- Email: [email protected]
Adherence to ACR Incidental Finding Guidelines
CASE STUDIES IN LEADERSHIP
Adherence to ACR Incidental Finding Guidelines Toshimasa J. Clark, MD, Glenn Coats, MD BRIEF RATIONALE Radiologists commonly encounter incidental findings, and in response, organizations such as the ACR have developed consensus management guidelines [1-9]. The use of such guidelines may increase the value of radiologists’ work by ensuring consistent management of incidental findings. There has been a paucity of data regarding radiologists’ adherence to the ACR incidental finding guidelines and methods to increase adherence. WHAT WE DID We investigated ACR incidental finding guideline adherence at a single institution for two specific entities, thyroid nodules seen on CT and gallbladder polyps seen on abdominal ultrasound. These entities were chosen because they are prevalent and because of previously demonstrated substantial variability in radiologists’ management recommendations [10-15]. As part of this investigation, we developed a computer application that implements all currently published ACR incidental finding guidelines, for use both as a reference standard and as a tool that radiologists may use in their day-to-day practice with the goal of 100% guideline adherence. ACR incidental findings white paper algorithms were implemented
as a JavaScript application, including incidental cystic renal, solid renal, liver, adrenal, cystic pancreatic, adnexal, vascular, splenic, nodal, gallbladder, and thyroid findings [1,3-5,7,8]. The application is free to use and is open source (GNU Public License; GNU, Cambridge, Massachusetts). It is accessible on the Internet at http://rad decisionsupport.com/apps/incidental_ app/index.html or via e-mail request ([email protected]). The institutional review board approved a retrospective analysis of chest CT studies demonstrating thyroid nodules and abdominal ultrasound studies demonstrating gallbladder polyps. We used freetext query software (Primordial Design Solutions, San Mateo, California) to identify consecutive studies with such findings. Each finding was input into the JavaScript computer application, with its output used as the reference standard. We reviewed the medical record to determine actual follow-up in practice. These data were recorded in a Microsoft Excel spreadsheet and analyzed with the Analysis ToolPak (Microsoft Corporation, Redmond, Washington).
OUTCOMES We report data from 75 chest CT studies with 75 thyroid nodules and
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.05.008
80 abdominal ultrasound studies with one or more gallbladder polyps. Patient and nodule characteristics are summarized in Table 1. Follow-up recommendations by radiologists and ACR management guidelines are summarized in Table 2 for thyroid nodules and Table 3 for gallbladder polyps, along with the observed actual follow-up and concordance between the radiologist and ACR recommendations. Notable findings include that 2.5% of 10.5% observed follow-up for thyroid nodules was not warranted per ACR recommendations and that gallbladder polyp follow-up was performed in actual practice (20%) more often than either the radiologist recommendations (8.8%) or ACR recommendations (1.25%), which indicates by definition that the majority of these follow-up studies were not indicated. There were statistically significant differences in the follow-up recommendations for thyroid nodules between radiologists and ACR management guidelines, whether or not no follow-up was considered equivalent to an absence of a followup recommendation (c2 < 0.001 in both cases). For gallbladder polyps, statistical significance was reached only when a lack of a follow-up recommendation was not considered to be equivalent to the explicit
1
Table 1. Characteristics of patients with gallbladder polyps on ultrasound and thyroid nodules on CT Variable Value Patients with gallbladder polyps on ultrasound Number of patients 78 Number of gallbladder polyps 80 (2 patients with multiple polyps) Gender 66% female Mean age (y) 47 Median age (y) 47.5 Mean gallbladder polyp size (mm) 4.1 Median gallbladder polyp size (mm) 4.0 Patients with thyroid nodules on CT Number of patients 75 Number of thyroid nodules 75 Gender 57% female Mean age (y) 60 Median age (y) 62 Mean thyroid nodule size (mm) 10.9 Median thyroid nodule size (mm) 10.0
recommendation of no further follow-up (c2 < 0.001). Another notable finding is that there were no cases for which both the radiologist and ACR recommendations for gallbladder polyps would have been for ultrasound follow-up or surgical consultation. Our data are concordant with those of Lehnert et al [15], who
