Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports

Introduction: This work proposes to improve the transmission of information between requiring physicians and radiologists. Objectives: Evaluate the implementation of a structured report (SR) in a university hospital. Methods: A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting. Results: For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/-4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/- 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/-3.8) minutes for thyroids with nodules and 3.67 (+/-2.51) minutes for thyroids without nodules. Most of the radiologists (76.2 percent) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80 percent preferred the SR. Discussion: From the requiring physicians' perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists. Conclusions: The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.

Ultrasonography-guided Fine-needle Aspiration Biopsy for Thyroid Nodules: Effective Technique and a Peculiar Smear Method

PURPOSE: We wanted to evaluate the effective methods that are appropriate for an endemic area of thyroid disease and to compare the differences of cytologic diagnostic rates with and without using a peculiar smear technique. MATERIALS AND METHODS: We analyzed the incidence rate of insufficient results, complications and the total procedure times of 1,126 thyroid nodules in 776 patients who underwent US-FNAB (ultrasonography-guided fine-needle aspiration biopsy) from January to December 2005. We compared the diagnostic rate between the two groups; the groups' tests were performed with a peculiar smear technique (Group A, n = 313) or with a conventional smear technique (Group B, n = 250). RESULTS: According to the size of the thyroid nodule, the incidence rate of an insufficient result on US-FNAB and the mean total procedure time for 1126 thyroid nodules in 776 patients were measured as 16.9% (52/308) and 208 seconds for nodules under 0.5 cm, 9.8% (30/306) and 160 seconds for nodules between 0.5 cm-1.0 cm, and 6.0% (30/504) and 134 seconds for nodules over 1.0 cm. These 776 patients showed no significant complications, except for mild pain. In Group A, the incidence rate of an insufficient result was calculated as 15.1% (14/93) for the group with nodules under 0.5 cm, 5.3% (5/95) for the group with nodules between 0.5 cm-1.0 cm, 4.8% (6/125) for the group with nodules over 1.0 cm, and 8.0% (25/313) for the total A Group. In Group B, the incidence rate of an insufficient result was measured as 33.3% (15/45) for the group with nodules under 0.5 cm, 28.1% (25/89) for the group with nodules between 0.5 cm-1.0 cm, 21.4% (24/112) for the group with nodules over 1.0 cm, and 25.7% (63/245) for the total B group. There was a statistically significant correlation between the rate of an insufficient result and the peculiar smear technique or the size of the thyroid nodule. CONCLUSION: We consider that US-FNAB is very simple, safe and accurate diagnostic method for thyroid nodules, and US-FNAB with a peculiar smear technique is able to increase the diagnostic rate for thyroid nodules.