Department of Radiology, Duke University School of Medicine, Durham, North Carolina 27710, USA.
J Nucl Med. 2010 Jan;51(1):158-63. doi: 10.2967/jnumed.109.066399. Epub 2009 Dec 15.
Our objective was to identify core elements for inclusion in oncologic PET reports and to evaluate a sample of reports in the National Oncologic PET Registry database.
A list of desirable elements in PET reports was compiled from American College of Radiology and Society of Nuclear Medicine guidelines. A training set of 20 randomly selected reports was evaluated by the 4-physician panel, and the results were used to formulate a consensus approach for assessing report content and quality. Each reviewer then scored 65 randomly selected reports-20 common to all reviewers. The scores were tabulated, and interrater variability was measured for the common cases.
Each report was assessed for 34 elements-21 primary and 11 additional questions related to 6 of these primary elements. Among the common cases, there was strong (> or = 0.70) interrater agreement for 30 of 34 elements. Among the unique cases, only 9 elements were included in more than 90% of the reports. Several important elements were not included in more than 40% of the reports: the reason for the study, a description of treatment history, a statement about comparison to other imaging, and time from radiopharmaceutical injection to imaging.
Essential elements that should be included in oncologic PET reports were missing from many reports. These deficiencies may render the reports less helpful to referring physicians, may lead to misdiagnoses, and may cause coding and billing errors. Interpreting physicians should audit their reports to ascertain that they include appropriate elements necessary for billing compliance and for effective communications with referring physicians.
我们的目的是确定纳入肿瘤 PET 报告的核心要素,并评估国家肿瘤 PET 注册数据库中的报告样本。
从美国放射学院和核医学协会的指南中编制了 PET 报告中理想元素的清单。由 4 位医师组成的小组对 20 份随机选择的报告进行评估,评估结果用于制定评估报告内容和质量的共识方法。然后,每位审阅者对 65 份随机选择的报告进行评分——其中 20 份报告为所有审阅者所共有。对评分进行制表,并测量常见病例的组内变异。
对 34 个要素进行了每个报告的评估——21 个主要要素和 11 个与这些主要要素中的 6 个相关的附加问题。在常见病例中,34 个要素中有 30 个要素的组内一致性很强(>或=0.70)。在独特病例中,只有 9 个要素包含在超过 90%的报告中。一些重要的要素没有包含在超过 40%的报告中:研究的原因、治疗史的描述、与其他成像的比较说明以及放射性药物注射到成像的时间。
许多报告中缺少应包含在肿瘤 PET 报告中的基本要素。这些缺陷可能会使报告对转诊医生的帮助不大,可能导致误诊,并可能导致编码和计费错误。解释医师应审核其报告,以确保报告中包含适当的要素,以符合计费要求,并与转诊医生进行有效的沟通。