showed high variability in management recommendations for thyroid nodules seen on CT at their institution. Similarly concordant are data from prior groups demonstrating wide interinstitution variability in adherence to Fleischner Society lung nodule management guidelines [16-21]. Although we are unaware
Table 2. Follow-up recommendations for thyroid nodules seen on CT Recommendation Radiologist recommendation for ultrasound follow-up Radiologist recommendation of no follow-up Radiologist absence of follow-up recommendation ACR recommendation for ultrasound follow-up ACR recommendation of no follow-up ACR absence of follow-up recommendation Actual follow-up in subsequent 12 months Proportion of actual follow-up indicated per ACR management guidelines Concordance of ACR and radiologist follow-up recommendations
Percentage 36 0 64 25 75 0 10.5 8 (2.5% not indicated) 17.3* 73.3†
Note: There exist statistically significant differences between the radiologist and ACR recommendations regardless of whether no follow-up is considered equivalent or not to an absence of a follow-up recommendation (c2 < 0.001 in both cases). *If a recommendation of no follow-up is not considered equivalent to an absence of a follow-up recommendation. † If a recommendation of no follow-up is considered equivalent to an absence of a follow-up recommendation.
2
of prior publications specifically addressing adherence to ACR incidental finding guidelines, data from an ACR case study indicate that one radiology practice observed 56% adherence to the thyroid nodule guidelines [22]. In this case study, the radiology practice created a video-based intervention and ultimately reported 92% guideline adherence [17]. It is possible that their use of a video tool resulted in radiologists’ knowing that they were being observed, which may have made them more self-aware of their behavior [23]. Rather than a video, we suggest that our computer application could be used to increase incidental finding guideline adherence. By the definition of its construction, use of the application and adoption of its output results in 100% adherence with ACR guidelines. Previous work has suggested that, at least for Lung-RADS, the use of a similar computer application can increase both the speed and accuracy of guideline application [24], and the application’s explicit recommendation of no follow-up may decrease ambiguity in radiologists’ reports. Our data from a single institution may not be generalizable to other institutions or to entities other than gallbladder polyps and thyroid nodules. We also did not determine whether an intervention such as the use of our computer application would result in sustained prospective increased adherence, but instead only projected that its use would result in greater adherence. Nevertheless, we believe that our findings of low concordance between radiologists recommendations and ACR guidelines are of interest and that use of the computer application that we
Journal of the American College of Radiology Volume - n Number - n - 2016
Table 3. Follow-up recommendations for gallbladder polyps seen on ultrasound Recommendation Radiologist recommendation for ultrasound follow-up Radiologist recommendation for general surgery consultation Radiologist recommendation of no follow-up Radiologist absence of follow-up recommendation ACR recommendation for ultrasound follow-up ACR recommendation for general surgery consultation ACR recommendation of no follow-up ACR absence of follow-up recommendation Actual follow-up in subsequent 12 mo
Proportion of actual follow-up indicated per ACR management guidelines Concordance of ACR and radiologist follow-up recommendations
Percentage 8.75 8.
1.25 0 90 9.
1.25 3.75 95 0 20 (5% not specifically for follow-up of polyps but for other general conditions) 1.25 (18.75% not indicated) 0* 88.8†
Note: There exist statistically significant differences between the radiologist and ACR recommendations if no follow-up is not considered equivalent or not to an absence of a follow-up recommendation (c2 < 0.001). There is no significant difference between radiologist and ACR recommendations if follow-up is considered equivalent or not to an absence of a follow-up recommendation (c2 ¼ 0.755 for ultrasound, c2 ¼ 0.843 for surgical consultation). *If a recommendation of no follow-up is not considered equivalent to an absence of a follow-up recommendation. † If a recommendation of no follow-up is considered equivalent to an absence of a follow-up recommendation.
10.
11.
12.
13.
14.
