The ACR's RADPEER program is currently the leading method for peer review in the United States. To date, more than 18,000 radiologists and more than 1,100 groups participate in the program. The ABR ...accepted RADPEER as a practice quality improvement in 2009, which can be applied toward maintenance of certification; there are currently over 2,200 practice quality improvement participants. There have been ongoing deliberations regarding the utility of RADPEER, its goals, and its scoring system since the preceding 2009 white paper. This white paper reviews the history and evolution of RADPEER and eRADPEER, the 2016 ACR Peer Review Committee's discussions, the updated recommended scoring system and lexicon for RADPEER, and updates to eRADPEER including the study type, age, and discrepancy classifications. The central goal of RADPEER to aid in nonpunitive peer learning is discussed.
The purpose of this article is to review fetal radiation doses and associated risks resulting from CT performed during pregnancy. The scanning parameters that influence dose and the techniques for ...estimating and reducing dose are explained.
Fetal radiation doses for CT examinations in which the fetus is not directly imaged-for example, head or chest CT-are minimal and need not figure in the risk-benefit analysis to perform the examination. In contrast, radiation dose should be considered with abdominopelvic CT because the fetus is likely to be exposed directly to the scanning beam. Safe implementation of CT in this setting requires an understanding of the factors influencing radiation dose. With this knowledge, when a risk-benefit analysis in a given clinical situation favors imaging using CT, the radiologist need not withhold or delay the examination and can achieve diagnostic-quality images while reducing radiation exposure.
To assess the impact of a Liver Imaging Reporting and Data System (LI-RADS) structured template on quality of reports for hepatocellular carcinoma (HCC).
A departmental structured LI-RADS template ...was adopted in April 2015. CT and MRI reports from September 2014 to February 2016 with probable or definite HCC were reviewed. Reporting of the following was recorded for each lesion and compared between template and free-text reports: (1) LI-RADS category, (2) Couinaud segment, and (3) unequivocal description of presence or absence of major LI-RADS HCC features: arterial phase hyperenhancement, "washout," diameter, threshold growth, and "capsule."
There were 306 definite or probable HCCs, 125 (40.8%) reported with free text and 181 (59.2%) with the template. LI-RADS category was reported in 23 of 125 (18.4%) HCCs with free text and in 178 of 181 (98.3%) HCCs with the template (P < .001). Couinaud segment was reported in 102 of 125 (81.6%) HCCs with free text and in 181 of 181 (100%) HCCs with the template (P < .001). Diameter was reported in 118 of 125 (94.4%) HCCs with free text and in 181 of 181 (100%) HCCs with the template (P = .001). Threshold growth was reported in 36 of 125 (28.8%) HCCs with free text and in 169 of 181 (93.4%) HCCs with the template (P < .001). Arterial phase hyperenhancement was reported in 101 of 125 (80.8%) HCCs with free text and in 177 of 181 (97.8%) HCCs with the template (P < .001). Washout was reported in 93 of 125 (74.4%) HCCs with free text and in 178 of 181 (98.3%) HCCs with the template (P < .001). Capsule was reported in 24 of 125 (19.2%) HCCs with free text and in 176 of 181 (97.2%) HCCs with the template (P < .001).
Use of structured LI-RADS template resulted in more comprehensive and consistent reporting of major HCC features and LI-RADS category compared with free-text reporting.
The objective of our study was to analyze body CT utilization trends, indications, fetal radiation doses, and scanning parameters associated with high fetal radiation doses (defined as > 30 mGy).
A ...retrospective review of all chest and abdominopelvic CT examinations performed between 1998 and 2005 of patients known to be pregnant was conducted. Demographics, gestational age, examination indication, and scan parameters were recorded. Fetal radiation dose was calculated for those abdominopelvic examinations with direct fetal irradiation.
