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  • RSNA 2012’s Patient-Centered Focus Sets Course for Radiology’s Future

    January 01, 2013

    The significant benefits of CT and patients’ direct access to radiology reports were among the patient-centered offerings at RSNA 2012.

     

    In tandem with the message delivered by 2012 RSNA President George S. Bisset, III, M.D., in his President’s Address, patient-centered programming kept RSNA 2012 attendees engaged and informed throughout the week. RSNA 2012 initiatives-including the new Radiology Cares campaign challenging radiologists to take a more visible and active role throughout their patients’ radiologic care—put patients front and center and established a course for the future. Dr. Bisset challenged attendees to maintain this focus long after the meeting ends. “Remember that we exist to serve our patients...not the other way around.” Highlights of Daily Bulletin coverage include:

    Significant Benefits of CT Reflected in Literature, Not Media Reports

    Anyone who needs a reminder of the tremendous daily benefits provided by CT need only imagine going any length of time without the modality.

    Daily Bulletin coverage of RSNA 2012 is available at RSNA.org/bulletin.

    After decades of relying on CT for everything from common everyday conditions to life-threatening ailments, can any of us imagine what the world would be like without CT—even for two weeks?

    That was the question—and the wakeup call—issued by Cynthia H. McCollough, Ph.D., in her RSNA 2012 session, “Radiation Dose in Medical Imaging: What Do the Numbers Really Mean?” that served as a reminder of the critical, often life-saving benefits CT provides despite the alarmist media stories focusing only on potential risks—however slight.

    “The benefits tend to get lost, so it’s important not only to refresh our memories, but to make sure we tell patients and referring physicians of the importance of CT as well,” said Dr. McCollough, a professor of medical physics and biomedical engineering at the Mayo Clinic in Rochester, Minn.

    The benefit-to-risk ratio is often misunderstood, Dr. McCollough said. She relayed the story of a small child brought to an emergency room crying, pale and vomiting after falling out of a window. Doctors followed guidelines stating that CT scans are typically only performed when a child loses consciousness after hitting his or her head, and that “a CT scan exposes a child to radiation equal to 300 X-rays, and can require sedation, which is risky.”

    Doctors discharged the child without performing a CT; he died hours later from a subdural hematoma.

    “The long and short of it is that the head CT would have detected bleeding in his brain, likely saving his life,” Dr. McCollough said. “Head CT finds these kinds of things everyday.”

    Such incidents are likely rooted in public fear generated by media reports relaying the hypothetical risks of radiation dosage without giving equal coverage to the overwhelming benefits provided by CT. By contrast, the media rarely focuses on risks involved with not receiving a necessary CT scan.

    “Our goal as imaging professionals is to put this information into perspective,” Dr. McCollough said.

    Data Proves Efficacy of CT

    While the risks associated with CT will continue to remain controversial, the benefits of medically appropriate CT are not, according to Dr. McCollough.

    “We must not continue to discuss small hypothetical risks without emphasizing large, well-documented benefits,” Dr. McCollough said. “Personal experience and anecdotal stories are not enough. Consensus guidelines and outcome studies must be cited.”

    Prospective, blinded, randomized trials are the gold standard for demonstrating the efficacy of CT, she said, pointing out that such research is available for new applications including CT colonography and coronary CT angiographs. “These new applications used to be the new kids on the block, so in order to get accepted, researchers performed blinded, randomized studies to prove their efficacy in quantitative ways,” Dr. McCollough said.

    The American College of Radiology (ACR) Appropriateness Criteria offers evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. Dr. McCollough cited many clinical scenarios for which ACR expert panels considered CT as one of the most or the single most appropriate imaging modality.

    Published research cited by Dr. McCollough includes, “Acute Appendicitis: A Meta-Analysis of Diagnostic Performance CT and Graded Compression US Related to Prevalence of Disease,” in Radiology and “Accuracy of Non-focused Helical CT for the Diagnosis of Acute Appendicitis: A 5-Year Review,” in the American Journal of Roentgenology.

    She also recommends citing observational/retrospective studies in which the clinician/surgeon determines a management plan without CT and then re-evaluates the plan incorporating CT results. Results quantify the number of changed diagnoses/management plans and the significance of those changes.

    Above all, she stresses maximizing the benefit-to-risk ratio whenever possible. The goal is always to keep doses as low as reasonably achievable, eliminate unnecessary exams/phases, commit to Image Gently and Image Wisely campaigns and invest in dose reduction technology.

