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2016 Barbosa-et-Al Portable Chest Radiographs
2016 Barbosa-et-Al Portable Chest Radiographs
Purpose: The aim of the study was to evaluate opinions and per-
ceptions of radiologists and referring practitioners regarding
T he radiology report is the primary means of communi-
cation between the radiologists and the referring
practitioner, documenting the radiologist analysis, with
reports of portable chest radiography (pCXR) obtained in the medical-legal and quality-of-care implications. In the
intensive care unit (ICU).
intensive care unit (ICU), the portable chest x-ray (pCXR)
Materials and Methods: A total of 1265 referring practitioners and is a major diagnostic tool.
76 radiologists were invited to participate in 2 internet-based sur- The interpretation of pCXR is challenging because of
veys, containing 15 and 17 multiple choice questions, respectively, frequently suboptimal image quality, large number of
similarly presented to both groups, utilizing a Likert scale or support devices, and multiple comorbidities. Moreover, the
multiple choices. Results were compared using the Fisher exact test radiologist is often pressed to provide a fast turnaround
or w2 test.
time, increasing the likelihood of dictation errors and
Results: One hundred ninety-two referring practitioners and 63 reduced information content. Finally, pCXRs are often
radiologists answered the surveys, resulting in response rates of interpreted with minimal or inadequate clinical informa-
15% and 83%. The majority of radiologists and referring practi- tion. Most institutions have not adopted structured report
tioners are satisfied with the quality of the reports; however, radi- templates for pCXR, and unstructured narrative reports
ologists and referring practitioners disagree about the reports’ predominate, with highly variable information content and
clinical value and impact, the referring practitioners having a more
consequent implications in quality.1
positive view. Both groups overwhelmingly agree that pertinent
clinical information is crucial for optimal image interpretation. The Prior surveys have elicited the perspectives of referring
2 groups differ in their preferences regarding report style and practitioners and radiologists regarding radiology report
information content, with radiologists strongly supporting concise quality and relevance. None, however, specifically targeted
reports emphasizing temporal changes and major findings, whereas ICU pCXR reporting. One of the first surveys of referring
referring practitioners prefer more complete, itemized structured practitioners’ needs and preferences2 proposed improve-
reports describing support devices in detail. ments in report structure and communication of urgent
Conclusions: The results substantiate the perceived clinical value of findings. A study of >800 CXR reports3 of inpatients
radiologist reports for pCXR, from the perspective of referring found high variability with respect to terminology and
practitioners. Nonetheless, there is disagreement regarding report substantial uncertainty regarding the diagnosis. Another
structure and content. Several issues were raised, offering oppor- study4 found a strong preference for itemized, structured
tunities for improvement, which may increase referring practi- reports, citing improved completeness and consistency as
tioners’ satisfaction and positively impact patient outcomes. Any major benefits. A large survey in the Netherlands5 found
strategy to implement standardized structured reports for pCXR that most referring practitioners and radiologists thought
will have to satisfy referring practitioners’ needs while optimizing that itemized structured reports are better suited to complex
radiologists’ efficiency, will have to be widely accepted, and will
examinations.
have to fulfill the overarching goal of maximizing the value of
pCXR reports. A pCXR report that does not address the ordering
referring practitioners’ needs, or is not available within a
Key Words: intensive care unit, portable chest radiography report, reasonable timeframe, can lead to poor outcomes in crit-
structured report template, clinical value, clinical utilization ically ill ICU patients. We elicited both referring practi-
tioners’ and radiologists’ perspectives regarding the overall
(J Thorac Imaging 2016;31:43–48)
clinical value and utilization of pCXR reports, in order to
better understand perceptions about quality and prefer-
From the *Department of Radiology, University of Pennsylvania, ences regarding report format and content and identify
Philadelphia, PA; and wDepartment of Radiology, Stanford Uni- opportunities for improvement.
versity, Stanford, CA.
The authors declare no conflicts of interest.
