Peter Andrew Marcovici MD, Presenter: Nothing to Disclose

Catherine Stamoulis PhD, Abstract Co-Author: Nothing to Disclose

Stephan Dieter Voss MD, PhD, Abstract Co-Author: Nothing to Disclose

George A. Taylor MD, Abstract Co-Author: Nothing to Disclose

Structured chest radiograph reports were rated to be more complete and more effective than unstructured chest radiograph reports, and calculated to be globally of higher quality.

Radiology report completeness and effectiveness are important aspects of quality. Unstructured reporting involves dictating in a free-text manner, customizing content to each case. Structured reporting aims to standardize format and lexicon, which may increase completeness and/or effectiveness. Structured reporting may improve the communication of findings made, and may also improve the nature of exam interpretation itself. The goal of this study was to compare unstructured and structured chest radiograph reports, in terms of their completeness and effectiveness.

This study was approved by the institutional review board. Following an educational lecture on the background of structured reporting, radiology trainees were provided with a chest radiograph structured reporting template. For each of the twelve trainees who completed the study, five randomly selected unstructured and five randomly selected structured chest radiograph reports were independently scored by four blinded physicians raters. Structured reports were rated as more complete than unstructured reports, on a 5-point scale (mean 4.42, SD 0.24 versus 3.99, SD 0.35, p<0.001). Structured reports were rated as more effective than unstructured reports (mean 4.11, SD 0.35 versus 3.85, SD 0.36, p<0.001). Structured reports were rated higher using a combined completeness and effectiveness score, on a 10-point scale (mean 8.54, SD 0.48 versus 7.83, SD 0.65, p<0.001).

This study blindly compared 60 unstructured to 60 structured chest radiograph reports, in terms of their completeness and effectiveness. Structured reports were found to be more complete and more effective, as well of overall higher quality. The use of structured reports may improve the communication of findings perceived by the radiologist. The use of structured reporting templates may also improve exam interpretation, converting it from a largely intuitive process, to one that is cognitively more rational.

Marcovici, P, Stamoulis, C, Voss, S, Taylor, G, Structured Radiology Reports Are More Complete and More Effective than Unstructured Reports.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13014795.html