostic error. The distribution of perceptual and cognitive errors among these 90 diagnostic errors was 54 (60.0%)/36 (40.0%). On multivariate logistic regression analysis, only low-dose FDG-PET/CT combined with concomitantly acquired and interpreted full-dose contrast-enhanced CT remained as significantly and independently associated with the presence of a diagnostic error, relative to low-dose FDG-PET/CT without concomitantly acquired and interpreted full-dose contrast-enhanced CT (odds ratio: 2.79 [95% confidence interval: 1.61-4.851, P <0.001). Patient age, gender, hospital status, indication for FDG-PET/CT scanning, single vs. double reading (i.e. two medical imaging specialists), reader experience, and reading by a nuclear medicine physician only vs. reading by both a nuclear medicine physician and a radiologist, were not significantly and independently associated with the presence of a diagnostic error. Conclusion: Diagnostic errors in clinical FDG-PET/CT based on addenda to the original report are relatively infrequent, though certainly non-negligible. Perceptual errors are slightly more frequent than cognitive errors. The availability of a concomitantly acquired and interpreted full-dose contrast-enhanced CT seems to increase diagnostic error rate. These data can be used for quality improvement and benchmarking purposes