Correspondence to: Eduardo J. Mortani Barbosa, Jr, MD, Department MATERIALS AND METHODS
of Radiology of the University of Pennsylvania, 3400 Spruce Street,
Philadelphia, PA 19104 (e-mail: eduardo.barbosa@uphs.upenn.
The research proposal detailing the study objectives
edu). and design was approved by the hospital Institutional
Supplemental Digital Content is available for this article. Direct URL Review Board, which waived the requirement for informed
citations appear in the printed text and are provided in the HTML consent (HIPAA waiver) of the research subjects.
and PDF versions of this article on the journal’s Website, www.
thoracicimaging.com.
Two similar surveys were designed for ICU referring
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. practitioners and radiologists at 2 tertiary care hospitals in a
DOI: 10.1097/RTI.0000000000000165 major academic health system in the Northeast United States.
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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Thorac Imaging Volume 31, Number 1, January 2016 Optimization of Portable Chest Radiography Reports
they look for answers in the body of the report [75/165 Report length is not perceived to correlate with thor-
(45.5%)]. oughness of the radiologists’ assessment, as the vast majority of
Most referring practitioners [75/156 (48.1%)] preferred a referring practitioners [135/153 (88.2%)] and radiologists [50/57
structured, itemized, complete report, organized by system; (87.7%)] agreed that even if a report is short, the assumption
57/156 (36.5%) preferred a concise report that only men- was that the radiologist reviewed the image thoroughly. The
tioned major findings and temporal changes. The majority of difference was not statistically significant (P = 0.753).
radiologists [33/58 (56.9%)], in contrast, preferred a concise We asked whether a global assessment score indicating
report that only mentioned major findings and temporal the need for intervention and the time frame for such (eg,
changes. Only 5/156 (3.2%) referring practitioners preferred level of urgency) would provide additional clinical value,
free text, unstructured reports compared with 11/58 (19.0%) without elaborating the details. Eighty-nine of 156 (57.1%)
radiologists. The difference between the 2 groups, however, referring practitioners and 31/58 (53.4%) radiologists sup-
did not reach statistical significance (P = 0.146). ported this idea, whereas 30/156 (19.2%) referring practi-
Both groups [91/156 (58.3%) referring practitioners tioners and 13/58 (22.4%) radiologists were against it. The
and 44/58 (79.3%) radiologists] preferred a concise difference was not statistically significant (P = 0.689).
description of temporal changes and major significant The vast majority of referring practitioners [135/156
findings instead of a detailed description of all findings (86.5%)] agreed that the language and style of pCXR
organized by system for follow-up pCXR reports. The reports were clear, with only 4/156 (2.6%) disagreeing, but
difference between the 2 groups was statistically significant radiologists were far more critical, with 26/58 (44.8%)
(P = 0.005), even though there was concordance, because agreeing and 15/58 (25.9%) disagreeing. The difference was
of the overwhelming support by radiologists of concise statistically significant (P < 0.0001).
reports. Nonetheless, when asked about a specific example Both groups [138/153 (90.2%) referring practitioners
(clinical support devices), most referring practitioners [101/ and 53/57 (93.0%) radiologists] demonstrated over-
156 (64.7%)] expressed their preference for a detailed whelming agreement with the concept that clinical infor-
description of type and position of every line/tube/device in mation must be provided in order for the radiologist to
every report, in contradistinction to most radiologists [44/ provide an optimal interpretation of pCXR. The difference
58 (75.9%)], who preferred that only new, changed, or was not statistically significant (P = 0.731).
malpositioned lines/tubes/devices be mentioned. The dif- We allowed free text comments to gain further insight.
ference was statistically significant (P < 0.0001). Thirty-one of 192 (16.1%) of the referring practitioners and
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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mortani Barbosa et al J Thorac Imaging Volume 31, Number 1, January 2016
46 | www.thoracicimaging.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Thorac Imaging Volume 31, Number 1, January 2016 Optimization of Portable Chest Radiography Reports
discrepancy has relevant implications, as it suggests the inherent in any voluntary survey, may not play a major role
need to improve communication between the 2 groups to in extrapolating the responses to the overall group opinion,
achieve a better mutual understanding of each group’s particularly among radiologists. Nonetheless, we did not
expectations, and also supports a structured report tem- have the resources to analyze nonrespondent data. Fur-
plate that separates the conclusion from the rest of the thermore, subgroup analysis comparing responses of
report (eg, Impression separate from Findings), to facilitate attending physicians and trainees was not feasible because of
effective communication.6,7 the relatively small sample size. This interesting question may
We assessed report quality from multiple perspectives, be addressed in larger surveys in the future.
