Cohort Study of Structured Reporting Compared with Conventional Dictation
Cohort Study of Structured Reporting Compared with Conventional Dictation
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DOI：
10.1148/radiol.2531090138
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发表时间：
2009-10-01
期刊：
影响因子：
19.7
通讯作者：
Littenberg, Benjamin
中科院分区：
文献类型：
--
作者：
Johnson, Annette J.;Chen, Michael Y. M.;Littenberg, Benjamin
目的：为了确定是否放射科居民谁使用结构化报告系统（SRS）产生更高质量的报告比居民谁使用传统的自由文本听写报告颅磁共振（MR）成像在患者怀疑有stroke.Materials and Methods：这项研究是由机构审查委员会批准，并符合健康保险及责任法案，知情同意书获得。这项研究包括居民，其中16人在对照组，18人在干预组。对于第1阶段，每名受试者审查了同一组25例脑MR成像病例，并通过使用自由文本传统听写来听写这些病例。对于第2阶段，4个月后，对照组重复相同的过程，而干预组通过使用SRS重新读取相同的MR成像病例以创建报告。由神经放射科医师根据共识解释和标准诊断（通过至少6个月的临床随访、影像学随访和/或组织学检查（如适用）确定）对住院医师生成的报告的准确性和完整性进行分级。通过使用Wilcoxon符号秩检验（配对数据）和Mann-Whitney U检验（非配对数据）分析准确性和完整性评分。干预组居民就他们对SRS的意见进行了调查。结果：对于第1阶段报告，对照组和干预组之间的准确性或完整性评分没有显着差异。（91.5至88.7）和完整性（68.7 ~ 54.3）干预组第2阶段与第1阶段的得分比较;与对照组的第1阶段相比，第2阶段的准确性（91.4至92.4）和完整性（67.8至71.7）评分增加（所有P值均<0.001）。最常见的投诉是，SRS是过于约束方面的报告内容，是耗时use.Conclusion：虽然有许多潜在的好处，结构化放射学报告，这样的变化不能被假定为提高报告的准确性或完整性。应测试任何SRS对报告内在质量的影响。(C)RSNA，2009年
Purpose: To determine if radiology residents who used a structured reporting system (SRS) produced higher quality reports than residents who used conventional free-text dictation to report cranial magnetic resonance (MR) imaging in patients suspected of having a stroke.Materials and Methods: The study was approved by an institutional review board and was HIPAA compliant; informed consent was obtained. This study included residents, with 16 in the control group and 18 in the intervention group. For phase 1, each subject reviewed the same set of 25 brain MR imaging cases and dictated the cases by using free-text conventional dictation. For phase 2, 4 months later, the control group repeated the same process, whereas the intervention group reread the same MR imaging cases by using SRS to create reports. Resident-generated reports were graded for accuracy and completeness by a neuroradiologist on the basis of consensus interpretations and criterion standard diagnoses as established with at least 6 months of clinical follow-up, imaging follow-up, and/or histologic examination where appropriate. Accuracy and completeness scores were analyzed by using a Wilcoxon signed rank test for paired data and a Mann-Whitney U test for nonpaired data. Intervention group residents were surveyed regarding their opinions of SRS.Results: For phase 1 reports, no significant difference in accuracy or completeness scores between control and intervention groups was found. Decreases in accuracy (91.5 to 88.7) and completeness (68.7 to 54.3) scores for phase 2 compared with phase 1 for the intervention group were found; increases in accuracy (91.4 to 92.4) and completeness (67.8 to 71.7) scores for phase 2 compared with phase 1 for the control group were found (all P values < .001). The most common complaints were that the SRS was overly constraining with regard to report content and was time-consuming to use.Conclusion: While there are many potential benefits of structuring radiology reports, such changes cannot be assumed to improve report accuracy or completeness. Any SRS should be tested for effect on intrinsic report quality. (C) RSNA, 2009