Letters

to the

Performance Students

U

by

of Quality

Editor

Assurance

departments assurance

Audits

after

From: Roghair Street,

Princeton,

NJ

radiology

view

departments

Community

08544

Medical screen-film

Group

machines,

(all in mammography

the

ance

audit.

ing

a format

May

1990

of Riverside

hospitals

and

decided

Sensitivity

and

similar

to the

General

and

Arlington

installed accuracy

new of the

a quality

assur-

to conduct

specificity

were

Park-

determined

by us-

student at Princeton University and was selected to develop and conduct the study. Charts for all individuals who underwent mammography least 1 year prior to the audit were evaluated. A total of 787 charts were pulled, but no follow-up study was made in 351 cases. The diagnosis based on the mammographic findings was

recorded

as “benign,”

of further

evaluation

The chart mammographic

was

studies nation these 97%

but

were

Quality

“benign

then reviewed or biopsy

the

but

(suspicious),”

patient

findings and data, a sensitivity

for results.

made history rate

with

or

Audit

Mammographic

a return

visit,

studies, were no the

either further

physical

examiFrom rate

ity, calculated as TP/(TP TN/(TN + FP), was 97%.

+ FN),

sized chart mammographic In

Performed*

Benign

22 6 28

store

and radiology

follow-up to confirm examination.

their

study,

and

retrieve

586 #{149} Radiology

interest,

Sickles

et al (1)

mammographic

required

89%, and

specificity,

mammographic groups. a normal

This diagnosis

ens

calculated

as

findings is study empha-

Patients

Angeles,

CA

during

90048

the

of Radiology, the (2) regarding sedation

during computed tomography imaging procedures, particularly the use of monitoring equipment.

most likely or airway

the

implementation gas exchange

of two

and

adverse effect of sedation obstruction (1). Because

assessing

existence

compatible or adult

1990 issue

Dr Cohen

airway

anof

magnettheir reDr Fisher

is either of the

of patients

dif-

undergoing

of devices designed to monitor is crucial to ensure the safety of

patients in this setting. Therefore, I would like

2 0 16

on

Los

(1) and

of visually

MR imaging, apnea and/or

Malignant

387 19 12

can be used

Center

in the June

by Dr Fisher

ficulty

to call

to the

attention

commercially

of your

available

monitors that are easily patients during MR imaging.

used

on The

MR

read-

imaging-

sedated pediatric model 515 Respira-

tion Monitor and model 8800 Capnometer (Biochem International, Waukesha, Wis) have been routinely used at our institution with our 1.5-T MR imagers for the past few years and

have

operated

detect

in a reliable

hypoventilation

use during MR tubing interface

manner.

and

are relatively

monitors

Both of these

upper

airway

inexpensive

imaging to the

devices

obstruction.

can

These

and can be modified

by simply lengthening patient (which does not

for

the plastic significantly

alter the sensitivity of the devices) so that the monitors can be placed at least 8 feet from the 1.S-T MR imager (2). Since these devices

contain

provide

instructions

the

of pathologic by many

time

Editor:

tides

Biopsy

was

700 cases from

total

Calvin HB, Monticciolo DL. mammography screening of 27,1 14 examinations. Radiol-

Pediatric

Boulevard,

stated that the hypoventilation

389 19 28

malignant

done

Sedated

Beverly

I read with of

Note-Values are numbers of patients. * Biopsy was performed in each case because of a clinical finding (bleeding at the nipple in three cases, palpable lesions in other cases). t Cases originally diagnosed as benign were considered to be proved benign if a subsequent mammogram was normal or if there was no evidence of malignancy at subsequent physical examinations. True-negative (TN) cases were those initially read as benign or suspicious and subsequently considered benign (n 406). True-positive (TP) cases were those with an abnormal screening interpretation and subsequent diagnosis of malignancy (n 16). False-positive (FP) cases were those with an abnormal screening interpretation but no accompanying diagnosis of cancer (n = 12). False-negative (FN) cases were those originally read as negative but subsequently found to be malignant (n 2). Thus, sensitiv-

Correlation routinely

Monitoring Imaging

U

8700

Data

Diagnosis

the

RA,

Frank C. Shellock, PhD Tower Musculoskeletal Imaging Cedars-Sinai Medical Center

malignancy.”

were reviewed (Table). of 89% and a specificity

Initial

Over

and

surveyors.

pediatric patients ic resonance (MR) marks concerning

Assurance

interpretation. reviewed,

From:

Diagnosis at Follow-upt

Benign Suspicious Probably

were

Reference 1. Sickles EA, Ominsky SH, Sollitto Medical audit of a rapid-throughput practice: methodology and results ogy 1990; 175:323-327.