    “While we can increase the benefit-to-risk ratio by decreasing the risk (i.e. decreasing dose), the deciding factor on whether or not the exam is justified is always dominated by the benefit discussion,” Dr. McCollough said.

    Most Patients Favor Direct Access to Radiology Reports

    A survey of a small cohort of patients shows that the majority favor direct access to their radiology reports—via an online portal immediately after the study is read—according to presenters an RSNA 2012 session.

    “I am now convinced that patients want our input as radiologists, and that’s good news,” said Annette J. Johnson, M.D., M.S., a co-presenter of “Providing Reports Directly to Patients: Should You Do It?” Dr. Johnson is an associate professor of radiology at Wake Forest Baptist Medical Center in Winston-Salem, N.C.

    Dr. Johnson’s team performed simulation- and focus group-based research with a small cohort of patients, asking if they would like to receive results via an online portal. For the simulation, they were asked to imagine that they had undergone spinal MR imaging to investigate leg weakness and back pain, with the results being potentially “normal,” “indeterminate” or “seriously abnormal” (possible cancer).

    The majority of patients—45 to 60 percent—responded that they would want to see the results immediately, even if their doctor most likely had not had a chance to review them. “Those surveyed overwhelmingly thought faster would be better,” Dr. Johnson said. “Patients clearly believe that they’re more anxious waiting for results.”

    The results did not vary significantly according to age, gender or scenario, even when the results were indeterminate or seriously abnormal, Dr. Johnson said. Respondents frequently answered that, given results before the opportunity to speak with their physicians, they would seek out information on their own or seek support from a knowledgeable family member, friend or fellow churchgoer.

    The notion of providing a radiology report to a layperson naturally raises concerns among radiologists, said session co-presenter Curtis P. Langlotz, M.D., Ph.D, who discussed apprehensions that arose at the University of Pennsylvania (UPenn) Health System in Philadelphia before a patient portal was implemented in June of this year.

    “Physicians were concerned that seeing reports would cause unnecessary anxiety for patients, and that this was not a compassionate way to communicate with them,” said Dr. Langlotz, vice-chair for informatics in the Department of Radiology at UPenn and a member of RSNA’s Radiology Informatics Committee. “They were also concerned that they would be overwhelmed with calls and questions and that patients might even figure out how to call the radiologists directly.”

    However, Dr. Langlotz added, “we had 85,000 activated accounts, and a grand total of four patient calls.”

    Richard Taxin, M.D., president of Southeast Radiology, Ltd., in Pennsylvania, noted a legislative program proposed about four years ago that would have made radiologists responsible for providing “summary reports” directly to patients, which was dismissed as “an unfunded mandate with potentially huge costs.”

    “More communication might improve patient care by making radiologists more visible to patients, but some radiologists don’t want to be seen,” Dr. Taxin said. “It could reduce malpractice lawsuits, but maybe we’re just kidding ourselves.”

    Proposals to optimize communication with patients included a “summary” of the report written in addition to the radiologist’s full report, condensed and explained in layperson’s terms. Writing such a summary would be time-consuming for radiologists, Dr. Johnson said, but radiologists can also opt to embed hyperlinks in the report to provide information on terms that might require additional definition.

    “The hyperlinks would direct patients to a credible source, which those surveyed really appreciated,” Dr. Johnson said.

    Asked about discrepancies between the “layperson’s” summary and the radiologist’s full report, co-presenter Leonard Berlin, M.D., was quick to respond. “There’s no reason there should be discrepancies,” said Dr. Berlin, a radiologist at Skokie Hospital, Illinois, and a professor of radiology at Rush University and the University of Illinois, Chicago. “The information should be the same, just condensed for the patient’s understanding. If the two summaries have different information, you’ve got a problem.”

    “It’s the information age, and people are no longer satisfied with someone telling them, ‘Oh, your MRI was fine,’” Dr. Johnson concluded. “Many physicians are concerned that patients won’t understand our reports. I think we underestimate them.”

    Cynthia H. McCollough, Ph.D.
    McCollough
    Taxin, Berlin, Johnson, Langlotz
    From left: Richard Taxin, M.D., Leonard Berlin, M.D., Annette J. Johnson, M.D., and Curtis P. Langlotz, M.D., Ph.D.
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