Background. Structured Thyroid Ultrasound Reports 1/8/2018. Clear Communication Improves Management

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1 Thyroid Ultrasound Reports Clear Communication Improves Management Corey J. Hiti, MD Wendy Yang, MD 2 Michael Campbell, MD FACS 2 Thomas Loehfelm, MD PhD UC Davis Medical Center Department of Radiology, 2 Department of Endocrinology Sacramento, California Dr. Preston Hickey, an early editor of the AJR and president of the American Roentgen Ray Society writes an article entitled Standardization of Roentgen-Ray Reports in 922 in which he advocated for standard terminology and structure in reports of the time period. In 988, in the face of increasing mammography utilization with disparate quality, the ACR convened the committees that would result in the production of the BI-RADS lexicon and report structure. Background In 2007, the ACR Intersociety Conference convened to discuss radiology reporting and released a summary statement advocating the use of structured reports in which reports are organized into sections that contain standardized language. Shortly thereafter, the RSNA established the Reporting Committee and the RadLex committee to develop structured reporting tools.

2 Purpose Implement a standard template in the Body Section of a university academic radiology practice to facilitate: Clear and consistent communication Data mining for ongoing quality improvement Quality metrics for radiologists Monitoring the impact on clinical decision making Methods Reach Nodule consensus Descriptions with radiology and Boilerplate endocrinology Text Included on a in classification the system at Right Lobe: the End of Every Report Revised [size] cm Korean ([vol] cc), Society {echotexture}. of Thyroid Radiology Consensus Statement and Recommendations Nodules: (K-TIRADS) malignancy risk stratification Note that guidelines differ among organizations regarding the management systemof thyroid nodules, and the decision to biopsy and length. {Location}, [size] cm, {composition}, of follow-up may vary depending on clinical factors. Based on such Introduce {suspicious a features}. structured [Free text.] template {KTIon factors, November FNA may not, be 206 indicated for nodules that meet the RADS Use encouraged Category} for all thyroid ultrasound recommendations below, while FNA may be appropriate for nodules that do not reports. meet the criteria listed below. echotexture: location: composition: suspicious ktirads category: features: design included constrained K-TI-RADS vocabulary Consensus Recommendations: for nodule descriptions, and. Category required Normal Superior None Very 2 hypoechoic (benign) malignancy risk assignment Category based 5 High on suspicion K-TIRADS Consider category biopsy if 2-5. > cm Category 4 Intermediate suspicion Consider biopsy if > cm 2. Category Mid Microcalcifications Heterogeneous Hypoechoic Consistent 3 (low suspicion) structure facilitates automated Category data 3 Low extraction suspicion by Consider parsing biopsy full-text if >.5 radiology cm reports. Nodule side, location, size, Category internal 2 content, Benign suspicious May consider features, biopsy for and spongiform K-TIRADS nodules > 2 3. Category Nonparallel Inferior Iso-4 (intermediate hyperechoic orientation suspicion) cm category were automatically extracted from the reports. 4. Category Spiculated Partially 5 (high cystic suspicion) margins For nodules not meeting criteria for biopsy, consider follow-up Random reports pre- and post-template ultrasound introduction year. reviewed to catalog 5. Partially Microlobulated cystic with margins comet tail nodules, determine whether biopsy Reference: was Ultrasonography performed and, Diagnosis if so, and the Imaging-Based final pathology Management 6. Extrathyroidal Spongiform extension of Thyroid Nodules: Revised Korean Society of Thyroid Radiology 7. Pure cysticwas set as a site default 206;7(3): to autopopulate for all thyroid ultrasounds on March 0th, 207 to improve compliance. Consensus Statement and Recommendations, Shin et al., Korean J Radiol 2

3 Compliance Correlates with More Complete Nodule Descriptions compliance = Percentage of thyroid ultrasounds dictated with the Complete nodule description = Percentage of fully described nodules. 00%.2 90% 80% 70% 60% % % 30% 20% 0% Introduced, Use Encouraged Set as System Default % 0//205-0/4/205 0/5/205-0/28/205 0/29/205 - //205 /2/205 - /25/205 /26/205-2/9/205 2/0/205-2/23/205 2/24/205 - /6/206 /7/206 - /20/206 /2/206-2/3/206 2/4/206-2/7/206 2/8/206-3/2/206 3/3/206-3/6/206 3/7/206-3/30/206 3/3/206-4/3/206 4/4/206-4/27/206 4/28/206-5//206 5/2/206-5/25/206 5/26/206-6/8/206 6/9/206-6/22/206 6/23/206-7/6/206 7/7/206-7/20/206 7/2/206-8/3/206 8/4/206-8/7/206 8/8/206-8/3/206 9//206-9/4/206 9/5/206-9/28/206 9/29/206-0/2/206 0/3/206-0/26/206 0/27/206 - /9/206 /0/206 - /23/206 /24/206-2/7/206 2/8/206-2/2/206 2/22/206 - /4/207 /5/207 - /8/207 /9/207-2//207 2/2/207-2/5/207 2/6/207-3//207 3/2/207-3/5/207 3/6/207-3/29/207 3/30/207-4/2/207 4/3/207-4/26/207 4/27/207-5/0/207 5//207-5/24/207 5/25/207-6/7/207 6/8/207-6/2/207 6/22/207-7/5/207 0 FNA Rate 40% 35% 30% 25% 20% 5% 0% 5% 0% FNA Rate by K-TIRADS Category and 2.% 20.0%.9% 0.0% 8.7% 5.5% 8.2%.9% 35.7% K-TIRADS Category and 26.7% 3

4 FNA Appropriateness by Size and KTIRADS Category K-TIRADS Category Threshold Total FNAs Appropriate FNAs Unk >= 5 mm 48 78% 00% 2 >= 20 mm 7 43% N/A 3 >= 5 mm 55 9% 00% 4 >= 0 mm 32 76% 00% 5 >= 0 mm 9 80% 75% Use of the structured template resulted in the near complete elimination of inappropriate FNA, defined as FNA of a nodule smaller than the indicated threshold. Biopsy Rate and Positive Rate Exams Nodules FNAs Cancers Nodules per Exam FNA Rate Positive Biopsy Rate % 6.3% % 9.4% 4

5 Conclusions 0 reporting utilizing an independently verified grading system and lexicon led to improvement in the rate of positive biopsies, suggesting that biopsies were requested for more suspicious lesions. 02 Reducing barriers to adoption of the standardized template by making the structured template the default template for the study type led to significantly improved compliance. 03 Nodules were more fully described after the implementation of the template, in accordance with the K-TIRADS lexicon, leading to elimination of inappropriate FNA References.Burnside ES, Sickles EA, Bassett LW, et al. The ACR BI-RADS experience: learning from history. J Am Coll Radiol 2009; 6: Dunnick NR, Langlotz CP. The radiology report of the future: a summary of the 2007 Intersociety Conference. J Am Coll Radiol 2008; 5: Hickey PM. Standardization of Roentgen-ray reports. American Journal of Roentgenology 922; 9: Langlotz CP. The Radiology Report: A Guide To Thoughtful Communication for Radiologists and other Medical Professionals. San Bernardino, CA, Shin JH, Baek JH, Chung J, et al. Ultrasonography Diagnosis and Imaging-Based Management of Thyroid Nodules: Revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations. Korean J Radiol 206; 7: