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28th July 2022
The use of a radiology report that included a field dedicated to further actions or recommendations has been shown to increase the number of recommendations which were acted upon, i.e., achieving diagnostic loop closure according to a study by US researchers.
Many diagnostic errors arise through process breakdowns in the patient-practitioner clinical encounter but also because of failures in follow-up and tracking of diagnostic information. One area in which there is known to be a breakdown of follow-up in formation is with a radiology report, as demonstrated in one study where the follow-up imaging adherence rate was only 58.1%. A possible suggested solution to ensure a higher level of greater imaging follow-ups has been the use of free text reports. However, in a study using machine learning to interpret the free text, it was found to be associated with extensive variability, creating difficulty for the machine learning algorithm, implying that it would also be potentially difficult for human recipients to fully understand such reports. Another related option has been to use a standardised radiology report. In fact, when compared to the conventional reporting, the standardised report was found to have better content and greater clarity than conventional reports.
For the present study, the US researchers wanted to further explore if the introduction of a standardised radiology report could improve the extent to which the diagnostic loop was closed, i.e., where recommendations were acted upon. As part of a quality improvement study, the team examined radiology reports for common imaging and where the radiologist had made further recommendations. These recommendations were then broken down into three categories: where a recommendation to perform a different test or a referral was needed; where a specific time frame to perform the action was stipulated; and finally if there were any contingencies, e.g., for smokers, a recommendation to repeat a scan 12 months later etc. In reviewing whether the loop was closed, the authors classified the follow-ups as: recommendation actioned; if there was a disagreement between the referring clinician and the recommendations; or finally, if the patient died or there was evidence of patient refusal.
Radiology report and loop closures
A total of 598 radiology reports were identified, all of which contained structured recommendations, 462 for additional or further radiology scans, e.g., ultrasound, CT or plain radiographs and 196 for non-radiologic actions with 24.6% of recommendations including contingencies.
The overall rate of completed actions (i.e., loop closure) was 87.4% and there were 31 open cases which were deemed to pose substantial clinical risk. In 57.3% of cases where the loop remained open, the necessary ordering or required action, while agreed upon, was not undertaken. In only 8% of cases, loops remained open because of a patient cancellation or because they did not turn up.
The authors concluded that use of a dedicated field within a radiology report resulted in loop closure in a large proportion of cases but that the presence of loops remaining open suggested the need for more reliable systems.
White T et al. Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance JAMA Netw Open 2022