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Original Research |
1 Department of Radiology, Monmouth Medical Center, 300 Second Ave., Long
Branch, NJ 07740.
2 Department of Medical Education, Monmouth Medical Center, Long Branch, NJ
07740.
3 Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ
07740.
Received January 20, 2007;
accepted after revision April 19, 2007.
Address correspondence to R. B. Ruchman.
Abstract
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MATERIALS AND METHODS. The preliminary reports for 11,908 emergency diagnostic imaging examinations interpreted after hours by residents over a 3-year period (January 2002-January 2005) were reviewed retrospectively for any discrepancy with the attending radiologist's final interpretation. A discrepancy was noted if verbal notification of the ordering physician was required. The medical charts of the cases for which there was a major discrepancy between the two interpretations were reviewed. The discrepancies were categorized as to the effect on patient morbidity. The resident discrepancy rates were also compared with RADPEER data from our institution.
RESULTS. The overall major discrepancy rate was 2.6%. This rate is comparable to RADPEER data, which found a misinterpretation rate of 2.1%. The technique most commonly involved in cases with discrepant interpretations was contrast-enhanced CT of the abdomen and pelvis, with the most common diagnosis related to acute appendicitis (total of 21 cases). The rate of discrepancy was highest for residents who were in their third year of training. The indications for these examinations varied; however, the effect on patient management was no significant effect in 92.8%, some negative effect in 6.9%, and significant negative effect in 0.3%.
CONCLUSION. The results of this investigation highlight the minimal discrepancy rate that occurs with overnight resident coverage. Thus, there is no detrimental effect on the quality of patient care from relying on preliminary interpretations made by radiology residents.
Keywords: academic radiology • diagnostic imaging • emergency radiology • misdiagnosis • on-call radiologist • resident education
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In an effort to improve our department's quality of patient care, we examined the discrepancy rates between on-call resident and attending interpretations by reviewing the preliminary reports of overnight cases over a 3-year period (January 2002-January 2005). The reports issued for overnight examinations were reviewed for discrepancies between the preliminary interpretation by the resident and the final interpretation by the attending radiologist. The cases were organized by the imaging technique and diagnosis, the resident's level of training, and the impact on patient care. Medical charts were reviewed to identify the clinical indication for the examinations and whether the delay in diagnosis had led to increased morbidity or mortality.
In addition, the radiology resident-attending radiologist discrepancy data were compared with attending radiologist-attending radiologist interpretation variability using the results of our department's internal review based on the RADPEER program (American College of Radiology [ACR]).
Several studies have documented the rates of discrepancies between radiology residents and attending radiologists, but few investigations have evaluated the clinical impact of the discrepancies [2-6]. Thus, the purpose of this study was to examine a large volume of overnight cases to determine the discrepancy rates between resident and attending interpretations and the negative effect, if any, on patient care.
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Discrepancies were judged to be either major or minor. A major discrepancy was defined as one that had the potential to significantly impact patient care if not corrected and required verbal communication of the revised interpretation to the ordering physician—for example, appendicitis. A minor discrepancy was a radiologic finding without direct consequence to patient care, such as a simple renal cyst, and therefore did not require verbal notification of the ordering physician. All major discrepancies were then categorized on the basis of the level of training of the resident, the imaging technique used, the body system, and the impact on patient care and treatment planning.
A retrospective review of the medical charts of the major discrepant cases was performed to assess the impact caused by the delay in diagnosis. The impact on patient morbidity was categorized as some negative impact, significant negative impact, or no impact. Cases were judged to have some negative effect if the treatment plan was altered and to have significant effect if complications, morbidity, or mortality resulted.
Comparison of attending-to-attending interpretation discrepancies was performed with the assistance of the RADPEER program [1]. The final quarterly results from the participation of nine attending radiologists, as calculated by the RADPEER program, were reviewed for the most common technique and type of error involved [1]. The results as calculated by the ACR were compared with the discrepancy rates between residents and attending radiologists in our program for the same imaging techniques. The RADPEER organization of the types of errors involved differs slightly from ours. The number and percentage of errors are listed by imaging technique under the following categories: agreement (category 1); difficult case, disagreement (category 2); and misinterpretation (categories 3 and 4).
All CT examinations were performed using an MDCT scanner (HiSpeed, GE Healthcare). CT protocols for the abdomen and pelvis acquired contiguous 5.0-mm transaxial images from the dome of the diaphragm through the inferior pubic rami. The oral contrast material administered was a barium sulfate suspension (2.1% weight/volume, 2.0% weight/weight; Readi-CAT 2, E-Z-EM), and the IV contrast material was iohexol (300 mg I/mL; Omnipaque, Amersham Health).
The scanning protocol for head CT was contiguous transaxial slices of 2.5 mm through the base of the skull and of 5.0 mm through the apex with a standard filter. The chest CT protocol was contiguous 5.0-mm slices from the thoracic inlet through the upper abdomen with both standard and lung filters. For pulmonary CT angiography, a series consisting of 0.625-mm contiguous transaxial images from the dome of the diaphragm to the superior mediastinum with a standard filter was added to the standard chest protocol.
Sonography examinations were performed by experienced technologists using transducers ranging from 3 to 5 MHz (128XPIO unit, Acuson). Permanent gray-scale images were acquired in the transverse and sagittal planes with Doppler imaging, when appropriate.