MR

recommendation

“probable

follow-up If there

at

determined.

Interpretation

of suitable

one outlined by Sickles et al in the (1). I am a 2nd-year premedicine

of Radiology

in chart

centers

accuracy (both false-negative and false-positive rates). Many radiologists have sons or daughters well qualified to conduct such an audit. Students on summer break are another potential source

Radiology

Calif) recently To test the

units.

radiologists

issue

the

Riverside,

three

was slightly under 200 work hours. This approach by any radiology group to assess its mammographic

Editor:

The

instruction

the

Chad A. 21 Olden

do not have a computer system to aid in quality audits. Our study could be conducted by one person

hazards

imager,

if the

position

(3-5).

ferromagnetic

components,

to all appropriate

of moving

this

equipment

monitor

is not

placed

types

of other

Several

monitors are also well as respirators

available from for ventilatory

it is important

personnel too close in

to the

a permanently MR

various support

to

regarding MR fixed

imaging-compatible

manufacturers, (3-5).

as

a References

used

a computer

statistics.

Many

system radiology

to

1.

Fisher

DM.

perspective.

Sedation

Radiology

of pediatric

1990;

patients:

an

anesthesiologist’s

175:613-615.

November

1990

2.

Cohen

3.

Shellock FG. Monitoring during MRI: an evaluation of the effect of high-field MRI on various patient monitors. Med Electronics September 1986: 93-97. Edelman RR, Shellock FG, Ahladis J. Practical MRI for the technologist and imaging specialist. In: Edelman RR, Hesselink J, eds. Clinical magnetic resonance imaging. Philadelphia: Saunders, 1990.

4.

5.

MD.

Pediatric

Shellock

FG.

onance

imaging.

Patient

U

sedation.

Biological

effects

Magn

and

Q

Reson

Harvard

Medical

Francis

1990;

safety

1989;

Confidentiality

175:611-612.

aspects

of magnetic

res-

5:243-261.

Brigham

and

Women’s

Hospital,

Boston,

MA

radiologists

02115

sponsibility not typically

to respect have the

have patient same

both

a legal

and

an

ethical

While

confidentiality (1). depth of doctor-patient

re-

we do

relation-

ship that the primary physician has, there is still the implied promise by all physicians not to disclose information about patients without their consent. The radiologist’s relationship with a patient ranges from interpreting a radiograph, in which case there is usually no direct contact, to performing a diagnostic or interventional study, where one does have some degree of direct contact with the patient. The patient’s right to confidentiality is the same, no matter what the depth of the doctor-patient relationship. A patient’s right to confidentiality takes many forms. The flagrant, intentional disclosure of confidential patient information is rare. Unauthorized disclosure to third parties and discussion

of a patient’s

disease

in public

areas

of the

hospital

are breaches of confidentiality against which all physicians must constantly be on guard. There is another, perhaps less obvious area of concern, which is the reason for this letter. Disclosure of clinical information, whether for research or teaching purposes, at society meetings and continuing education courses is a breach of confidentiality if a particular patient can be identified. It is conceivable that a patient would

give

explicit

permission

to be identified,

but this would

occurrence,

since

the

overwhelming

majority

phy,

or

tient’s opposed which

magnetic

resonance

images,

name is relatively large with to traditional radiographs. the patient can be identified

dentiality,

but

Radiologists

this

seems

should

be

where

the

size

of the

pa-

respect to image size, as Publication of images in is also a breach of confi-

to be an

even

grateful

to patients

more

rare for

occurrence. providing

material to use for research and educational purposes. Let us, at the least, respect their right to confidentiality. Whoever photographs images that will be used for a presentation should be aware that patient names should be removed from final

image.

