Rationale and Objectives
To evaluate the performance of radiology residents in the interpretation of on-call, emergency “triple-rule-out” (TRO) computed tomographic (CT) studies in patients with acute chest pain.
Materials and Methods
The study was institutional review board–approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as “unlikely to be significant” (minor discrepancies) or “likely to be significant” for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident’s TRO interpretations was compared to 609 emergent non–electrocardiography (ECG)-synchronized chest CT studies using Pearson χ 2 test.
Results
Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P < .001), but there was no difference in the frequency of major discrepancies (2.1% vs. 2.8%, P = .55). Minor discrepancies in the TRO group most commonly resulted from missed extrathoracic findings with missed liver lesions being the most frequent. Major discrepancies mostly encompassed cardiac and extracardiac vascular findings but did not result in unnecessary interventions, significant immediate changes in management, or adverse patient outcomes.
Conclusions
On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non–ECG-synchronized chest CT.
In patients presenting with acute, undifferentiated, or atypical chest pain, computed tomography (CT) offers the possibility of ruling out obstructive coronary artery disease, pulmonary embolism, acute aortic syndrome, and other pathologies in a single comprehensive evaluation . This approach is commonly referred to as “triple-rule-out” (TRO) CT and is performed as an electrocardiography (ECG)–synchronized CT angiography (CTA) study of the heart or the entire chest . Evidence on the clinical utility of this approach is rapidly accumulating .
At the majority of academic institutions throughout the United States, preliminary interpretation of emergent diagnostic imaging studies in the on-call setting is provided by radiology trainees. On-call imaging studies are typically reviewed and finalized by subspecialty attending radiologists during normal business hours. For a number of imaging modalities and indications, a small but significant discrepancy rate between preliminary residents’ and final subspecialists’ interpretation has been demonstrated .
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Materials and methods
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Study Design and Selection of Studies
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CT Examination Protocols
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Grading of Discrepancies between Preliminary and Final Interpretation
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Analysis of Sources of Discrepancies
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Analysis of Potential Impact on Patient Management and Outcome
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Statistical Analysis
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Results
Examinations Included
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Frequency of Discrepancies between Preliminary and Final Interpretation
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Table 1
Agreement and Discrepancy Rates for the Triple-Rule-Out and Control Groups
Triple-Rule-Out Group ( n = 617), n (%) Control Group ( n = 609), n (%)P Value All discrepancies 69 (11.2) 41 (6.7) .008 Minor discrepancies 56 (9.1) 24 (3.9) <.001 Major discrepancies 13 (2.1) 17 (2.8) .55
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Sources of Minor Discrepancies in the Non–ECG-Synchronized Chest CT Control Group
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Table 2
Most Common Sources of “Minor” Discrepancies in the Control Group
Category of Abnormalities Number of Cases with Discrepancies Most Common Discrepancies Pulmonary parenchymal 9 Missed pulmonary nodules ( n = 4) Extrathoracic 9 Missed splenic lesions ( n = 2) Vascular 5 Missed subsegmental pulmonary embolism ( n = 2)
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Sources of Major Discrepancies in the Non–ECG-Synchronized Chest CT Control Group
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Table 3
Sources of “Major” Discrepancies in the Control Group
Number of Cases with Discrepancies Discrepancy 3 Missed pulmonary embolus 3 Missed pneumonia 3 Missed pulmonary edema 1 Missed left ventricular hypertrophy 1 Missed diffuse bronchiectasis 1 Missed stab wound tract hemorrhage 1 Missed esophagitis 1 Missed ascites 1 Missed lung mass 1 Missed pneumothorax 1 Missed premature coronary artery disease 17 Total
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Sources of Minor Discrepancies in the TRO Group
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Table 4
Most Common Sources of “Minor” Discrepancies in the Triple-Rule-Out Group
Category of Abnormalities Number of Cases with Discrepancies Most Common Discrepancy Extrathoracic 12 Missed liver lesion ( n = 8) Coronary 9 Overcalling degree of coronary stenosis ( n = 6) Congenital cardiac 9 Missed ventricular septal defect ( n = 4) Pulmonary parenchymal 7 Missed pulmonary nodules ( n = 5) Cardiac noncoronary 7 Subtle wall motion abnormalities ( n = 3)
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Sources of Major Discrepancies in the TRO Group
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Table 5
Sources of “Major” Discrepancies in the Triple-Rule-Out Group
Number of Cases with Discrepancies Discrepancy 4 Overcalling degree of coronary stenosis 1 Missed anomalous origin with “malignant” course of right coronary artery 1 Missed global hypokinesis with left ventricular enlargement and heart failure 1 Overestimation of calcium score 1 Missed displaced sternal body fracture 1 Low ejection fraction 1 Esophagitis 1 Left ventricular hypertrophy 1 Pericarditis 1 Mediastinal lymphadenopathy 13 Total
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Impact on Patient Management and Outcome
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Discussion
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