Rationale and Objectives
This study was designed to evaluate the performance of radiology residents in interpreting emergency department (ED) chest radiographs for congestive heart failure and to characterize the factors associated with a subsequent amended interpretation by an attending radiologist.
Materials and Methods
We retrospectively reviewed all amended reports for ED chest radiographs between January 2004 and July 2005 and identified those with discrepant interpretations regarding the diagnosis of congestive heart failure. A total of 1.9% (476 of 24,600) of chest radiographs were amended over the study period. Forty-eight patients (75% female, mean age 66 years) whose chest radiograph was amended for the diagnosis of congestive heart failure and were available for review formed the study population. A control group of 35 patients (69% female, mean age 67 years) were individually matched to a convenience subset of patients by age, gender, clinical indication, and radiographic projection. Chest radiographs were in the anteroposterior projection in 62% (30 of 48) of study patients and 60% (21 of 35) of controls. A blinded expert panel of three board-certified cardiothoracic radiologists jointly reviewed each chest radiograph for the presence or absence of congestive heart failure and its specific radiographic findings.
Results
The expert panel diagnosed congestive heart failure in 19% (9 of 48) of study patients and in 23% (8 of 35) of controls ( P = .65). When present, congestive heart failure was mild to moderate in severity in both the study and control groups ( P = 1.00). There was a significant difference in the expert panel agreement between the attending versus the resident interpretation (65% versus 35%, P = .008), for the study group. This resulted in fair agreement (κ = 0.29) between the expert panel and the attending interpretation and no agreement (κ = −0.29) between the expert panel and the resident interpretation. In contrast, the expert panel agreed with the joint resident/attending interpretation in 83% (29 of 35) of controls, yielding substantial agreement (κ = 0.72).
Conclusion
Interpretation of chest radiographs for congestive heart failure by radiology residents has a low error rate. The majority of chest radiographs with discrepant resident and attending interpretations were portable films of female patients with subtle radiographic findings of congestive heart failure, and were inherently difficult to interpret.
With a prevalence of 1% to 2% and an incidence of 400,000 persons per year, the ubiquity of congestive heart failure in the United States is alarming. Despite advances in diagnosis and treatment, the median survival of slightly greater than 3 years for men and 5 years for women is unchanged from that of the early 1970s. One third of patients with congestive heart failure are hospitalized every year, making it the leading diagnosis-related group in patients over 65 years of age and the single greatest cost to the Centers for Medicare and Medicaid Services (CMS) ( ). This high hospitalization rate may be partially explained by the recidivist nature of congestive heart failure, which prompts a high frequency of emergency department (ED) visits ( ).
The presenting signs and symptoms of congestive heart failure are well characterized. Unfortunately, each sign or symptom alone provides inadequate sensitivity or specificity, and the most common presenting symptom in the ED, dyspnea, is nonspecific ( ). Validated clinical and radiographic scores, such as the Framingham Criteria and Boston Criteria, are useful in diagnosing congestive heart failure ( ). Relatively recently, a biochemical marker, brain natriuretic peptide (BNP) and its precursor, Pro-BNP, also proved helpful in identifying the presence of congestive heart failure ( ). This biochemical marker, when added to certain clinical and radiographic findings, demonstrates enhanced diagnostic ability ( ).
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Materials and methods
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Table 1
Chest Radiograph and Patient Characteristics
Study Group (n = 48) Controls (n = 35)P Value Gender, n (%) Male 14 (29) 11 (31) .82 Female 34 (71) 24 (69) .82 Age, mean (SD), yr 65.7 (17.9) 66.9 (12.7) .72 Film projection(s), n (%) Posteroanterior and lateral 18 (38) 14 (40) .82 Anteroposterior 30 (62) 21 (60) .82 Resident experience/year, n (%) PGY-II 9 (19) 4 (11) .37 PGY-III 34 (71) 18 (51) .07 PGY-IV 5 (10) 13 (37) .004 † Mean resident PGY level (SD) 2.92 (0.54) 3.26 (0.66) .02 † Positive resident CHF diagnoses (%) 24 (50) 12 (34) ‡ .15 Positive attending CHF diagnoses 24 (50) 12 (34) ‡ .15 Positive panel CHF diagnoses 9 (19) 8 (23) .65
*Percentages are rounded and may not add up to 100%.
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Statistical Analysis
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Results
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Table 2
Characteristics of Congestive Heart Failure for Study and Control Groups as Described by the Expert Panel
Characteristic, n (%) Study Group (n = 9) Controls (n = 8)P Value Cephalization 7 (78) 8 (100) .47 Kerley B-lines 2 (22) 0 (0) .47 Bronchial wall thickening 1 (11) 0 (0) 1.00 Hilar haziness 3 (33) 3 (38) 1.00 Diffuse increase in lung density 3 (33) 1 (12) .58 Airspace opacities 0 0 1.00 Pleural effusion 6 (67) 5 (63) 1.00 Cardiomegaly 5 (56) 4 (50) 1.00
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Table 3
Expert Panel, Preliminary Resident, and Staff Radiologist Agreement
Expert Panel Agreement Resident Attending_P_ Value Study group 17/48 (35%) 31/48 (65%) .008
Table 4
Expert Panel, Preliminary Resident, and Staff Radiologist Interrater Reliability
Study Group Control Group Resident Versus Expert Panel Attending Versus Expert Panel Attending/Resident Versus Expert Panel Unweighted κ value (95% CI) −0.29 (−0.79 to 0.21) 0.29 (0.02 to 0.56) 0.72 (0.47 to 0.98)
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Discussion
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