Implications of inadequate patient histories on the radiological examinations
Implications of inadequate patient histories on the radiological examinations
Introduction
Radiology is a medical specialty that uses imaging techniques for the diagnosis and treatment of diseases. Commonly used radiological techniques include X-ray radiography, ultrasound, computed tomography (CT), positron emission tomography (PET) and magnetic resonance imaging (MRI). A number of factors influence the diagnosis made by radiological techniques. Some of these factors include type of the disease, type of the technique used, parameters of the instrument used, interpersonal differences between the radiologists and clinical history of the patient.
The availability or non-availability of the clinical history affects the diagnosis of radiological examinations significantly. Suggestive clinical history increases the sensitivity of the interpretation of radiographs. This history makes the reader carry out a careful visual search for abnormalities related to the history. Therefore, unavailability of clinical history may result in perceptual misses in the diagnosis and may lead to diagnostic errors (Doubilet & Herman, 1981).
The belief that radiologists are there to perform investigations requested by physicians/specialists is a misconception. In a multi-disciplinary team, the role of a clinical radiologist is to aid the other members of the team in accurate diagnosis. In order to take complete benefit from radiology, it is imperative that complete patient history is provided to the radiologists (Depasquale & Crockford, 2005).
Several researchers have focused on the effect of availability of clinical history of the patient on the radiological diagnosis. The clinical history helps in improving the accuracy of the radiological studies at two distinct stages of the result interpretation viz. perception and interpretation. Perception means the identification of abnormal areas & their features and interpretation refers to attribution of observed findings to a disease process. If the clinical information is provided before the test, it assists both perceptions and interpretation. However, some researchers believe that reading of the clinical information may lead to a bias in decision making. For example, clinical information may bias the radiographer to see a defect that may not be present. Therefore, the clinical information may defeat the purpose of a diagnostic test. A better way to utilize the clinical history is to read the diagnostic tests first, and then analyze the clinical information followed by re-reading of the test results before final reporting. This sequence of events minimizes the bias and aids the interpretation of results accurately (Loy & Irwig, 2004).
In a study conducted with eleven radiologists, they were asked to read the test films with and without clinical history of the patient. A statistically significant increase in the true-positive diagnosis was noted when the history was provided. In case of a patient with a cyst in the lungs, 75% of the radiologists could diagnose correctly when the patient history was given. On the contrary, only 25% of the radiologists could diagnose the condition correctly when patient history was not given. This study emphasizes the need of clinical history for proper and accurate diagnosis of radiologic films (Doubilet & Herman, 1981). In a similar study, the effect of availability of clinical history on the sensitivity for stroke detection by unenhanced CT and diffusion-weighted MRI was evaluated. Availability of clinical history indicating the early stroke significantly improved the sensitivity of detecting strokes with unenhanced CT. However, this sensitivity did not affect the sensitivity for detections of stroke with MRI (Mullins et al., 2002).
History of the problem
The fact that clinical information and patient history improves the accuracy of X-ray examination is known to the clinicians and researchers since last fifty years (Loy & Irwig, 2004). A similar positive correlation has been established between the availability of clinical history and other radiologic techniques such as CT and MRI (Mullins et al., 2002). However, in majority of the hospital settings, clinical history is not provided to the radiologists. This unavailability sometimes results in misdiagnosis of the disease or a wrong choice of radiological technique by the radiologist. Apart for the summarized patient history, the provision of previous radiologic information (films and reports) also facilitates specific diagnosis and facilitates keen observations by the radiologists (Aideyan, Berbaum & Smith, 1995).
The problem deserves attention
Studies are needed in this area for improvements in reporting of the clinical history. It may serve as a useful guide for planning and conduct of diagnostic tests. However, inaccurate information may affect the test reading adversely (Loy & Irwig, 2004). Radiology request forms provide a complete clinical picture to the radiologists so that they may be in a better position to decide on best radiological examination necessary and subsequently aid in the diagnosis. Therefore, there is an urgent need for increasing the awareness about the radiology request forms in the referring practitioners (Depasquale & Crockford, 2005).
