Sahni V Anik, Silveira Patricia C, Sainani Nisha I, Khorasani Ramin
1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Fl, Brookline, MA 02445.
2 Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
AJR Am J Roentgenol. 2015 Sep;205(3):584-8. doi: 10.2214/AJR.14.14053.
The purpose of this study is to assess the impact of implementing a structured report template on the quality of MRI reports for rectal cancer staging.
After excluding examinations performed after surgery or neoadjuvant therapy, we analyzed all rectal cancer staging MRI reports finalized at an academic medical center 12 months before and after an intervention consisting of implementing a structured report template integrated into the institution's speech recognition system. The primary outcome measure was the quality of rectal cancer staging MRI reports classified as optimal, satisfactory, or unsatisfactory, on the basis of the documentation of 14 quality measures predefined by a consensus of the institution's abdominal radiology subspecialists. Chi-square and t tests were used to assess differences in report quality and documentation of each discrete quality measure before and after the intervention.
The study cohort included 106 MRI reports from 104 patients (mean age, 60 years; 58.5% male); 52 (49.1%) of the reports were completed before implementation of the structured report template. After implementation, the proportion of total reports classified as optimal or satisfactory increased from 38.5% (20/52) to 70.4% (38/54) (p = 0.0010). No reports generated before the intervention were classified as optimal, whereas 40.7% (22/54) of reports were classified as optimal after the intervention.
Implementation and voluntary use of a structured report template improved the quality of MRI reports for rectal cancer staging compared with free-text format.
本研究旨在评估实施结构化报告模板对直肠癌分期MRI报告质量的影响。
排除手术后或新辅助治疗后进行的检查后,我们分析了在实施一项干预措施(将结构化报告模板集成到机构的语音识别系统中)前后12个月,在一家学术医疗中心完成的所有直肠癌分期MRI报告。主要结局指标是根据该机构腹部放射学亚专科专家共识预先定义的14项质量指标的记录情况,将直肠癌分期MRI报告的质量分为最佳、满意或不满意。采用卡方检验和t检验评估干预前后报告质量及各离散质量指标记录情况的差异。
研究队列包括来自104例患者的106份MRI报告(平均年龄60岁;58.5%为男性);其中52份(49.1%)报告在结构化报告模板实施前完成。实施后,分类为最佳或满意的报告总数比例从38.5%(20/52)增至70.4%(38/54)(p = 0.0010)。干预前生成的报告无一份被分类为最佳,而干预后40.7%(22/54)的报告被分类为最佳。
与自由文本格式相比,结构化报告模板的实施和自愿使用提高了直肠癌分期MRI报告的质量。