15.
developed and make freely available could reduce report variability and result in 100% incidental findings guideline adherence.
REFERENCES 1. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7:754-73. 2. Erasmus JJ, Connolly JE, McAdams HP, et al. Solitary pulmonary nodules: part I. Morphologic evaluation for differentiation of benign and malignant lesions. Radiographics 2000;20:43-58. 3. Heller MT, Harisinghani M, Neitlich JD, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 3: white paper of the ACR Incidental
4.
5.
6.
7.
Journal of the American College of Radiology Clark, Coats n Case Studies in Leadership
Findings Committee II on splenic and nodal findings. J Am Coll Radiol 2013;10: 833-9. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 2015;12:143-50. Khosa F, Krinsky G, Macari M, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol 2013;10:789-94. Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology 2013;266: 304-17. Patel MD, Ascher SM, Paspulati RM, et al. Managing incidental findings on
16.
17.
18.
19.
abdominal and pelvic CT and MRI, part 1: white paper of the ACR Incidental Findings Committee II on adnexal findings. J Am Coll Radiol 2013;10:675-81. Sebastian S, Araujo C, Neitlich JD, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings. J Am Coll Radiol 2013;10:953-6. MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 2005;237: 395-400. Yoon DY, Chang SK, Choi CS, et al. The prevalence and significance of incidental thyroid nodules identified on computed tomography. J Comput Assist Tomogr 2008;32:810-5. Youserm DM, Huang T, Loevner LA, et al. Clinical and economic impact of incidental thyroid lesions found with CT and MR. AJNR Am J Neuroradiol 1997;18:1423-8. Lin WR, Lin DY, Tai DI, et al. Prevalence of and risk factors for gallbladder polyps detected by ultrasonography among healthy Chinese: analysis of 34 669 cases. J Gastroenterol Hepatol 2008;23:965-9. Jorgensen T, Jensen KH. Polyps in the gallbladder. A prevalence study. Scand J Gastroenterol 1990;25:281-6. Segawa K, Arisawa T, Niwa Y, et al. Prevalence of gallbladder polyps among apparently healthy Japanese: ultrasonographic study. Am J Gastroenterol 1992;87:630-3. Lehnert BE, Sandstrom CK, Gross JA, et al. Variability in management recommendations for incidental thyroid nodules detected on CT of the cervical spine in the emergency department. J Am Coll Radiol 2014;11:681-5. Eisenberg RL, Bankier AA, Boiselle PM. Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology 2010;255:218-24. Eisenberg RL, Fleischner S. Ways to improve radiologists’ adherence to Fleischner Society guidelines for management of pulmonary nodules. J Am Coll Radiol 2013;10:439-41. Lacson R, Prevedello LM, Andriole KP, et al. Factors associated with radiologists’ adherence to Fleischner Society guidelines for management of pulmonary nodules. J Am Coll Radiol 2012;9: 468-73. MacMahon H. Compliance with Fleischner Society guidelines for management of
3
lung nodules: lessons and opportunities. Radiology 2010;255:14-5. 20. Masciocchi M, Wagner B, Lloyd B. Quality review: Fleischner criteria adherence by radiologists in a large community hospital. J Am Coll Radiol 2012;9:336-9. 21. Ridge CA, Hobbs BD, Bukoye BA, et al. Incidentally detected lung nodules: clinical predictors of adherence to Fleischner
Society surveillance guidelines. J Comput Assist Tomogr 2014;38:89-95. 22. American College of Radiology. Imaging 3.0 case study: reducing variability. Available at: https://www.acr.org/w/media/ACR/ Documents/PDF/Economics/Imaging3/ CaseStudies/2015/QualityAndSafety/ ReducingVariability/Imaging3_Reducing Variability_October2015.pdf. Accessed May 19, 2016.
23. Beaman AL, Klentz B, Diener E, et al. Selfawareness and transgression in children: two field studies. J Pers Soc Psychol 1979;37:1835-46. 24. Clark TJ, Flood TF, Maximin ST, et al. Lung CT Screening Reporting and Data System speed and accuracy are increased with the use of a semiautomated computer application. J Am Coll Radiol 2015;12: 1301-6.
Toshimasa J. Clark, MD, and Glenn Coats, MD, are from the University of Colorado Denver, Aurora, Colorado. The authors have no conflicts of interest related to the material discussed in this article. Toshimasa J. Clark, MD: University of Colorado Denver, 12401 E 17th Avenue, MS L954, Aurora, CO 80045; e-mail: [email protected].
4
Journal of the American College of Radiology Volume - n Number - n - 2016
Adherence to ACR Incidental Finding Guidelines Toshimasa J. Clark, MD, Glenn Coats, MD BRIEF RATIONALE Radiologists commonly encounter incidental findings, and in response, organizations such as the ACR have developed consensus management guidelines [1-9]. The use of such guidelines may increase the value of radiologists’ work by ensuring consistent management of incidental findings. There has been a paucity of data regarding radiologists’ adherence to the ACR incidental finding guidelines and methods to increase adherence. WHAT WE DID We investigated ACR incidental finding guideline adherence at a single institution for two specific entities, thyroid nodules seen on CT and gallbladder polyps seen on abdominal ultrasound. These entities were chosen because they are prevalent and because of previously demonstrated substantial variability in radiologists’ management recommendations [10-15]. As part of this investigation, we developed a computer application that implements all currently published ACR incidental finding guidelines, for use both as a reference standard and as a tool that radiologists may use in their day-to-day practice with the goal of 100% guideline adherence. ACR incidental findings white paper algorithms were implemented
as a JavaScript application, including incidental cystic renal, solid renal, liver, adrenal, cystic pancreatic, adnexal, vascular, splenic, nodal, gallbladder, and thyroid findings [1,3-5,7,8]. The application is free to use and is open source (GNU Public License; GNU, Cambridge, Massachusetts). It is accessible on the Internet at http://rad decisionsupport.com/apps/incidental_ app/index.html or via e-mail request ([email protected]). The institutional review board approved a retrospective analysis of chest CT studies demonstrating thyroid nodules and abdominal ultrasound studies demonstrating gallbladder polyps. We used freetext query software (Primordial Design Solutions, San Mateo, California) to identify consecutive studies with such findings. Each finding was input into the JavaScript computer application, with its output used as the reference standard. We reviewed the medical record to determine actual follow-up in practice. These data were recorded in a Microsoft Excel spreadsheet and analyzed with the Analysis ToolPak (Microsoft Corporation, Redmond, Washington).
OUTCOMES We report data from 75 chest CT studies with 75 thyroid nodules and
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.05.008
80 abdominal ultrasound studies with one or more gallbladder polyps. Patient and nodule characteristics are summarized in Table 1. Follow-up recommendations by radiologists and ACR management guidelines are summarized in Table 2 for thyroid nodules and Table 3 for gallbladder polyps, along with the observed actual follow-up and concordance between the radiologist and ACR recommendations. Notable findings include that 2.5% of 10.5% observed follow-up for thyroid nodules was not warranted per ACR recommendations and that gallbladder polyp follow-up was performed in actual practice (20%) more often than either the radiologist recommendations (8.8%) or ACR recommendations (1.25%), which indicates by definition that the majority of these follow-up studies were not indicated. There were statistically significant differences in the follow-up recommendations for thyroid nodules between radiologists and ACR management guidelines, whether or not no follow-up was considered equivalent to an absence of a followup recommendation (c2 < 0.001 in both cases). For gallbladder polyps, statistical significance was reached only when a lack of a follow-up recommendation was not considered to be equivalent to the explicit
1
Table 1. Characteristics of patients with gallbladder polyps on ultrasound and thyroid nodules on CT Variable Value Patients with gallbladder polyps on ultrasound Number of patients 78 Number of gallbladder polyps 80 (2 patients with multiple polyps) Gender 66% female Mean age (y) 47 Median age (y) 47.5 Mean gallbladder polyp size (mm) 4.1 Median gallbladder polyp size (mm) 4.0 Patients with thyroid nodules on CT Number of patients 75 Number of thyroid nodules 75 Gender 57% female Mean age (y) 60 Median age (y) 62 Mean thyroid nodule size (mm) 10.9 Median thyroid nodule size (mm) 10.0
