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Parents of Pediatric Radiology Patients Prefer Timely Reporting and Discussing Results with Referring Providers
ARTICLE IN PRESS
Social and Economic Isues in Imaging
Parents of Pediatric Radiology Patients Prefer Timely Reporting and Discussing Results with Referring Providers Emily A. Edwards, MD, Andre Cote, MD, Andrew S. Phelps, MD, David M. Naeger, MD
Rationale and Objectives: With the introduction of new communication channels, such as encrypted messaging and online electronic medical record patient portals, there are ever-increasing ways for patients and their families to access their medical information. While patient preferences regarding how they receive the results of their radiology examinations have been assessed in the adult population, there is limited data on parent preferences for pediatric radiology patients. Materials and Methods: The aim of this study was to determine how the parents of pediatric radiology patients prefer to receive the results of their child’s imaging studies. The study design was an institutional review board-approved anonymous voluntary survey distributed to parents in a pediatric radiology waiting room. Results: Of the current possible ways to receive radiology results, most parents preferred to receive their child’s radiology results from the referring doctor (65%). A minority of parents preferred to receive the results from a radiologist in-person (16%) or via the radiology report (16%). In multiple hypothetical scenarios, parents also preferred to receive radiology results from the referring doctor rather than the radiologist, with the single exception being when no subsequent appointment with the referring doctor was planned. When asked to prioritize the most important aspect of receiving radiology test results, most parents prefer having results available quickly (65%). Conclusion: This survey suggests that in the pediatric radiology realm, efforts toward timely reporting will likely have a greater impact on patient satisfaction than prioritizing more in-person radiologist-patient communication. Key Words: Pediatric radiology; Patient-centered radiology; Family-centered care; Communication; Results reporting. © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
C
ommunication between physicians and patients and their families is an essential component of the doctor-patient relationship (1). Historically, communication between diagnostic radiologists and patients has been moderated by the patient’s referring physician, who received the radiologist’s report and discussed the results of the imaging study with the patient. In this practice model, direct communication between patients and diagnostic radiologists is infrequent (with a few notable exceptions, such as women’s
Acad Radiol 2019; &:1–5 From the University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California (E.A.E., A.S.P.); Hofstra University, Department of Medicine, Long Island, New York (A.C.); Denver Health and Hospital Authority, University of Colorado School of Medicine, Department of Radiology, 777 Bannock St., MC0024, Denver, CO (D.M.N.). Received May 25, 2019; revised July 3, 2019; accepted July 12, 2019. Address correspondence to: D.N. e-mail: [email protected] © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.07.010
imaging), and some have even described radiologists as “invisible” to patients (2). With the introduction of new communication channels, such as direct, secure messaging, and online electronic medical record patient portals, there are ever-increasing ways for patients and their families to access their medical information, each with a unique set of advantages and challenges (3 5). How radiology fits into this shifting communication environment is a topic of ongoing discussion in clinical practice and in the literature, as radiologists seek to meet the needs of patients and their families, referring providers, and the healthcare system. In response to these changes, some authors advocate for increasing visibility of radiologists though more direct patient communication (6 8), while others question the value versus the cost of such a change, which would constitute a significant disruption of the current model (9). While patient preferences regarding how they receive the results of their radiology examinations have been assessed in the adult population (10 13) there is limited data on parent preferences for pediatric radiology patients. The aim of this study was
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ARTICLE IN PRESS EDWARDS ET AL
to determine how the parents of pediatric radiology patients prefer to receive the results of their child’s imaging studies. METHODS This study was institutional review board-approved and HIPAA compliant. On 20 randomly-selected days spread out over a four-month period, paper-based surveys were offered to parents of pediatric radiology patients at an academic children’s hospital at the time of check-in for outpatient radiology examinations. Survey participation was voluntary and anonymous, though limited nonprotected demographic data were collected; surveys were stored separate from any patient-specific documents. Inclusion criteria for participation were English-speaking parents of pediatric radiology patients with at least one prior visit to the radiology department. The survey included nine questions, assessing how quickly and in what way respondents usually receive the results of their child’s imaging studies, how they would prefer to receive those results, and several hypothetical scenarios in which parents could choose to discuss results with either their referring provider or a radiologist. Statistical significance was calculated using the t test and was defined as p < 0.05.
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TABLE 2. Time Elapsed to Parents Receiving Radiology Test Results How long do you usually wait to learn the results of your child’s radiology tests? (n = 103) One hour 22 (21.4%) One day 33 (32.0%) One week 29 (28.2%) One month 3 (2.9%) I don’t usually learn the results 2 (1.9%) Other 14 (13.6%)
How Parents Currently Receive Radiology Results
The majority of parents (53.4%) reported receiving results within 24 hours (Table 2). The majority of parents receive results through their child’s doctor, either in-person (36%), via phone or email (24%), or through the doctor’s office (7%) (Table 3). Only 9% of parents report discussing results of their child’s imaging studies with the radiologist, while 12% access radiology test results via an online medical record portal.