most importantly from the clinical value of pCXR, but also Another potential limitation is the generalizability of
from correctness and clarity of language. The majority of the results, given that the all the respondents practice within
both groups agree that pCXR reports provide value by a major urban tertiary-care academic institution. It is rea-
mentioning important issues the referring practitioners sonable to assume that this diverse practitioner population
might not have noticed had they analyzed the image with- is representative of major urban centers in the United
out the report. Nonetheless, when asked the more specific States, but not necessarily of smaller community or rural
question of whether the pCXR report positively impacts practices, or even urban centers in other countries.
management and clinical outcomes for ICU patients, there An intriguing question is whether CXRs should be
is disagreement, with radiologists being skeptical and reported at all. Prior studies11 have compared radiologists
undecided, whereas referring practitioners overwhelmingly and nonradiologists to assess their accuracy at interpreting
agreed. Whether the referring practitioners’ perception a variety of findings on chest radiography. The radiologists’
translates to measurable differences in patient outcomes is a performance was substantially superior to other specialists.
question open to investigation, but it suggests that pCXR Our data strongly corroborate that referring practitioners
reports are a fundamental component of the referring perceive value in having a radiologist interpreting a pCXR,
practitioners’ arsenal to manage complex ICU patients. and it suggests that the radiologist report may potentially
In terms of report clarity and correctness, radiologists positively impact patient management and outcomes.
were self-critical, being undecided regarding clarity and cor- There is a common misconception that the most per-
rectness. Referring practitioners had a more favorable opinion, formed imaging study worldwide, the chest radiograph, is a
with an overwhelming majority agreeing that reports are “simple” examination, regarding imaging acquisition and
clearly written, and a small majority agreeing that they are interpretation, which we believe is far from the truth.
adequately proofread. This difference may arise due to the fact Because all the information is present in a single image, its
that radiologists are exposed to a far greater number of reports interpretation may be more challenging than “complex”
and therefore to a greater number of poorly written reports cross-sectional imaging modalities. Moreover, this is
with grammatical/typographical errors. In any case, the amplified in the ICU setting, wherein multiple comorbid-
responses indicate that there is opportunity for improvement. ities and diagnoses are the rule, vast numbers of support
Both groups demonstrate overwhelming agreement that devices are commonly used, and imaging quality is fre-
it is crucial for the radiologist to have access to relevant quently suboptimal. Therefore, even though ICU pCXR
clinical information to be able to provide an optimal report. constitutes a small portion of the field of radiology, many
Nonetheless, this ideal scenario does not conform to reality. of the issues addressed in the surveys are applicable to other
Analysis of free text comments indicates that many referring modalities and clinical settings, although they are more
practitioners are frustrated with the inability to convey acutely relevant in the realm of pCXR reporting.
relevant, tailored information to radiologists and by them A radiology report is primarily a communication tool.
frequently ignoring clinical questions. Similarly, many radi- It is only relevant if it is able to convey the thought process
ologists are frustrated with the incomplete, inaccurate, or and concerns of the radiologist clearly, accurately, and in a
even incorrect patient history. Once again, communication is timely manner. Moreover, referring practitioners must be
the core issue. The solution may arise from better, more able to act upon the report.
flexible IT systems that allow better flow of information Our results allow better delineation of the challenges
without creating additional burden to either group.8,9 and inform a prescription for the future.12–14 The first chal-
There are limitations to our study. Our overall response lenge is improving IT infrastructure to foster better com-
rate was relatively low (19.0%) but not substantially different munication between referring practitioners and radiologists
from similar prior studies.5,10 However, it is important to and ensuring that both sides have the ability to seamlessly
emphasize that this was skewed downward because of the enter and access relevant and accurate clinical information.
large number of trainees that we had to include in the The second challenge is to create a structured report template
e-mailing list who do not rotate in the ICUs, and therefore that is organized in such way as to optimize efficiency, sim-
were much less likely to respond. We did not have access to plify report generation, guarantee the presence of crucial
lists of trainees by specialty. Nonetheless, we were able to information, and maximize clinical relevance and value.15–18
obtain more customized lists for ICU referring practitioners Our proposed template for pCXR, based on our survey
(excluding residents) and radiologists, which were totally results, is a structured report with 3 sections: Impression,
inclusive (all eligible practitioners at the participating hospi- Additional Comments, and Technique. The Impression
tals were invited). The response rate from ICU referring appears at the top, contains a fill-in field that can be dictated
practitioners (excluding residents) at 50.7% was higher than as free text, should be highly concise, and should contain only
most published studies, and the response rate from radiol- answers to clinical questions and/or clinically relevant find-
ogists was very high at 87.5%, which is surprising given that ings and diagnoses. Additional Comments contains all the
the invitation to the surveys was sent only twice. This sug- other findings under subheaders such as Lungs/Pleural
gests that the topic is of great interest to radiologists who Spaces, Cardiac/Mediastinum, Skeleton, and Support Devi-
report pCXR. Furthermore, the response rate from these ces. It should not be redundant with the Impression section
groups would suggest that nonrespondent bias, which is and would contain fill-in fields that can be set to a default
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. www.thoracicimaging.com | 47
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Mortani Barbosa et al J Thorac Imaging Volume 31, Number 1, January 2016
value, filled with free text or with standard macros. Ade- 5. Bosmans JML, Weyler JJ, De Schepper AM, et al. The
quately positioned support devices, in particular, can be radiology report as seen by radiologists and referring referring
described using standard macros, at the same time satisfying practitioners: results of the COVER and ROVER surveys.
referring practitioners’ needs and allowing radiologists to be Radiology. 2011;259:184–195.
most efficient. Finally, Technique would contain a descrip- 6. Dunnick NR, Langlotz CP. The radiology report of the future:
tion of the radiographic technique, prior comparisons, and a summary of the 2007 Intersociety Conference. J Am Coll
clinical indication, elements that are necessary for billing Radiol. 2008;5:626–629.
compliance. We advise against implementing strict 7. Cohen MD. The radiology report of the future: the ignored
standardized report templates using pick-lists for the fields, as impression. J Am Coll Radiol. 2008;5:1017.
8. Sistrom CL, Langlotz CP. A framework for improving
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number of choices for the pick lists is large, as it often has to
9. Garvey CJ, Connolly S. Radiology reporting—where does the
be for proper pCXR interpretation. radiologist’s duty end? Lancet. 2006;367:443–445.
We believe that in this era of diminishing reimburse- 10. Johnson AJ, Ying J, Swan JS, et al. Improving the quality of
ments streamlining the structure and content of ICU pCXR radiology reporting: a practitioner survey to define the target.
reports on the basis of feedback from the referring practi- J Am Coll Radiol. 2004;1:497–505.
tioner, can better serve ICU clinical needs and improve 11. Mehrotra P, Bosemani V, Cox J. Do radiologists still need to
referring practitioner satisfaction without compromising report chest x rays? Postgrad Med J. 2009;85:339–341.
radiologist efficiency in report creation, all desirable out- 12. Hall F. The radiology report of the future. Radiology.
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ACKNOWLEDGMENT 14. Reiner BI, Knight N, Siegel EL. Radiology reporting, past,
present, and future: the radiologist’s perspective. J Am Coll
The authors would like to thank Yanly Wang, MS, for
Radiol. 2007;4:313–319.
her contributions on statistical analysis of the data.
15. Johnson AJ, Chen MYM, Zapadka ME, et al. Radiology
report clarity: a cohort study of structured reporting compared
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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.