recommendation of no further follow-up (c2 < 0.001). Another notable finding is that there were no cases for which both the radiologist and ACR recommendations for gallbladder polyps would have been for ultrasound follow-up or surgical consultation. Our data are concordant with those of Lehnert et al [15], who
showed high variability in management recommendations for thyroid nodules seen on CT at their institution. Similarly concordant are data from prior groups demonstrating wide interinstitution variability in adherence to Fleischner Society lung nodule management guidelines [16-21]. Although we are unaware
Table 2. Follow-up recommendations for thyroid nodules seen on CT Recommendation Radiologist recommendation for ultrasound follow-up Radiologist recommendation of no follow-up Radiologist absence of follow-up recommendation ACR recommendation for ultrasound follow-up ACR recommendation of no follow-up ACR absence of follow-up recommendation Actual follow-up in subsequent 12 months Proportion of actual follow-up indicated per ACR management guidelines Concordance of ACR and radiologist follow-up recommendations
Percentage 36 0 64 25 75 0 10.5 8 (2.5% not indicated) 17.3* 73.3†
Note: There exist statistically significant differences between the radiologist and ACR recommendations regardless of whether no follow-up is considered equivalent or not to an absence of a follow-up recommendation (c2 < 0.001 in both cases). *If a recommendation of no follow-up is not considered equivalent to an absence of a follow-up recommendation. † If a recommendation of no follow-up is considered equivalent to an absence of a follow-up recommendation.
2
of prior publications specifically addressing adherence to ACR incidental finding guidelines, data from an ACR case study indicate that one radiology practice observed 56% adherence to the thyroid nodule guidelines [22]. In this case study, the radiology practice created a video-based intervention and ultimately reported 92% guideline adherence [17]. It is possible that their use of a video tool resulted in radiologists’ knowing that they were being observed, which may have made them more self-aware of their behavior [23]. Rather than a video, we suggest that our computer application could be used to increase incidental finding guideline adherence. By the definition of its construction, use of the application and adoption of its output results in 100% adherence with ACR guidelines. Previous work has suggested that, at least for Lung-RADS, the use of a similar computer application can increase both the speed and accuracy of guideline application [24], and the application’s explicit recommendation of no follow-up may decrease ambiguity in radiologists’ reports. Our data from a single institution may not be generalizable to other institutions or to entities other than gallbladder polyps and thyroid nodules. We also did not determine whether an intervention such as the use of our computer application would result in sustained prospective increased adherence, but instead only projected that its use would result in greater adherence. Nevertheless, we believe that our findings of low concordance between radiologists recommendations and ACR guidelines are of interest and that use of the computer application that we
Journal of the American College of Radiology Volume - n Number - n - 2016
Table 3. Follow-up recommendations for gallbladder polyps seen on ultrasound Recommendation Radiologist recommendation for ultrasound follow-up Radiologist recommendation for general surgery consultation Radiologist recommendation of no follow-up Radiologist absence of follow-up recommendation ACR recommendation for ultrasound follow-up ACR recommendation for general surgery consultation ACR recommendation of no follow-up ACR absence of follow-up recommendation Actual follow-up in subsequent 12 mo
Proportion of actual follow-up indicated per ACR management guidelines Concordance of ACR and radiologist follow-up recommendations
Percentage 8.75 8.
1.25 0 90 9.
1.25 3.75 95 0 20 (5% not specifically for follow-up of polyps but for other general conditions) 1.25 (18.75% not indicated) 0* 88.8†
Note: There exist statistically significant differences between the radiologist and ACR recommendations if no follow-up is not considered equivalent or not to an absence of a follow-up recommendation (c2 < 0.001). There is no significant difference between radiologist and ACR recommendations if follow-up is considered equivalent or not to an absence of a follow-up recommendation (c2 ¼ 0.755 for ultrasound, c2 ¼ 0.843 for surgical consultation). *If a recommendation of no follow-up is not considered equivalent to an absence of a follow-up recommendation. † If a recommendation of no follow-up is considered equivalent to an absence of a follow-up recommendation.