How Parents Would Prefer to Receive Radiology Results
RESULTS Demographics
A total of 112 surveys were collected, with a response rate by eligible participants of 21%. Of those 112 surveys, 96 (85.7%) were completely filled out and 16 (14.3%) were partially filled out. The demographics results are summarized in Table 1. The majority of parents completing the survey were women (81%) and college educated (60%). The average age of the parent’s child was 9 years old, with a range of 6 weeks 17 years. TABLE 1. Demographic Data Demographics of the Parent Completing the Survey Parent age (n = 105) Average 40.7 years (range 20-66 years) Parent gender (n = 108) 80.6% women Parent education (n = 107) High school (n = 15) 14.0% College (n = 64) 59.8% Grad/professional 25.2% (n = 27) Other (n = 1) 0.9% Child (patient) demographics Child age (n = 107) Average 9.3 years (range 6 weeks-17 years) Child gender (n = 107) 60.7% girls Outpatient radiology visAverage 2.4 visits/year, its/year (n = 99) median 2 visits/year (range 0-10) Travel time to children’s Average 111 minutes, hospital (n = 107) median 90 minutes (range 10-540)
2
The majority of parents preferred to receive the results through their child’s doctor, either in-person (37%) or by phone, or e-mail (28%) (Table 4). A minority of parents preferred to receive their results from a radiologist, via an in-person discussion (16%), a printed copy of the report from the radiology department (7%), or by mail (3%). A small number of parents preferred to access radiology test results via an online medical record portal (6%). When asked to prioritize the various aspects of how they might receive radiology test results, a majority of parents prioritized having results available quickly (65%) over the other options (Table 5). TABLE 3. Current Means for Receiving Radiology Test Results How do you usually receive the results of your child’s radiology test? (n = 104) I usually don’t receive the results 3 (2.0%) The radiology doctor (radiologist) discusses the 13 (8.7%) results with me in-person Someone in the radiology department gives me a 0 paper copy of the results My child’s doctor discusses the results with me 54 (36.2%) in-person My child’s doctor contacts me by phone or email 36 (24.2%) with the results I contact the doctor’s office by phone or email to 11 (7.4%) get the results I receive a paper copy of the results in the mail 4 (2.7%) I look up the results online in my child’s secure 18 (12.1%) online medical record Other 10 (6.7%)
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TABLE 4. Preferred Means for Receiving Radiology Test Results (Total Answers) How would you MOST PREFER to receive the results of your child’s radiology test? (n = 131) I usually wouldn’t receive the results 2 (1.5%) The radiology doctor (radiologist) would discuss 21 (16.0%) the results with me in-person Someone in the radiology department would give 9 (6.9%) me a paper copy of the results My child’s doctor would discuss the results with 49 (37.4%) me in-person My child’s doctor would contact me by phone or 34 (26.0%) email with the results I would contact the doctor’s office by phone or 2 (1.5%) email to get the results I would receive a paper copy of the results in the 4 (3.1%) mail I would look up the results online in my child’s 8 (6.1%) secure online medical record Other 2 (1.5%)
Hypothetical Scenarios Discussing Results with Radiologist Versus Referring Provider
In a hypothetical scenario where parents were given the option of reviewing their radiology test results first with their child’s doctor or with the radiologist, the majority of parents preferred to discuss results with their child’s doctor (66%) (Table 6). This preference was even stronger when a clinic appointment was already scheduled (74%), although there was a similar degree of preference for learning results from their child’s doctor regardless of whether the test results were normal (61%) or abnormal (62%). The only hypothetical scenario in which a slight majority of parents preferred to discuss the results with the radiologist first (53%) was if they did not already have an appointment scheduled to see their referring provider. Associations Between Demographics and Parent Communication Preferences
Parents who preferred to discuss the results with a radiologist in a majority of queried hypothetical scenarios (defined as preferring initial communication with the radiologist in three TABLE 5. Prioritization of Different Aspects of Radiology Result Reporting (Total Answers) Typically, the results from a radiology test are sent directly to your child’s doctor. After the radiology test is done, what is the MOST IMPORTANT to you? (n = 141) Discussing the results in-person with a doctor 35 (24.8%) My child’s doctor receives the results as quickly as 38 (27.0%) possible Receiving the results in the way that is most conve- 15 (10.6%) nient for me (in-person, by phone, by email, by mail, online medical record, etc) Shortest possible wait time for me to learn the results 53 (37.6%)
PARENTS OF PEDIATRIC RADIOLOGY PATIENTS
TABLE 6. Hypothetical Scenarios Assessing Preference for Discussing Results with the Radiologist Versus the Ordering Provider If you were given the option to discuss your child’s radiology results with the radiology doctor, the FIRST person you would prefer to discuss the results with is: (n = 105) Child’s doctor 69 (65.7%) Radiologist 36 (34.3%) We already have a clinic appointment scheduled after the radiology test. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 108) Child’s doctor 80 (74.1%) Radiologist 28 (25.9%) We do not have a clinic appointment scheduled after the radiology test. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 105) Child’s doctor 49 (46.7%) Radiologist 56 (53.3%) The test result is normal. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 106) Child’s doctor 65 (61.3%) Radiologist 41 (38.7%) The test result is not normal, meaning that something unexpected or potentially serious has been found. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 107) Child’s doctor 66 (61.7%) Radiologist 41 (38.3%)
or more of the five scenarios) were not statistically significantly different with respect to age (p = 0.11), their child’s age (p = 0.09), number of radiology visits per year for their child (p = 0.053), or travel distance to the hospital (p = 0.57).
