Rationale and Objectives
Providing evidence-based appropriate imaging potentially increases diagnostic yield and prevents unnecessary imaging. The American College of Radiology’s (ACR) evidence-based Appropriateness Criteria ® (ACR-AC) were developed to provide imaging guidelines given various clinical scenarios. The goal of this study was to evaluate the knowledge level of the appropriate thoracic imaging study to be performed, given a clinical scenario.
Methods
An online survey comprising 20 multiple-choice questions was developed on the basis of excerpts from the ACR-AC for thoracic imaging. The survey was piloted and invitations were sent out to resident trainees in radiology ( n = 32), medicine ( n = 119), and surgery ( n = 40) and to pulmonary and critical medicine fellows ( n = 16).
Results
Sixty-nine trainees (33%) completed the survey. The trainees among those who completed the survey included 14 (20%) in radiology, 32 (46%) in medicine, eight (12%) in surgery, and 15 (22%) in pulmonary and critical medicine. Of the 69 trainees, most were male ( n = 47 [68%]), aged 25 to 35 years ( n = 65 [94%]), and in postgraduate years 1 to 3 ( n = 44 [64%]). The overall median and percentage number of correct responses were 13 (interquartile range [IQR], 11–15) and 65% ( n = 44), respectively. As would be expected, radiology residents performed better, with a median number of correct responses of 15 (IQR, 11–16) compared to 10 (IQR, 9–12) for medicine trainees, nine (IQR, 9–12) for surgery trainees, and 13 (IQR, 12–15) for pulmonary and critical medicine trainees. There was an increase in the median number of correct responses with years of training, ranging from 10 for postgraduate year 1 to 12 for postgraduate year 6.
Conclusions
This study shows an opportunity to increase the awareness of the ACR-AC. Increasing the awareness of the ACR-AC among trainees will likely increase their use in practice and ultimately improve patient care.
Imaging studies remain an integral and growing component of health care. Providing the appropriate evidence-based imaging studies increases diagnostic yield and prevents unnecessary imaging and the concomitant delays in diagnosis . The American College of Radiology’s (ACR) evidence-based Appropriateness Criteria ® (ACR-AC) were developed to provide imaging guidelines for specific clinical scenarios . The ACR-AC have been available for more than a decade, but previous studies have suggested continued limited awareness among resident trainees and attending physicians . In academic institutions, resident trainees are responsible for most of the imaging ordering, and therefore the goal of this study was to evaluate the knowledge level of the appropriate imaging in the context of thoracic imaging. To that end, this study was based on the ACR-AC for thoracic imaging, available on the ACR’s Web site .
Methods
Study Design
The study was performed at the Cleveleand Clinic Foundation (CCF) in Cleveland, Ohio during July and August 2010. We developed an online survey comprising 20 multiple-choice questions on the basis of direct excerpts from the ACR-AC for thoracic imaging . Multiple-choice responses were created to include the most appropriate choices as dictated in the ACR-AC document, along with other typical imaging alternatives. The survey was piloted and invitations were sent out to resident trainees in radiology ( n = 32), medicine ( n = 119), and surgery ( n = 40) as well as fellows in pulmonary and critical medicine ( n = 16). Two reminder e-mails were sent to the trainees at 3 and 6 weeks. At the end of the study, all trainees were provided with the most appropriate responses to the survey questions and Internet links to the relevant ACR-AC documents. There was no a priori assessment of knowledge or awareness of the ACR-AC, and such a question was not included in the survey to avoid subsequent Internet searches. Ethics approval exemption was obtained for the study from the institutional review board.
