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The influence of clinical information on diagnostic radiology

The influence of clinical information on diagnostic radiology. Michael Hickman MIV. Overview. Berbaum KS, el- Khoury GY, Franken EA Jr , Kathol M, Montgomery WJ, Hesson W . Impact of clinical history on fracture detection with radiography . Radiology . 1988; 168:507-511

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The influence of clinical information on diagnostic radiology

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  1. The influence of clinical information on diagnostic radiology Michael Hickman MIV

  2. Overview • Berbaum KS, el-Khoury GY, Franken EA Jr, Kathol M, Montgomery WJ, Hesson W. Impact of clinical history on fracture detection with radiography. Radiology. 1988; 168:507-511 • Houssami N, Irwig L, et al. The influence of clinical information on the accuracy of diagnostic mammography. Breast Cancer Research and Treatment. 2004; 85:223-228 • Leslie A, Jones AJ, Goddard PR. The influence of clinical information on the reporting of CT by radiologists. British Journal of Radiology. 2000; 73:1052-1055 • Loy C, Irwig L. Accuracy of diagnostic tests read with and without clinical information. JAMA. 2004; 292:1602-1609

  3. The Arguement • In favor of providing radiologist with clinical information: • Accuracy of the read may be improved with additional information • Schreiber suggested better accuracy with chest x-ray readings when given clinical information in 1963 • In favor of not providing radiologist with clinical information: • Clinical information may bias the reading • Clinical information should be incorporated into decision making only after an unbiased read

  4. Definitions • Accuracy: quantified in terms of sensitivity, specificity, and ROC curves • Sensitivity: the proportion of individuals with a disease who have positive test results • Specificity: the proportion of individuals without a disease who have negative test results • Receiver operating characteristic (ROC) curves: test accuracy estimates for a test at several thresholds are joined together • Perception: the identification of abnormalities • Interpretation: the attribution of observed abnormalities to a disease process

  5. Impact of Clinical History on Fracture Detection with Radiography • Objective: Assess the effect of knowledge of localizing symptoms and signs on the detection of fractures in radiographs of trauma patients. • Materials and Methods: Seven radiologists from University of Iowa; 40 radiographs (26 subtle fractures, 14 normal) • Procedure: 2 sessions separated by 4 months; All 40 radiographs read, half of radiographs shown with clinical information in first session and vice versa in second session. Each radiograph read twice, once with and once without clinical information.

  6. Impact of Clinical History on Fracture Detection with Radiography • Results: Interpretations with clinical data were more accurate than interpretations without clinical clues. • Improved accuracy was based on higher true-positives rates rather than lower false-positive rates • The most important information was location

  7. Impact of Clinical History on Fracture Detection with Radiography • Discussion: “Clinical information affects detection of radiographic abnormalities, but mechanisms of the effect remain unclear.” • Clinical information • Indication of specific locations for intensive evaluation • Clues to search for particular abnormalities • Localizing clues facilitate the detection of subtle fractures largely by an increase in the true-positive rate with little to no change in false-positive rate • Improved PERCEPTION • 1 out of 5 radiologist are sued annually for malpractice with the largest category of suits involving missed diagnosis, fractures most common (1988).

  8. The influence of clinical information on the accuracy of diagnostic mammography • Objective: Examine the influence of knowledge of clinical information on the accuracy of mammography in women referred for investigation of breast symptoms • Methods: 2 radiologist read 480 mammograms (240 with cancer, 240 without) first without clinical information and then with information a few days later. • Clinical information: type and site of symptoms, but without knowledge of the level of suspicion of cancer based on clinical exam

  9. The influence of clinical information on the accuracy of diagnostic mammography • Results: Clinical information improved radiologists ability to detect breast cancer • Symptoms between cancer and non-cancer patients did not substantially differ • Clinical information “directed” the radiologist to the area of interest which led to improved PERCEPTION • Specific symptom and site or quadrant of the breast were the most crucial

  10. The influence of clinical information on the reporting of CT by radiologists • Objective: Determine whether clinical information alters the CT report • Method: Prospective blinded study consisted of 50 consecutive patients who had a CT performed. Each study was read by 2 of 3 radiologists, before and after knowledge of clinical information.

  11. The influence of clinical information on the reporting of CT by radiologists

  12. The influence of clinical information on the reporting of CT by radiologists • Results: 19% of CT reports were changed after clinical information was known; 83% of reports became more accurate and 17% became less accurate after the correct clinical information was known • CT contains a great deal of information with multiple systems and several body areas; “The more complex the investigation, the more important the clinical information.”

  13. Accuracy of Diagnostic Tests Read With and Without Clinical Information • Objective: To determine whether diagnostic tests are more accurate when read with clinical information or without it. • Study Selection: A systematic review of all articles comparing the accuracy of tests read twice by the same readers, once without and once with clinical information, but otherwise under identical conditions. Only articles that reported sensitivity and specificity or receiver operating characteristic (ROC) curves were included. • 16 articles met criteria

  14. Accuracy of Diagnostic Tests Read With and Without Clinical Information

  15. Accuracy of Diagnostic Tests Read With and Without Clinical Information

  16. Accuracy of Diagnostic Tests Read With and Without Clinical Information • Results: 9 out of 16 articles reported improved areas under ROC curves, more significantly with fabricated clinical information; 4 out of 5 articles reported improved sensitivity without loss of specificity • Conclusion: Clinical information improves accuracy by improving reader’s PERCEPTION

  17. Summary • Clinical information improves overall accuracy with CTs, mammography, and x-rays. • Accuracy is improved by increasing sensitivity without dramatically affecting specificity  PERCEPTION • The most crucial clinical information for the radiologist is location of symptoms. • Further studies should be conducted to investigate the impact of providing clinical information at different stages of the perception-interpretation sequence.

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