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Most major discrepancies involved abdominal CT examinations (56.4%). As Table 1 shows, the most frequently missed or corrected diagnosis was acute appendicitis, with 21 cases. These cases represent 11.9% of the discrepancy cases involving abdominal CT. Of the 21 acute appendicitis cases, 81% involved a false-negative or missed diagnosis and 19% involved a false-positive or equivocal diagnosis. The second most commonly missed diagnosis was pulmonary embolism (PE) with 17 cases in total, which represents 35% of the total number of chest CT discrepancy cases. The majority of the 312 discrepancies occurred with the third postgraduate year (124, 39.7%) and the fourth postgraduate year (110, 35.3%) residents. Second (33, 10.6%) and fifth (45, 14.4%) postgraduate year residents take 6 months or less of call annually. A comparison of the discrepancy rates per year of training is compared with other studies in Table 2.
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A review of all the available charts (287/312, 92%) was performed. The reviewers assessed the effect of each discrepancy on the basis of the nature of the presenting complaint, the effect on patient management, and the final outcome. Most of the discrepancies (267/287, 93%) had no significant impact on patient care. The remaining discrepancies had some negative effect (19/287, 6.6%). The discrepancy had a significant negative effect in only one case (0.3%). The one major discrepancy that was thought to have a significant detrimental effect on patient outcome involved a case of ischemic colitis. A review of the patient's medical record indicated the appropriate physician was advised of the corrected report within 6 hours of the preliminary interpretation. Although the patient died, it is not clear whether the final outcome would have changed if there had been no delay in diagnosis.
The comparison of attending-attending interpretation variability was calculated by the RADPEER program: 675 cases were reviewed and submitted to RADPEER during the last quarter of 2004. The results of the RADPEER data for the attending-to-attending discrepancy rates were 12 CT cases and two sonography cases of misinterpretation (categories 3 and 4) over a 1-year period (2004-2005). These data yield a misinterpretation rate of 2.1% (14/675).
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The results of the current study show a minimal discrepancy rate with overnight resident coverage at a community-based academic medical center. The overall discrepancy rate for the study period in our department, 2.6%, is consistent with those reported by others who have compared resident and attending interpretations in the literature [2, 3, 5, 7]. Carney et al. [2] found a 3.8% discrepancy rate between radiology resident and attending radiologist interpretations, with the most common involving CT scans (94%). Wechsler et al. [8] found a major discrepancy rate of 1.2%; Wysoki et al. [9], a discrepancy rate of 1.7%; Velmahos et al. [7], a major discrepancy rate of 5.0%; and Bechtold et al. [3], an overall error rate of 7.6% in comparison with radiologists interpreting abdominal CT examinations. False-negative detection errors occurred more often than false-positive errors [2]—that is, it is more common to miss a finding than to misinterpret one.
In our study, 81% of the discrepancies related to appendicitis were false-negative cases. Although the greatest number of discrepant cases involved CT of the abdomen and pelvis for appendicitis, there were a significant number of discrepant cases involving CT pulmonary arteriography for PE. Of the 55 discrepant cases involving chest CT, 48 involved PE (87.3% of chest CT discrepancies). PE and appendicitis have been noted in other investigations of on-call discrepancy as being commonly misdiagnosed [2, 6]. This may be due to inherent limitations based on the quality of the examination and the presence of equivocal findings [10]. Nevertheless, a chart review of the cases of appendicitis and PE failed to reveal a significant impact on patient care. Our results confirm the published data that these diagnoses should be approached with caution [11, 12].
A review of the medical charts revealed a single case in which a discrepancy had a major clinical impact (0.3%). The percentage of cases with some negative clinical impact due to a discrepancy was 6.9%. These cases represent those in which the treatment plan was altered on the basis of the final interpretation.
The number of patients examined and the various imaging techniques involved are strengths of this study. In the current study, we compared the resident-to-attending discrepancy rate with the attending-to-attending discrepancy rate as calculated by the RADPEER program [1].
The rate calculated by the RADPEER program is comparable with literature documenting the effect of reinterpretations of the original attending radiologist's interpretation. Gollub et al. [13] found a higher rate, 17%, in possible changes in treatment planning due to attending reinterpretations. Although all attending radiologists are board-certified, a limitation of our study is that the morning case review was not limited to their areas of subspecialty training. At our institution, overnight cases are interpreted by the on-call attending radiologist regardless of his or her specialty. Thus, the individual discrepant cases were not necessarily reviewed by a subspecialist in that area. Furthermore, the final attending interpretation was accepted as the correct interpretation. The cases were not reviewed to determine whether the attending radiologist's interpretation was accurate.
In addition, residents providing overnight coverage can contact the attending radiologist for backup if needed. Attending radiologists have the ability to review cases if the resident has a question regarding the examination. There was no way of determining whether any discrepant cases had been reviewed by the attending radiologist overnight. These cases would not constitute a resident-attending discrepancy. Another limitation is that the criteria for assessing the impact on patient care are largely subjective. Finally, in examining the results of our discrepancy rates, we did not identify the risk factors associated with a discrepant interpretation. Further study is required to elucidate that issue.
On the basis of our results, we have concluded that the discrepancy rate between resident and attending interpretations of overnight cases is very low (2.6%). More important, the results are comparable to misinterpretation rates of the attending radiologists in our program (2.1%) for the same imaging techniques. Finally, despite the fact that discrepancies do occur, independent, but supervised, decision making by residents appears to have a minimal negative impact on the quality of patient care. Thus, there is a proper balance between resident education and quality patient care.
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