Data Analysis
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Results
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Table 1
Correct Responses to 20 Survey Questions from Residents and Fellows Across Four Training Institutes, Cleveland Clinic Foundation, July and August 2010
Training Institute_n_ (%) Median (Interquartile Range) Correct ∗ Percentage Correct Radiology 14 (20) 15 (11–16) 75 Medicine 32 (46) 13 (11–15) 65 Surgery 8 (12) 12 (10–14) 60 Pulmonary and critical medicine 15 (22) 13 (12–15) 65 Overall 69 (100) 13 (11–15) 65
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Table 2
Correct Responses to 20 Survey Questions from Residents and Fellows by Postgraduate Year, Cleveland Clinic Foundation, July and August 2010
Postgraduate Year_n_ (%) Median (Interquartile Range) Correct ∗ Percentage Correct 1 20 (29) 10 (9–13) 50 2 13 (19) 13 (12–14) 65 3 11 (16) 14 (12–15) 70 4 12 (17) 15 (13–16) 75 5 10 (15) 15 (13–15) 75 6 3 (4) 15 (10–16) 75
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Table 3
Correct and Most Frequent Incorrect Resident and Fellow Responses on a 20-question Survey Based on the American College of Radiology Appropriateness Criteria ® for Thoracic Imaging, Cleveland Clinic Foundation, July and August 2010
Clinical Scenario (Reference) Correct Answer (Rating Score ∗ ) Correct Responses Most Frequent Response 1. Acute asthma, suspected pneumonia, pneumothorax Chest radiograph (9) 17.6 (88%) No imaging needed, 2 (10%) 2. Acute exacerbation of COPD with one or more of leukocytosis, pain CAD, or CAD history Chest radiograph (9) 17.6 (88%) CT chest without contrast, 1.6 (8%) 3. Chronic dyspnea, suspected pulmonary origin, age >40 y, negative physical exam Chest radiograph (8) 13 (65%) CT chest without contrast, 6 (30%) 4. Chronic dyspnea, suspected pulmonary origin in any age, positive physical exam Chest radiograph (9) 7.6 (38%) CT chest without contrast, 11.8 (59%) 5. Hemoptysis with two risk factors, age >40 y, and >40 pack-year smoking history Chest radiograph (9)
CT chest without contrast (9) 13 (65%) CTA chest (noncoronary), 3.4 (17%) 6. Massive hemoptysis without cardiopulmonary compromise Chest radiograph (9)
CT chest without contrast (9)
Embolization bronchial artery (8) 16.6 (83%) CTA chest (noncoronary), 2.6 (13%) 7. Chronic cardiopulmonary disease, age >70 y, previous 6-mo radiograph available Chest radiograph (6) 1.8 (9%) No imaging needed, 9.2 (46%) 8. Compromised respiratory function in patient with ET tube Chest radiograph portable after catheter/tube insertion (9) 10.4 (52%) Chest radiograph portable follow-up, 9 (45%) 9. Respiratory compromise during tube insertion Chest radiograph portable after catheter/tube insertion (8) 15 (75%) Chest radiograph portable follow-up, 4.2 (21%) 10. Moderate or severe HTN: DBP 105–114 or ≥115 mm Hg Chest radiograph (5) 5 (25%) No imaging needed, 15 (75%) 11. Screening for pulmonary metastases with primary of bone and soft tissue sarcoma Chest radiograph (9)
CT chest no contrast (9) 11 (55%) FDG-PET whole body, 7.2 (36%) 12. Screening for pulmonary metastases with primary of malignant melanoma Chest radiograph (9)
CT chest no contrast (8) 11 (55%) FDG-PET whole body, 7.8 (39%) 13. Screening for pulmonary metastases with primary of renal cell carcinoma Chest radiograph (8)
CT chest no contrast (7) 12.6 (63%) FDG-PET whole body, 6.2 (31%) 14. Solitary pulmonary nodule ≤1 cm, low clinical suspicion for cancer Watchful waiting with CT follow-up (8)
CT chest no contrast (7) 17.6 (88%) Chest radiograph, 2 (10%) 15. Solitary pulmonary nodule ≤1 cm, moderate to high clinical suspicion for cancer CT chest no contrast (8) 3.8 (19%) CT chest with contrast, 7.4 (37%) 16. Nodule ≥1 cm, moderate to high clinical suspicion for cancer FDG-PET whole body (8)
Transthoracic need biopsy (8)
CT chest no contrast (8) 13 (65%) CT with contrast, 6.4 (32%) 17. Staging of bronchogenic carcinoma for non-small-cell carcinoma CT chest with or without contrast (including upper abdomen) (9)
FDG-PET whole body (8)
Chest radiograph (8)
MRI head with contrast (7) 18.6 (93%) 99m Tc bone scan whole body, 1.4 (7%) 18. Staging of small cell cancer CT chest with or without contrast (including upper abdomen) (9)
Chest radiograph (9)
MRI head with contrast (8)
FDG-PET whole body (7) 19.2 (96%) 99m Tc bone scan whole body, 0.8 (4%) 19. Positive chest radiograph including diffuse confluent opacities in HIV+ patient CT chest no contrast (6) 16.2 (81%) Chest radiograph, 2.8 (14%) 20. Positive chest radiograph, infection other than PCP suspected in HIV+ CT chest no contrast (6) 14.8 (74%) Chest radiograph, 2 (10%)
CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CT, computed tomography; CTA, computed tomographic angiography; DBP, diastolic blood pressure; ET, endotracheal; FDG, fluorodeoxyglucose; HIV, human immunodeficiency virus; HTN, hypertension; MRI, magnetic resonance imaging; PCP, Pneumocystis carinii pneumonia; PET, positron emission tomography.
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Discussion
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Study Limitations
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Conclusions
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References
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