DISCUSSION This survey highlights several important points regarding communication with parents of pediatric radiology patients. Most parents currently receive outpatient imaging results through their child’s doctor—either in-person or by phone or email—and when given the choice, a majority of parents prefer to receive results in these ways. Compared to how they currently receive radiology test results, a few more parents would prefer the options of discussing results with the radiologist or obtaining a paper copy of the report from the radiology department, while fewer parents would prefer to personally initiate contact with the referring provider’s office for results or accessing results via an online patient portal. Of note, access to reports via a portal is offered to all patients at our institution; 99% of reports are dictated within 24 hours with patient access via the portal available shortly thereafter. While there is a general preference for discussing results with the referring provider, regardless of whether the test result is normal or abnormal, a slim majority of parents would prefer to discuss results with the radiologist if they do not have a follow-up appointment scheduled with their child’s doctor. 3
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Finally, we noted parents strongly prioritized speed over other aspects of radiology results reporting. Numerous previously reported studies have shown limited patient understanding of the role of the radiologist (11,14,15). Given the wealth of data on the topic, and in the name of brevity, our study opted not to reassess this area via additional questions. To ensure all survey respondents had a common understanding, however, we did include a short paragraph at the beginning of the survey explicitly describing radiologist training and qualifications. The full text of the survey is included in Appendix A. The most in-depth evaluations on patient preference for reporting come from the adult radiology literature. We chose to focus this survey specifically on the communication preferences of the parents of pediatric radiology patients, both because this is a relatively less studied topic and because the communication needs of pediatric patients and their parents may be different from those of adult patients. For example, for pediatric patients, providers are communicating not just with the patient but also their parent or caregiver. Pediatric patients are also relying on their parents or caregivers to be their advocates and decision-makers, rather than acting of their own accord as an independent adult is able to do. The available adult oriented studies have yielded mixed results with respect to with whom patients most prefer to discuss the results of their imaging studies (8,11,16). Many studies seem to suggest a desire among patients for discussing results with a radiologist (11,16,17) though a common criticism of such studies is the failure to acknowledge monetary and nonmonetary costs in some survey questions. There are some data in the adult literature showing patient preferences toward discussing radiology results with referring providers (10); this specific adult-focused study specifically incorporated de facto “costs” of such conversations, such as having to wait to have the conversation with the radiologist while the study is being interpreted. Though our study did not factor in the costs of any communication method, our results are more in-line with those showing a preference for patients (or parents of patients in this case) to discuss radiology examinations with their child’s doctor, either in-person or via phone or email (37% and 26%, respectively), rather than with a radiologist. One pediatric-focused study also points out that in addition to the workflow changes that may be necessary for parents to review their child’s imaging studies with a radiologist, not all radiologists are necessarily adequately prepared to deliver difficult news to a patient and their family in the event that the results of the radiology examination are abnormal (18). Our study did however suggest that there is a small unmet need to communicate with radiologists: 32% of parents preferred to receive results from radiology, with 16% preferring in-person communication with the radiologist. These preferences compare to 24% of respondents who indicate they currently receive results from the radiologist, 9% via in-person communication. This aligns with previous literature revealing that some patients do value discussing imaging test results with a radiologist (11,17,19). This survey also identified 4
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another unmet need: while no patients reported currently receiving a paper copy of their results from the radiology department, 7% of respondents preferred to receive their results this way, rather than through in-person or electronic means of communication. We did not assess how long or under what circumstances parents would be willing to wait in the radiology department for such a report. In addition to how parents receive radiology test results, how quickly they receive results is also a critical consideration for parents of pediatric radiology patients in this survey. Our study showed that the majority of parents prioritized minimal wait time over the possibility of waiting longer for in-person result communication (65% versus 25%). This prioritization of rapid turnaround of results is consistent with previous literature (12,13,20,21). Interestingly, in our survey of hypothetical situations in which parents could review results first with either their child’s doctor or the radiologist, the only scenario in which a majority of parents preferred reviewing results with the radiologist was when they had no upcoming appointment with their child’s doctor. This result further corroborates the observation that minimizing wait time to receive results is very important to parents of pediatric radiology patients, thereby representing an additional opportunity for radiologists to fill an unmet need for parents who wish to discuss the results of their child’s radiology test in a timely manner. This study had several limitations. First, as is common in voluntary survey work, we had a relatively low survey response rate of 21%. Sufficient front desk staffing was an important contributing factor as radiology department staff members were unable to offer detailed explanations and guidance regarding the surveys during periods of high clinical volume; survey response rates anecdotally appeared to be lower during those busy times. Needing to attend to their children while in the waiting room, particularly for those with multiple children, was a commonly cited reason for parents declining survey participation. Additional limitations include that the survey was only offered in English due to inadequate financial resources for the number of translations that would be required, and lack of translation support to address parent questions about completing the survey; the exclusion of non-English speaking families does introduce a degree of bias, as their radiology result communication preferences may differ. In this survey we were specifically interested in determining how parents were receiving the results of their child’s imaging studies, and how their preferences may differ from the current reality. For this reason, parents with no prior experience having received a radiology result for their child were not included. Although parents with prior radiology examination experience may be more familiar with (and possibly biased toward) the status quo, they are also likely more aware of the needs and wants of patients and families undergoing imaging tests. Finally, this survey was conducted at a single institution. Though this institution serves a large geographic area with diverse patients, those presenting to tertiary medical center are not necessarily representative of all pediatric
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patients, though likely out population is representative of those presenting to large pediatric facilities. Despite the limitations, the study identifies several trends that could provide radiologists with opportunities to improve patient satisfaction. In general, most parents seem to prefer the current communication model where they receive radiology test results from the referring provider. Furthermore, parents place a premium on receiving results quickly. This suggests that focusing improvement efforts on decreasing report turnaround time may have the greatest positive impact on the results communication experience of parents of pediatric radiology patients, although it is important to note that turnaround time within radiology is only one part of the typical chain of events in results communication, with little to no radiologist influence over the timing or means of communication between the patient and the referring provider. Alternatively, radiology practices may consider modifying or adding to their current communication systems to be more patient- and family-centered (22,23), such as offering direct communication to the minority of parents interested in such a service, offering printed copies of the radiology report for those willing to wait, or arranging for direct communication with patients who do not have an appointment scheduled with their referring provider. By building communication systems that mirror parent priorities, with an emphasis on minimizing wait time for results, radiologists can better meet the needs of pediatric radiology patients and their families.
CONCLUSION Our survey shows that parents of pediatric radiology patients prioritize receiving radiology results quickly. While most parents currently receive results from their child’s doctor, and prefer to receive results this way, a minority of parents would prefer to discuss results with the radiologist, providing radiologists with an opportunity to connect with these particular patients. Another approach by which radiologists could potentially improve patient satisfaction would be reducing report turnaround time, or considering alternative communication strategies to decrease wait time to learn results.
FINANCIAL SUPPORT This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. REFERENCES 1. 2.
Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152(9):1423–1433. Glazer GM, Ruiz-Wibbelsmann JA. The invisible radiologist. Radiology 2011; 258(1):18–22. doi:10.1148/radiol.10101447.
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3. Johnson AJ, Hawkins H, Applegate KE. Web-based results distribution: new channels of communication from radiologists to patients. J Am Coll Radiol 2005; 2(2):168–173. doi:10.1016/j.jacr.2004.06.018. 4. Cahill JE, Gilbert MR, Armstrong TS. Personal health records as portal to the electronic medical record. J Neurooncol 2014; 117(1):1–6. doi:10.1007/s11060-013-1333-x. 5. Bruno MA, Petscavage-Thomas JM, Mohr MJ, et al. The “open letter”: radiologists’ reports in the era of patient web portals. J Am Coll Radiol 2014; 11(9):863–867. doi:10.1016/j.jacr.2014.03.014. 6. Berlin L. Communicating results of all outpatient radiologic examinations directly to patients: the time has come. AJR Am J Roentgenol 2009; 192 (3):571–573. doi:10.2214/AJR.08.1954. 7. Boland GWL. Visibility of radiologists: helping to secure your future. AJR Am J Roentgenol 2009; 192(5):1373–1374. doi:10.2214/AJR.08.1824. 8. Kuhlman M, Meyer M, Krupinski EA. Direct reporting of results to patients: the future of radiology? Acad Radiol 2012; 19(6):646–650. doi:10.1016/j.acra.2012.02.020. 9. Jha S. Communicating results directly to patients: don’t ignore the price tag of this added “value.”. Acad Radiol 2012; 19(6):643–645. doi:10.1016/j.acra.2012.04.001. 10. Cabarrus M, Naeger DM, Rybkin A, et al. Patients Prefer Results From the Ordering Provider and Access to Their Radiology Reports. J Am Coll Radiol. Elsevier 2015; 12(6):556–562. doi:10.1016/j.jacr.2014.12.009. 11. Koney N, Roudenko A, Ro M, et al. Patients want to meet with imaging experts. J Am Coll Radiol. Elsevier 2016; 13(4):465–470. 12. Johnson AJ, Easterling D, Williams LS, et al. Insight from patients for radiologists: improving our reporting systems. J Am Coll Radiol 2009; 6 (11):786–794. doi:10.1016/j.jacr.2015.11.011. 13. Basu PA, Ruiz-Wibbelsmann JA, Spielman SB, et al. Creating a patientcentered imaging service: determining what patients want. AJR Am J Roentgenol 2011; 196(3):605–610. doi:10.2214/AJR.10.5333. 14. Bosmans JM, Dhondt M, Smits L, et al. Are patients ready for communication with radiologists? Results of the R2P2 survey. Acta radiol 2016; 57(9):1089–1098. doi:10.1177/0284185115617348. 15. Miller P, Gunderman R, Lightburn J, et al. Enhancing patients’ experiences in radiology: through patient-radiologist interaction. Acad Radiol 2013; 20(6):778–781. doi:10.1016/j.acra.2012.12.015. 16. Schreiber MH, Leonard Jr M, Rieniets CY. Disclosure of imaging findings to patients directly by radiologists: survey of patients’ preferences. AJR Am J Roentgenol 1995; 165(2):467–469. doi:10.2214/ ajr.165.2.7618577. 17. Ragavendra N, Laifer-Narin SL, Melany ML, et al. Disclosure of results of sonographic examinations to patients by sonologists. AJR Am J Roentgenol. Am Roentgen Ray Soc 1998; 170(6):1423–1425. doi:10.2214/ ajr.170.6.9609147. 18. Koch BL, Hater D, Nees K, et al. Improving communication, collaboration, and faculty comfort in communicating difficult news in the pediatric radiology department. AJR Am J Roentgenol 2016; 207(5):971–975. doi:10.2214/AJR.16.16641. 19. Pahade J, Couto C, Davis RB, et al. Reviewing imaging examination results with a radiologist immediately after study completion: patient preferences and assessment of feasibility in an academic department. AJR Am J Roentgenol 2012; 199(4):844–851. doi:10.2214/AJR.11.8064. 20. Kolata G. Radiologists are reducing the pain of uncertainty. The New York Times, New York, Nov 24, 2014. Section D, Page 1. 21. Woolen S, Kazerooni EA, Wall A, et al. Waiting for radiology test results: patient expectations and emotional disutility. J Am Coll Radiol 2018; 15 (2):274–281. doi:10.1016/j.jacr.2017.09.017. 22. Hammerman HJ. Communicating imaging results to patients: OnSite results. Am J Roentgenol 2009; 192(4):852–853. doi:10.2214/AJR.08.2293. American Roentgen Ray Society. 23. Smith JN, Gunderman RB. Should we inform patients of radiology results? Radiology 2010; 255(2):317–321. doi:10.1148/radiol.10091608. pubs.rsna.org.
SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at doi:10.1016/j.acra.2019.07.010.
5
Social and Economic Isues in Imaging
Parents of Pediatric Radiology Patients Prefer Timely Reporting and Discussing Results with Referring Providers Emily A. Edwards, MD, Andre Cote, MD, Andrew S. Phelps, MD, David M. Naeger, MD
Rationale and Objectives: With the introduction of new communication channels, such as encrypted messaging and online electronic medical record patient portals, there are ever-increasing ways for patients and their families to access their medical information. While patient preferences regarding how they receive the results of their radiology examinations have been assessed in the adult population, there is limited data on parent preferences for pediatric radiology patients. Materials and Methods: The aim of this study was to determine how the parents of pediatric radiology patients prefer to receive the results of their child’s imaging studies. The study design was an institutional review board-approved anonymous voluntary survey distributed to parents in a pediatric radiology waiting room. Results: Of the current possible ways to receive radiology results, most parents preferred to receive their child’s radiology results from the referring doctor (65%). A minority of parents preferred to receive the results from a radiologist in-person (16%) or via the radiology report (16%). In multiple hypothetical scenarios, parents also preferred to receive radiology results from the referring doctor rather than the radiologist, with the single exception being when no subsequent appointment with the referring doctor was planned. When asked to prioritize the most important aspect of receiving radiology test results, most parents prefer having results available quickly (65%). Conclusion: This survey suggests that in the pediatric radiology realm, efforts toward timely reporting will likely have a greater impact on patient satisfaction than prioritizing more in-person radiologist-patient communication. Key Words: Pediatric radiology; Patient-centered radiology; Family-centered care; Communication; Results reporting. © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
C
ommunication between physicians and patients and their families is an essential component of the doctor-patient relationship (1). Historically, communication between diagnostic radiologists and patients has been moderated by the patient’s referring physician, who received the radiologist’s report and discussed the results of the imaging study with the patient. In this practice model, direct communication between patients and diagnostic radiologists is infrequent (with a few notable exceptions, such as women’s
Acad Radiol 2019; &:1–5 From the University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California (E.A.E., A.S.P.); Hofstra University, Department of Medicine, Long Island, New York (A.C.); Denver Health and Hospital Authority, University of Colorado School of Medicine, Department of Radiology, 777 Bannock St., MC0024, Denver, CO (D.M.N.). Received May 25, 2019; revised July 3, 2019; accepted July 12, 2019. Address correspondence to: D.N. e-mail: [email protected] © 2019 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2019.07.010
imaging), and some have even described radiologists as “invisible” to patients (2). With the introduction of new communication channels, such as direct, secure messaging, and online electronic medical record patient portals, there are ever-increasing ways for patients and their families to access their medical information, each with a unique set of advantages and challenges (3 5). How radiology fits into this shifting communication environment is a topic of ongoing discussion in clinical practice and in the literature, as radiologists seek to meet the needs of patients and their families, referring providers, and the healthcare system. In response to these changes, some authors advocate for increasing visibility of radiologists though more direct patient communication (6 8), while others question the value versus the cost of such a change, which would constitute a significant disruption of the current model (9). While patient preferences regarding how they receive the results of their radiology examinations have been assessed in the adult population (10 13) there is limited data on parent preferences for pediatric radiology patients. The aim of this study was
1
ARTICLE IN PRESS EDWARDS ET AL
to determine how the parents of pediatric radiology patients prefer to receive the results of their child’s imaging studies. METHODS This study was institutional review board-approved and HIPAA compliant. On 20 randomly-selected days spread out over a four-month period, paper-based surveys were offered to parents of pediatric radiology patients at an academic children’s hospital at the time of check-in for outpatient radiology examinations. Survey participation was voluntary and anonymous, though limited nonprotected demographic data were collected; surveys were stored separate from any patient-specific documents. Inclusion criteria for participation were English-speaking parents of pediatric radiology patients with at least one prior visit to the radiology department. The survey included nine questions, assessing how quickly and in what way respondents usually receive the results of their child’s imaging studies, how they would prefer to receive those results, and several hypothetical scenarios in which parents could choose to discuss results with either their referring provider or a radiologist. Statistical significance was calculated using the t test and was defined as p < 0.05.
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TABLE 2. Time Elapsed to Parents Receiving Radiology Test Results How long do you usually wait to learn the results of your child’s radiology tests? (n = 103) One hour 22 (21.4%) One day 33 (32.0%) One week 29 (28.2%) One month 3 (2.9%) I don’t usually learn the results 2 (1.9%) Other 14 (13.6%)
How Parents Currently Receive Radiology Results
The majority of parents (53.4%) reported receiving results within 24 hours (Table 2). The majority of parents receive results through their child’s doctor, either in-person (36%), via phone or email (24%), or through the doctor’s office (7%) (Table 3). Only 9% of parents report discussing results of their child’s imaging studies with the radiologist, while 12% access radiology test results via an online medical record portal.
How Parents Would Prefer to Receive Radiology Results
RESULTS Demographics
A total of 112 surveys were collected, with a response rate by eligible participants of 21%. Of those 112 surveys, 96 (85.7%) were completely filled out and 16 (14.3%) were partially filled out. The demographics results are summarized in Table 1. The majority of parents completing the survey were women (81%) and college educated (60%). The average age of the parent’s child was 9 years old, with a range of 6 weeks 17 years. TABLE 1. Demographic Data Demographics of the Parent Completing the Survey Parent age (n = 105) Average 40.7 years (range 20-66 years) Parent gender (n = 108) 80.6% women Parent education (n = 107) High school (n = 15) 14.0% College (n = 64) 59.8% Grad/professional 25.2% (n = 27) Other (n = 1) 0.9% Child (patient) demographics Child age (n = 107) Average 9.3 years (range 6 weeks-17 years) Child gender (n = 107) 60.7% girls Outpatient radiology visAverage 2.4 visits/year, its/year (n = 99) median 2 visits/year (range 0-10) Travel time to children’s Average 111 minutes, hospital (n = 107) median 90 minutes (range 10-540)
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The majority of parents preferred to receive the results through their child’s doctor, either in-person (37%) or by phone, or e-mail (28%) (Table 4). A minority of parents preferred to receive their results from a radiologist, via an in-person discussion (16%), a printed copy of the report from the radiology department (7%), or by mail (3%). A small number of parents preferred to access radiology test results via an online medical record portal (6%). When asked to prioritize the various aspects of how they might receive radiology test results, a majority of parents prioritized having results available quickly (65%) over the other options (Table 5). TABLE 3. Current Means for Receiving Radiology Test Results How do you usually receive the results of your child’s radiology test? (n = 104) I usually don’t receive the results 3 (2.0%) The radiology doctor (radiologist) discusses the 13 (8.7%) results with me in-person Someone in the radiology department gives me a 0 paper copy of the results My child’s doctor discusses the results with me 54 (36.2%) in-person My child’s doctor contacts me by phone or email 36 (24.2%) with the results I contact the doctor’s office by phone or email to 11 (7.4%) get the results I receive a paper copy of the results in the mail 4 (2.7%) I look up the results online in my child’s secure 18 (12.1%) online medical record Other 10 (6.7%)
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TABLE 4. Preferred Means for Receiving Radiology Test Results (Total Answers) How would you MOST PREFER to receive the results of your child’s radiology test? (n = 131) I usually wouldn’t receive the results 2 (1.5%) The radiology doctor (radiologist) would discuss 21 (16.0%) the results with me in-person Someone in the radiology department would give 9 (6.9%) me a paper copy of the results My child’s doctor would discuss the results with 49 (37.4%) me in-person My child’s doctor would contact me by phone or 34 (26.0%) email with the results I would contact the doctor’s office by phone or 2 (1.5%) email to get the results I would receive a paper copy of the results in the 4 (3.1%) mail I would look up the results online in my child’s 8 (6.1%) secure online medical record Other 2 (1.5%)
Hypothetical Scenarios Discussing Results with Radiologist Versus Referring Provider
In a hypothetical scenario where parents were given the option of reviewing their radiology test results first with their child’s doctor or with the radiologist, the majority of parents preferred to discuss results with their child’s doctor (66%) (Table 6). This preference was even stronger when a clinic appointment was already scheduled (74%), although there was a similar degree of preference for learning results from their child’s doctor regardless of whether the test results were normal (61%) or abnormal (62%). The only hypothetical scenario in which a slight majority of parents preferred to discuss the results with the radiologist first (53%) was if they did not already have an appointment scheduled to see their referring provider. Associations Between Demographics and Parent Communication Preferences
Parents who preferred to discuss the results with a radiologist in a majority of queried hypothetical scenarios (defined as preferring initial communication with the radiologist in three TABLE 5. Prioritization of Different Aspects of Radiology Result Reporting (Total Answers) Typically, the results from a radiology test are sent directly to your child’s doctor. After the radiology test is done, what is the MOST IMPORTANT to you? (n = 141) Discussing the results in-person with a doctor 35 (24.8%) My child’s doctor receives the results as quickly as 38 (27.0%) possible Receiving the results in the way that is most conve- 15 (10.6%) nient for me (in-person, by phone, by email, by mail, online medical record, etc) Shortest possible wait time for me to learn the results 53 (37.6%)
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TABLE 6. Hypothetical Scenarios Assessing Preference for Discussing Results with the Radiologist Versus the Ordering Provider If you were given the option to discuss your child’s radiology results with the radiology doctor, the FIRST person you would prefer to discuss the results with is: (n = 105) Child’s doctor 69 (65.7%) Radiologist 36 (34.3%) We already have a clinic appointment scheduled after the radiology test. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 108) Child’s doctor 80 (74.1%) Radiologist 28 (25.9%) We do not have a clinic appointment scheduled after the radiology test. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 105) Child’s doctor 49 (46.7%) Radiologist 56 (53.3%) The test result is normal. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 106) Child’s doctor 65 (61.3%) Radiologist 41 (38.7%) The test result is not normal, meaning that something unexpected or potentially serious has been found. In this situation, the FIRST person I would prefer to discuss the results with is: (n = 107) Child’s doctor 66 (61.7%) Radiologist 41 (38.3%)
or more of the five scenarios) were not statistically significantly different with respect to age (p = 0.11), their child’s age (p = 0.09), number of radiology visits per year for their child (p = 0.053), or travel distance to the hospital (p = 0.57).
DISCUSSION This survey highlights several important points regarding communication with parents of pediatric radiology patients. Most parents currently receive outpatient imaging results through their child’s doctor—either in-person or by phone or email—and when given the choice, a majority of parents prefer to receive results in these ways. Compared to how they currently receive radiology test results, a few more parents would prefer the options of discussing results with the radiologist or obtaining a paper copy of the report from the radiology department, while fewer parents would prefer to personally initiate contact with the referring provider’s office for results or accessing results via an online patient portal. Of note, access to reports via a portal is offered to all patients at our institution; 99% of reports are dictated within 24 hours with patient access via the portal available shortly thereafter. While there is a general preference for discussing results with the referring provider, regardless of whether the test result is normal or abnormal, a slim majority of parents would prefer to discuss results with the radiologist if they do not have a follow-up appointment scheduled with their child’s doctor. 3
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Finally, we noted parents strongly prioritized speed over other aspects of radiology results reporting. Numerous previously reported studies have shown limited patient understanding of the role of the radiologist (11,14,15). Given the wealth of data on the topic, and in the name of brevity, our study opted not to reassess this area via additional questions. To ensure all survey respondents had a common understanding, however, we did include a short paragraph at the beginning of the survey explicitly describing radiologist training and qualifications. The full text of the survey is included in Appendix A. The most in-depth evaluations on patient preference for reporting come from the adult radiology literature. We chose to focus this survey specifically on the communication preferences of the parents of pediatric radiology patients, both because this is a relatively less studied topic and because the communication needs of pediatric patients and their parents may be different from those of adult patients. For example, for pediatric patients, providers are communicating not just with the patient but also their parent or caregiver. Pediatric patients are also relying on their parents or caregivers to be their advocates and decision-makers, rather than acting of their own accord as an independent adult is able to do. The available adult oriented studies have yielded mixed results with respect to with whom patients most prefer to discuss the results of their imaging studies (8,11,16). Many studies seem to suggest a desire among patients for discussing results with a radiologist (11,16,17) though a common criticism of such studies is the failure to acknowledge monetary and nonmonetary costs in some survey questions. There are some data in the adult literature showing patient preferences toward discussing radiology results with referring providers (10); this specific adult-focused study specifically incorporated de facto “costs” of such conversations, such as having to wait to have the conversation with the radiologist while the study is being interpreted. Though our study did not factor in the costs of any communication method, our results are more in-line with those showing a preference for patients (or parents of patients in this case) to discuss radiology examinations with their child’s doctor, either in-person or via phone or email (37% and 26%, respectively), rather than with a radiologist. One pediatric-focused study also points out that in addition to the workflow changes that may be necessary for parents to review their child’s imaging studies with a radiologist, not all radiologists are necessarily adequately prepared to deliver difficult news to a patient and their family in the event that the results of the radiology examination are abnormal (18). Our study did however suggest that there is a small unmet need to communicate with radiologists: 32% of parents preferred to receive results from radiology, with 16% preferring in-person communication with the radiologist. These preferences compare to 24% of respondents who indicate they currently receive results from the radiologist, 9% via in-person communication. This aligns with previous literature revealing that some patients do value discussing imaging test results with a radiologist (11,17,19). This survey also identified 4