From a database of more than 170,000 chest and more than 180,000 abdominopelvic CT examinations, 74 chest and 86 abdominopelvic examinations of pregnant patients were identified. Chest CT use increased on average 75%/y/1,000 deliveries in pregnancy versus 19%/y increase in all patients (p = 0.2700). Abdominopelvic CT utilization increase was on average 22%/y/1,000 deliveries in pregnant patients versus 13%/y increase in all patients (p = 0.1865). The most common indication for chest CT during pregnancy was suspected pulmonary embolism (85%, 63/74) and for abdominopelvic CT, suspected appendicitis (58%, 50/86). The average fetal dose from abdominopelvic CT was 24.8 mGy (range, 6.7-56 mGy); one examination exceeded the 50-mGy threshold for increased risk of childhood cancer. Scanning parameters associated with a dose of more than 30 mGy were a pitch of less than 1 (p = 0.0080) and more than one series acquisition (p = 0.0136).
Growth of CT during pregnancy reflects the trend of increased CT utilization in the general population. Avoiding use of CT in pregnant patients with suspected appendicitis would significantly decrease fetal radiation exposure. Abdominopelvic CT during pregnancy should be carefully planned and monitored so as not to exceed the fetal radiation dose for negligible risk.
A major outcome of the current health care reform process is the move away from unrestricted fee-for-service payment models toward those that are based on the delivery of better patient value and ...outcomes. The authors' purpose, therefore, is to critically evaluate and define those components of the overall imaging enterprise that deliver meaningful value to both patients and referrers and to determine how these components might be measured and quantified. These metrics might then be used to lobby providers and payers for sustainable payment solutions for radiologists and radiology services. The authors evaluated radiology operations and services using the framework of the imaging value chain, which divides radiology service into a number of discrete value-added activities, which ultimately deliver the primary product, most often the actionable report for diagnostic imaging or an effective outcome for interventional radiology. These value activities include scheduling and imaging appropriateness and stewardship, patient preparation, protocol design, modality operations, reporting, report communication, and clinical follow-up (eg, mammography reminder letters). Two further categories are hospital or health care organization citizenship and examination outcome. Each is discussed in turn, with specific activities highlighted.
The radiographic appearance of bone metastases is usually determined by tumor histology and can be osteolytic, osteoblastic, or mixed. We present a patient with coexistent bone metastasis from ...multiple myeloma and prostate adenocarcinoma who exhibited synchronous bone involvement of both histologies within the same bone lesion, a rare phenomenon that has not been previously reported and led to atypical radiographic findings. The radiograph of a 71-year-old man with thigh swelling and pain demonstrated a lytic femoral lesion. Magnetic resonance imaging (MRI) confirmed a destructive process, but showed coexistent metaphyseal sclerosis. Multiple myeloma was suspected by demonstration of monoclonal gammopathy and confirmed by computed tomography (CT)-guided biopsy. Incidentally, CT demonstrated areas of sclerosis corresponding to T
hypointensity on MRI. Further studies revealed osteoblastic spinal metastasis, prostate enhancement on CT and prostate-specific antigen (PSA) level of 90 ng/mL, concerning for concomitant prostate neoplasm. After endoprosthetic reconstruction, pathology of the femur identified both plasma cell neoplasm and metastatic prostate adenocarcinoma. An association between prostate cancer and multiple myeloma is hypothesized due to tumor microenvironment similarities and possible common genetic variations, however, coexisting bone metastases have never been reported. This unusual finding explains the discrepant imaging features in our patient and is evidenced that certain clinical situations merit contemplation of atypical presentations of common malignancies even if this leads to additional testing.