The

ultimate

responsibility,

however,

lies

with the physician who presents the image. Despite its rare occurrence, the presentation of images in which the patient can be identified is something that all presenters should strive to prevent. Awareness of this responsibility should help prevent such a breach of patient confidentiality.

writing

Manage

Volume

BD.

The

patient’s

right

1989; 4:204-209.

177 #{149} Number

2

to confidentiality.

that

information

this

we

point

find

the

article,

we

on that

same

true

increase

of our

screening

Division

have

continued

group to be

We have

mammograms

for

developed

to gather

of patients,

the possibility

sensitivity.

that time, 1 1 of 208 total cancers er but were picked up by virtue We

have

sensitivity

mentioned

might

and

that double

been the

double past

reading

reading

3 years.

for independent

all

During

first read-

were missed by the of double reading.

a system

at

86.5%.

double

read-

ing (with the use of automated multiviewers) that is quite ficient and results in very little increase in total radiologist time. We have not increased the cost to the patient because double reading.

The authors efit

are certainly

of a medical

audit.

correct

We have

about

learned

The authors are also correct takes to perform an ongoing is streamlined

tine,

as they

considerably

I hope raphy

that all

will

heed

its

take

radiologists

the

and

time engaged

time

to read

and effort it if the procedure

will

part

of the

rou-

be required.

in screening

this

benre-

and false-negative

it becomes

additional

of

by careful

about the time audit. However,

suggest

less

ef-

the educational more

view of our true-positive, false-positive, cases than we have by any other means.

mammog-

important

article

and

message.

References 1

.

Murphy assurance

WA Jr. Destouet for mammography

JM, Monsees screening

BS. Professional quality programs. Radiology 1990;

175:319-320. 2.

Bind RE. Low-cost screening mammography: report on finances and review of 21,716 consecutive cases. Radiology 1989; 171:87-90.

U

Comparison

J Med

Pract

of Digital and Radiography: Study

Musculoskeletal Performance

Conventional Observer

From: John

M. Bramble,

MD,

Department Medical

of Diagnostic Center

39th

and

Street

and

Mark

D. Murphey,

Radiology,

Rainbow

MD

University

Boulevard,

Kansas

of Kansas

City,

KS 66103

Editor:

In the April well-designed

ventional

1990 issue and

radiography

of Radiology,

executed

study

Wegryn comparing

(1). The results

et al presented digital

do not agree

a

and

with

con-

the

findings quirements

in our studies of digital image spatial resolution refor nondisplaced fractures and subperiosteal resorption (2,3). Wegryn et al reach the conclusion that a matrix size of 1,024 X 840 X 12 bits (1.5 line pairs per millimeter [lp/ mm]) is sufficient for identification of many musculoskeletal abnormalities and that 2,048 X 1,680 X 12 bits (2.5 lp/mm) is needed

Reference 1. Hirsh

Radiology NC 28204

of pre-

senters do not show such an image. It almost certainly is not intentional and probably occurs as an oversight or perhaps from lack of awareness that this is a breach of confidentiality. It is more likely to occur with ultrasound, computed tomogra-

the

Since

follow-up

be

the exception and not the rule. The statistical presentation of data certainly poses no threat to patient confidentiality (1). I have been dismayed at times, however, to see images presented where the patient’s name can be read. Such a presentation is a rare

for

Editor:

The authors

physicians,

Assurance Programs

Richard E. Bird, MD Charlotte Radiology, Providence 1611 East Third Street, Charlotte,

Editor: As

Quality Screening

From:

91.5%.

School

Street,

U Professional Mammography

The article by Drs Murphy, Destouet, and Monsees (1), which appeared in the May 1990 issue of Radiology, was excellent and made several very important points. The authors mentioned the likelihood of underestimating the magnitude of false-negative mammographic interpretations on an initial medical audit. We reported the results of the medical audit of our screening program in the April 1989 issue of Radiology (2). At that time we reported sensitivity of

in Radiology

From: Douglas L. Brown, MD Department of Radiology, 75

Radiology

for

visualization

of some

abnormalities.

of nondisplaced fractures, we concluded resolution less than 2.88 lp/mm could nostic performance. There are important

In

the

study

that using a spatial adversely affect diagpoints that we would

Radiology

#{149} 587