Providence, RI - Test result reports sent from nuclear cardiology labs to requesting physicians frequently omit important information, including basics like the report date or clear quantification of the myocardial defect [1].
A retrospective study of 1301 US nuclear cardiology labs applying for accreditation by the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL) found that 57% were noncompliant with at least one of 18 required reporting elements and site characteristics of ICANL standards in 2008. The results of the study, led by Dr Peter Tilkemeier (Miriam Hospital, Providence, RI), appear in the Journal of Nuclear Cardiology.
The most common mistake, made by 26.4% of labs, was not listing the date of the report. "The date of the report sounds like a very minor thing, but the date of the report is the means of tracking the time it takes from when the patient walks out the door until when the study is read by a physician and then proofread by a physician, which is very important," said Mary Beth Farrell, study coauthor and Director of Accreditation at the Intersocietal Accreditation Commission.
Almost 20% of the labs did not always include the myocardial defect size, severity, type, and location in the report using standardized terminology.
"The most important part of the test is to communicate the results to the person who is caring for the patient," Farrell told heartwire. Educating nuclear cardiology imaging lab personnel about the importance of clear communication with physicians requesting tests is one of "the primary goals for the American Society of Nuclear Cardiology," Farrell said.
The compliance process, itself, appears to be one of the best education tools. The study found that labs were more likely to comply with ICANL reporting standards the more times they had been through the accreditation process. Also, laboratories in states that did not require accreditation for reimbursement had greater noncompliance compared with laboratories in states with that requirement, the study found.
"The data demonstrate that the ICANL accreditation process works," Tilkemeier and colleagues argue. "By setting standards of policies and procedures, based on guideline documents developed by the professional societies, ICANL is an instrument driving the improvement process. . . . Accreditation is a learning process for the laboratories." The study found that labs usually went through two accreditation application cycles before reaching full compliance. The authors speculate it took this long because "changing long-standing processes requires time and multiple interventions that include motivation, belief in the change, and accountability."
In an accompanying editorial [2], Dr Frans Wackers (Yale University, New Haven, CT) observes: "One may feel that accreditation is just one more burden imposed on physicians and laboratories in an already (over) regulated medical practice environment, [but the study by Tilkemeier et al shows] the process of accreditation, ie, submitting data on all aspects of a laboratory and receiving feedback from reviewers, appears to have educational value."
Clarity counts
"The report, being an instrument of communication, must be evaluated for its effectiveness. Nuclear cardiology is not that esoteric that it cannot be described in plain English," Wackers argues. "If the wording of a report does not convey a clear message that is informative to the referring physician, communication has failed, as well as the purpose of performing the test in the first place."
"Curiously, some people who speak perfectly normal and understandable English in normal life may use very strange, indirect and convoluted language when creating a nuclear cardiology report," Wackers observes. "One of the reasons for unclear and cautious language may be the hesitation to commit unequivocally to either normal or abnormal interpretation. Not infrequently an interpreter has to make a choice between artifact and true perfusion abnormality. The interpreter, being the expert, should not share his/her ambiguity with the referring clinician, but bite the bullet and commit him/herself one way or the other in clear language."
Patterns of noncompliance
The study also assigned importance scores for each reporting element required by the ICANL standards. The most important elements are succinct impression, defect quantification, wall motion findings, indication, timeliness, and nomenclature or standardization. Moderately important elements include physician's signature, description of procedure, date of report, nonradioactive dose and route of administration, and exact dose of the radiopharmaceutical.
The study found that labs in western US states were more likely to miss the most important report elements than labs in other regions and mobile labs had higher rates of missed report elements than multispecialty facilities, private practices, or hospitals. Hospitals generally had the best rates of compliance weighted by severity, "but you can't outright say that hospitals were [always] better than private centers," Farrell stressed. The number of tests the lab performed and number of interpreting physicians working at the lab did not affect the distribution of severity of noncompliant elements.
Even prior to this study, many cardiologists were pushing for improvement in the quality of reporting from nuclear cardiology labs, Farrell said. "We expected as much and now we have the data to say specifically, what parts of the country we should spend more time on and we know the specific elements [of reports] that are most frequently missed."
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