The MFI is framed as three questions: 1) What are we trying to accomplish? (ie, SMART aim statement), 2) How will we know a change is an improvement? (ie, battery of metrics), 3) What changes can we ...make that will result in improvement? (ie, change concepts to be tested with PDSA cycles).1 In this model, proposed process changes are iteratively tested and results analyzed, similar to scientific hypothesis testing. Mura, waste related to the presence of unevenness in workload; eg, only scheduling MRI scans during daytime/midweek); Muri, waste resulting from overstressed staff, equipment, or processes; eg, overbooking outpatient CT scans; and Muda, waste resulting from non-value-added processes; eg, requiring patients to register multiple times during a mammogram visit. The key drivers are identified during brainstorming sessions by the QI team members most familiar with the work, drawing from their clinical experience or other aspects of the workflow. Because they help achieve the aim, these drivers are commonly referred to as the "leading indicators," while the outcomes are referred to as "lagging indicators." Design changes to the system are identified as change interventions,11 These changes are deliberately intended to improve performance of the key drivers, not the outcome, Importantly, no changes can directly improve the outcome without improving the key processes, Without knowing how the key drivers are performing; ie, without measurement), it is impossible to know why the outcome is improving or getting worse, PICK Chart The PICK (Possible, Implement, Challenge, Kill) chart (Figure 5) is used to help determine which changes should be prioritized, This tool incorporates two dimensions: the degree of impact, and the difficulty of implementation (Figure 5).12 The team can review the suggested change interventions together and use sticky notes or a smartboard to place the proposed changes into the quadrants of the chart, High-impact, low-effort changes should definitely be implemented ("Implement"), whereas low-impact, high-effort changes should be avoided ("Kill"), Those that are easy to implement but have low impact may be considered based on time and resources ("Possible"), Those of high impact but high difficulty to enact ("Challenge"), such as creating a new program, may be considered, but they require significant investment in resources to achieve a long-term return aligned with an organization's overall strategy, Fishbone Diagram The Fishbone diagram (Figure 6), also known as a cause and effect or Ishikawa diagram, maps the possible causes of problems into categories, It is useful for identifying all aspects of a particular process or workflow, The tool was designed as a template for root-cause analysis, whereby a manager could ask "why" five times in order to arrive at the cause of a problem, Categories are modified according to the project and may include materials, machines, methods, measurement, environment, and people,13 Pareto Chart The Pareto principle, also known as the 80/20 rule, arose from an observation that approximately 80 percent of a problem derives from approximately 20 percent of the causes, Similar to the PICK chart, the Pareto chart (Figure 7) organizes factors by those that contribute the most to a particular problem; separating the "vital few" from the "trivial many" ,14 Waste Walk Tool Eliminating waste is the central tenet of Lean, The waste in a system may be identified by taking a "waste walk" (or several) through the workplace to record observations of the people, processes, and environment, Wasted time, effort, and other resources can then be categorized and corrective actions developed to eliminate that waste, Corrective
The aim of this study was to compare the accuracy of coronary atherosclerosis reporting before and after the implementation of a structured reporting chest CT template.
A noncardiac, noncontrast ...chest CT structured reporting template was developed and mandated for department-wide use at a large academic center. The template included the statement "There are no coronary artery calcifications." All noncardiac, noncontrast chest CT examinations reported over 3 days, 1 month after template implementation (structured template group), and from a 3-day period 1 year prior (control group) were retrospectively collected. Final radiology reports were reviewed and designated positive or negative for coronary calcifications. CT images were reviewed in consensus by 2 radiologists, who scored each case for the presence or absence of coronary calcifications, blinded to the original report. Statistical analysis was performed using Pearson χ(2) and Fisher exact tests.
Sixty-five percent (69 of 106) of structured template group and 58% (62 of 106) of control group cases had coronary calcifications. Reports from the structured template group were more likely to correctly state the presence or absence of coronary atherosclerosis compared with those from the control group (96.2% vs 85.8%; odds ratio, 4.2; 95% confidence interval, 1.3-13.1; P = .008). Structured template group reports were less likely to be falsely negative compared with control group reports (3.8% vs 11.7%; odds ratio, 3.4; 95% confidence interval, 1.0-10.8; P = .03).
Implementing a structured reporting template improves reporting accuracy of coronary calcifications.
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