Proposed solution to the problem
The issue of unavailability of patient history to the radiologists can be addressed by filling up of the radiology request forms by the referring doctors. Radiology request forms are essential communication tools between the doctors, radiographers/radiologists and patients/families. These forms help the radiologists understand the clinical history of the patient and decide whether the exposure is justified. However, no standard format of radiology request forms is available till date (Depasquale & Crockford, 2005). Computerized patient history forms or electronic medical records of the patients may be helpful in accurate radiological diagnosis.
A standard radiology request form should contain the following information:
- Clinical history and background
- The question to be answered
- Ward (in case of in-patients)
Justification for the solution
An adequately completed radiology request form ensures appropriate investigation of the patient. The Royal College of Radiologists (RCR) issues the guidelines regarding the completion of these forms. According to RCR, these forms should be completed accurately to avoid misinterpretation. Forms should ideally be type-written and sufficient clinical details should be supplied so that the imaging specialist may understand the diagnostic/clinical problems to be resolved by radiological investigation. Studies conducted to evaluate the completeness of the radiology request forms revealed that a number of blank fields were left in the forms. The forms lacked ‘questions to be answered’ in 17% of the studied cases (Oswal, Sapherson & Rehman, 2009).
The other possible solutions to the unavailability of patient history are time and resource consuming. However, high quality studies may be performed using diverse diagnostic tests and clinical situations so as to standardize the interpretation of test results in absence of clinical history of the patients. Cross tabulation of clinical information against test results in diseased and healthy subjects may be provided to the radiologists for reference (Loy & Irwig, 2004).
Implementation plan for solution
Every hospital has a different radiology request form and there are differences in the layout, nomenclature of different fields and variation in the required fields. Having a single form for one type of imaging modality throughout the country may improve the completeness of the forms (with special reference to the clinical history). Therefore, a joint initiative by hospitals is required in this concern. Secondly, all hospitals should inform the radiology experts not to accept partially filled forms. Thirdly, the hospitals may implement the system of electronic medical records (with complete patient history) that can be shared with the radiology division of the same hospital through an online system (Oswal, Sapherson & Rehman, 2009).
There may be certain challenges in the implementation of the solution. For example, newly joined junior doctors may not be aware of the importance of duly-filled radiology request forms. Therefore, it is the responsibility of the radiology division of the hospital to disseminate the information to the doctors. This may be done by circulating standardized guidelines for the use of request forms in the hospital.
Conclusion
Clinical history of a patient significantly affects the diagnosis of radiological examinations. Studies have implicated the utility of clinical history in accurate diagnosis by the radiologists. The current radiology referral process is inadequate as it does not mandatorily include clinical history of the patient. Therefore, it is recommended that radiologists should return the incomplete radiology request forms and should pay attention to the clinical history during the reading of the tests.
Appendix
A sample of radiology request form (adapted from Depasquale & Crockford, 2005).
References
Aideyan, U. O., Berbaum, K. & Smith, W. L. (1995). Influence of prior radiologic information on the interpretation of radiographic examinations. Academic Radiology, 2, 205-208.
Depasquale, R. & Crockford, M. P. (2005). Are radiology request forms adequately filled in? Malta Medical Journal, 17(4), 36-38.
Doubilet, P. & Herman, P. G. (1981). Interpretation of radiographs: Effect of clinical history. American Journal of Roentgenology, 137, 1055-1058.
Loy, C. T. & Irwig, L. (2004). Accuracy of diagnostic tests read with and without clinical information. Journal of American Medical Association, 292(13), 1602-1609.
Mullins, M. E., Lev, M. H., Schellingerhout, D., Koroshetz, W. J. & Gonzalez, R. G. (2002). Influence of availability of clinical history on detection of early stroke using unenhanced CT and diffusion-weighted MR imaging. American Journal of Roentgenology, 179, 223-228.
Oswal, D., Sapherson, D. & Rehman, A. (2009). A study of adequacy of completion of radiology request forms. Radiography, 15, 209-213.
