Weber Tim Frederik, Spurny Manuela, Hasse Felix Christian, Sedlaczek Oliver, Haag Georg Martin, Springfeld Christoph, Mokry Theresa, Jäger Dirk, Kauczor Hans-Ulrich, Berger Anne Katrin
Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69121, Heidelberg, Germany.
Department of Medical Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, Heidelberg, Germany.
Insights Imaging. 2020 Sep 29;11(1):106. doi: 10.1186/s13244-020-00907-1.
Our aim was to develop a structured reporting concept (structured oncology report, SOR) for general follow-up assessment of cancer patients in clinical routine. Furthermore, we analysed the report quality of SOR compared to conventional reports (CR) as assessed by referring oncologists.
SOR was designed to provide standardised layout, tabulated tumour burden documentation and standardised conclusion using uniform terminology. A software application for reporting was programmed to ensure consistency of layout and vocabulary and to facilitate utilisation of SOR. Report quality was analysed for 25 SOR and 25 CR retrospectively by 6 medical oncologists using a 7-point scale (score 1 representing the best score) for 6 questionnaire items addressing different elements of report quality and overall satisfaction. A score of ≤ 3 was defined as a positive rating.
In the first year after full implementation, 7471 imaging examinations were reported using SOR. The proportion of SOR in relation to all oncology reports increased from 49 to 95% within a few months. Report quality scores were better for SOR for each questionnaire item (p < 0.001 each). Averaged over all questionnaire item scores were 1.98 ± 1.22 for SOR and 3.05 ± 1.93 for CR (p < 0.001). The overall satisfaction score was 2.15 ± 1.32 for SOR and 3.39 ± 2.08 for CR (p < 0.001). The proportion of positive ratings was higher for SOR (89% versus 67%; p < 0.001).
Department-wide structured reporting for follow-up imaging performed for assessment of anticancer treatment efficacy is feasible using a dedicated software application. Satisfaction of referring oncologist with report quality is superior for structured reports.
我们的目标是开发一种结构化报告概念（结构化肿瘤学报告，SOR），用于临床常规中癌症患者的一般随访评估。此外，我们分析了与传统报告（CR）相比，SOR的报告质量，由会诊肿瘤学家进行评估。
SOR旨在提供标准化的布局、列表形式的肿瘤负荷记录以及使用统一术语的标准化结论。编写了一个报告软件应用程序，以确保布局和词汇的一致性，并便于SOR的使用。6名医学肿瘤学家对25份SOR和25份CR进行回顾性报告质量分析，使用7分制（1分代表最佳分数）对涉及报告质量不同要素和总体满意度的6个问卷项目进行评分。评分≤3被定义为正面评价。
在全面实施后的第一年，使用SOR报告了7471次影像检查。SOR在所有肿瘤学报告中的比例在几个月内从49%增加到95%。每个问卷项目的SOR报告质量得分更高（每项p<0.001）。所有问卷项目得分的平均值，SOR为1.98±1.22，CR为3.05±1.93（p<0.001）。总体满意度得分，SOR为2.15±1.32，CR为3.39±2.08（p<0.001）。SOR的正面评价比例更高（89%对67%；p<0.001）。
使用专用软件应用程序，在部门范围内对用于评估抗癌治疗疗效的随访影像进行结构化报告是可行的。会诊肿瘤学家对结构化报告的报告质量满意度更高。