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another unmet need: while no patients reported currently receiving a paper copy of their results from the radiology department, 7% of respondents preferred to receive their results this way, rather than through in-person or electronic means of communication. We did not assess how long or under what circumstances parents would be willing to wait in the radiology department for such a report. In addition to how parents receive radiology test results, how quickly they receive results is also a critical consideration for parents of pediatric radiology patients in this survey. Our study showed that the majority of parents prioritized minimal wait time over the possibility of waiting longer for in-person result communication (65% versus 25%). This prioritization of rapid turnaround of results is consistent with previous literature (12,13,20,21). Interestingly, in our survey of hypothetical situations in which parents could review results first with either their child’s doctor or the radiologist, the only scenario in which a majority of parents preferred reviewing results with the radiologist was when they had no upcoming appointment with their child’s doctor. This result further corroborates the observation that minimizing wait time to receive results is very important to parents of pediatric radiology patients, thereby representing an additional opportunity for radiologists to fill an unmet need for parents who wish to discuss the results of their child’s radiology test in a timely manner. This study had several limitations. First, as is common in voluntary survey work, we had a relatively low survey response rate of 21%. Sufficient front desk staffing was an important contributing factor as radiology department staff members were unable to offer detailed explanations and guidance regarding the surveys during periods of high clinical volume; survey response rates anecdotally appeared to be lower during those busy times. Needing to attend to their children while in the waiting room, particularly for those with multiple children, was a commonly cited reason for parents declining survey participation. Additional limitations include that the survey was only offered in English due to inadequate financial resources for the number of translations that would be required, and lack of translation support to address parent questions about completing the survey; the exclusion of non-English speaking families does introduce a degree of bias, as their radiology result communication preferences may differ. In this survey we were specifically interested in determining how parents were receiving the results of their child’s imaging studies, and how their preferences may differ from the current reality. For this reason, parents with no prior experience having received a radiology result for their child were not included. Although parents with prior radiology examination experience may be more familiar with (and possibly biased toward) the status quo, they are also likely more aware of the needs and wants of patients and families undergoing imaging tests. Finally, this survey was conducted at a single institution. Though this institution serves a large geographic area with diverse patients, those presenting to tertiary medical center are not necessarily representative of all pediatric
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patients, though likely out population is representative of those presenting to large pediatric facilities. Despite the limitations, the study identifies several trends that could provide radiologists with opportunities to improve patient satisfaction. In general, most parents seem to prefer the current communication model where they receive radiology test results from the referring provider. Furthermore, parents place a premium on receiving results quickly. This suggests that focusing improvement efforts on decreasing report turnaround time may have the greatest positive impact on the results communication experience of parents of pediatric radiology patients, although it is important to note that turnaround time within radiology is only one part of the typical chain of events in results communication, with little to no radiologist influence over the timing or means of communication between the patient and the referring provider. Alternatively, radiology practices may consider modifying or adding to their current communication systems to be more patient- and family-centered (22,23), such as offering direct communication to the minority of parents interested in such a service, offering printed copies of the radiology report for those willing to wait, or arranging for direct communication with patients who do not have an appointment scheduled with their referring provider. By building communication systems that mirror parent priorities, with an emphasis on minimizing wait time for results, radiologists can better meet the needs of pediatric radiology patients and their families.
CONCLUSION Our survey shows that parents of pediatric radiology patients prioritize receiving radiology results quickly. While most parents currently receive results from their child’s doctor, and prefer to receive results this way, a minority of parents would prefer to discuss results with the radiologist, providing radiologists with an opportunity to connect with these particular patients. Another approach by which radiologists could potentially improve patient satisfaction would be reducing report turnaround time, or considering alternative communication strategies to decrease wait time to learn results.
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SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at doi:10.1016/j.acra.2019.07.010.
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