Do interventional radiologists prefer structured or free-text reports?

Using structured reports in interventional radiology (IR) is preferred by radiologists and referring physicians, according to a new study published in the Journal of Vascular and Interventional Radiology.

“Numerous studies have demonstrated that both radiologists and ordering physicians prefer structured diagnostic radiology reports,” wrote lead author Olga Brook, MD, with Beth Israel Deaconess Medical Center in Boston, and colleagues. “Advantages of diagnostic radiology structured reports include fewer report errors and reduced report turnaround time. Similar to its added value in diagnostic radiology, structured reporting has been proposed to be beneficial in interventional radiology (IR) for quality improvement and research purposes.”

The researchers compared the efficacy of structured and free-text reports for common IR procedures on report quality and report coding and value. They reviewed 432 consecutive free-text IR reports and 415 structured IR reports that were created four months before and after the implementation of structured reporting, respectively. The reports were reviewed to assess user friendliness, compliance with reporting requirements for regulatory requirements and coding. Staff, trainees and referring physicians to IR were surveyed on procedure report attributes including detail, quality and clarity.

During full-text reporting, the complete and accurate documentation of procedural details for fluoroscopy dose, time and amount of contrast agent was approximately 60 percent, 58 percent and 61 percent, respectively. Those percentages were higher during structured reporting at 93, 93 and 94 percent, respectively.

“The present study demonstrates that structured IR reports, similar to structured diagnostic radiology reports, can provide multifaceted value,” the authors wrote. “First, the results suggest that structured IR reports can help to improve compliance with recommendations and requirements for reporting procedural information as per each state’s department of public of health guidelines and national [American College of Radiology] and [Society of Interventional Radiology] guidelines. Recording and report inclusion of patient dose has been an integral part of quality assurance programs as well as patient safety.”

Addendum requests for insufficient documentation also dropped from 28 percent with free-text reports to 12 percent in structured reports.

Approximately 88 percent of IR physicians found the structured reports easier to complete, while 81 percent said they required less time to complete the reports. Referring physician survey respondents said they were significantly more satisfied with structured reports than with free-text reports. Seventy-one percent of referring physicians found improved readability in structured reports over free-text. And 86 percent found structured reports more helpful in planning patient care and future procedures.

“Both interventional radiologists and referring physicians to IR found improved procedural and clinical detail in IR reports with the implementation of structured reporting,” the authors wrote.