Michael Hickman MIV

Berbaum KS, el-Khoury GY, Franken EA Jr, Kathol M, Montgomery WJ, Hesson W. Impact of clinical history on fracture detection with radiography. Radiology. 1988; 168:507-511

Houssami N, Irwig L, et al. The influence of clinical information on the accuracy of diagnostic mammography. Breast Cancer Research and Treatment. 2004; 85:223-228

Leslie A, Jones AJ, Goddard PR. The influence of clinical information on the reporting of CT by radiologists. British Journal of Radiology. 2000; 73:1052-1055

Loy C, Irwig L. Accuracy of diagnostic tests read with and without clinical information. JAMA. 2004; 292:1602-1609

In favor of providing radiologist with clinical information: Accuracy of the read may be improved with

additional information Schreiber suggested better accuracy with chest

x-ray readings when given clinical information in 1963

In favor of not providing radiologist with clinical information: Clinical information may bias the reading Clinical information should be incorporated into

decision making only after an unbiased read

Accuracy: quantified in terms of sensitivity, specificity, and ROC curves Sensitivity: the proportion of

individuals with a disease who have positive test results

Specificity: the proportion of individuals without a disease who have negative test results

Receiver operating characteristic (ROC) curves: test accuracy estimates for a test at several thresholds are joined together

Perception: the identification of abnormalities

Interpretation: the attribution of observed abnormalities to a disease process

Objective: Assess the effect of knowledge of localizing symptoms and signs on the detection of fractures in radiographs of trauma patients.

Materials and Methods: Seven radiologists from University of Iowa; 40 radiographs (26 subtle fractures, 14 normal) Procedure: 2 sessions separated by

4 months; All 40 radiographs read, half of radiographs shown with clinical information in first session and vice versa in second session. Each radiograph read twice, once with and once without clinical information.

Results: Interpretations with clinical data were more accurate than interpretations without clinical clues. Improved accuracy was based on higher true-

positives rates rather than lower false-positive rates

The most important information was location

Discussion: “Clinical information affects detection of radiographic abnormalities, but mechanisms of the effect remain unclear.” Clinical information

Indication of specific locations for intensive evaluation Clues to search for particular abnormalities

Localizing clues facilitate the detection of subtle fractures largely by an increase in the true-positive rate with little to no change in false-positive rate Improved PERCEPTION

1 out of 5 radiologist are sued annually for malpractice with the largest category of suits involving missed diagnosis, fractures most common (1988).

Objective: Examine the influence of knowledge of clinical information on the accuracy of mammography in women referred for investigation of breast symptoms

Methods: 2 radiologist read 480 mammograms (240 with cancer, 240 without) first without clinical information and then with information a few days later. Clinical information: type and

site of symptoms, but without knowledge of the level of suspicion of cancer based on clinical exam

Results: Clinical information improved radiologists ability to detect breast cancer Symptoms between cancer and non-

cancer patients did not substantially differ Clinical information “directed” the

radiologist to the area of interest which led to improved PERCEPTION

Specific symptom and site or quadrant of the breast were the most crucial

Objective: Determine whether clinical information alters the CT report

Method: Prospective blinded study consisted of 50 consecutive patients who had a CT performed. Each study was read by 2 of 3 radiologists, before and after knowledge of clinical information.

Results: 19% of CT reports were changed after clinical information was known; 83% of reports became more accurate and 17% became less accurate after the correct clinical information was known CT contains a great deal of information with

multiple systems and several body areas; “The more complex the investigation, the more important the clinical information.”

Objective: To determine whether diagnostic tests are more accurate when read with clinical information or without it.

Study Selection: A systematic review of all articles comparing the accuracy of tests read twice by the same readers, once without and once with clinical information, but otherwise under identical conditions. Only articles that reported sensitivity and specificity or receiver operating characteristic (ROC) curves were included. 16 articles met criteria

Results: 9 out of 16 articles reported improved areas under ROC curves, more significantly with fabricated clinical information; 4 out of 5 articles reported improved sensitivity without loss of specificity

Conclusion: Clinical information improves accuracy by improving reader’s PERCEPTION

Clinical information improves overall accuracy with CTs, mammography, and x-rays.

Accuracy is improved by increasing sensitivity without dramatically affecting specificity PERCEPTION

The most crucial clinical information for the radiologist is location of symptoms.

Further studies should be conducted to investigate the impact of providing clinical information at different stages of the perception-interpretation sequence.