10.
11.
12.
13.
14.
15.
developed and make freely available could reduce report variability and result in 100% incidental findings guideline adherence.
REFERENCES 1. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010;7:754-73. 2. Erasmus JJ, Connolly JE, McAdams HP, et al. Solitary pulmonary nodules: part I. Morphologic evaluation for differentiation of benign and malignant lesions. Radiographics 2000;20:43-58. 3. Heller MT, Harisinghani M, Neitlich JD, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 3: white paper of the ACR Incidental
4.
5.
6.
7.
Journal of the American College of Radiology Clark, Coats n Case Studies in Leadership
Findings Committee II on splenic and nodal findings. J Am Coll Radiol 2013;10: 833-9. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 2015;12:143-50. Khosa F, Krinsky G, Macari M, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 2: white paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol 2013;10:789-94. Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology 2013;266: 304-17. Patel MD, Ascher SM, Paspulati RM, et al. Managing incidental findings on
16.
17.
18.
19.
abdominal and pelvic CT and MRI, part 1: white paper of the ACR Incidental Findings Committee II on adnexal findings. J Am Coll Radiol 2013;10:675-81. Sebastian S, Araujo C, Neitlich JD, et al. Managing incidental findings on abdominal and pelvic CT and MRI, part 4: white paper of the ACR Incidental Findings Committee II on gallbladder and biliary findings. J Am Coll Radiol 2013;10:953-6. MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 2005;237: 395-400. Yoon DY, Chang SK, Choi CS, et al. The prevalence and significance of incidental thyroid nodules identified on computed tomography. J Comput Assist Tomogr 2008;32:810-5. Youserm DM, Huang T, Loevner LA, et al. Clinical and economic impact of incidental thyroid lesions found with CT and MR. AJNR Am J Neuroradiol 1997;18:1423-8. Lin WR, Lin DY, Tai DI, et al. Prevalence of and risk factors for gallbladder polyps detected by ultrasonography among healthy Chinese: analysis of 34 669 cases. J Gastroenterol Hepatol 2008;23:965-9. Jorgensen T, Jensen KH. Polyps in the gallbladder. A prevalence study. Scand J Gastroenterol 1990;25:281-6. Segawa K, Arisawa T, Niwa Y, et al. Prevalence of gallbladder polyps among apparently healthy Japanese: ultrasonographic study. Am J Gastroenterol 1992;87:630-3. Lehnert BE, Sandstrom CK, Gross JA, et al. Variability in management recommendations for incidental thyroid nodules detected on CT of the cervical spine in the emergency department. J Am Coll Radiol 2014;11:681-5. Eisenberg RL, Bankier AA, Boiselle PM. Compliance with Fleischner Society guidelines for management of small lung nodules: a survey of 834 radiologists. Radiology 2010;255:218-24. Eisenberg RL, Fleischner S. Ways to improve radiologists’ adherence to Fleischner Society guidelines for management of pulmonary nodules. J Am Coll Radiol 2013;10:439-41. Lacson R, Prevedello LM, Andriole KP, et al. Factors associated with radiologists’ adherence to Fleischner Society guidelines for management of pulmonary nodules. J Am Coll Radiol 2012;9: 468-73. MacMahon H. Compliance with Fleischner Society guidelines for management of
3
lung nodules: lessons and opportunities. Radiology 2010;255:14-5. 20. Masciocchi M, Wagner B, Lloyd B. Quality review: Fleischner criteria adherence by radiologists in a large community hospital. J Am Coll Radiol 2012;9:336-9. 21. Ridge CA, Hobbs BD, Bukoye BA, et al. Incidentally detected lung nodules: clinical predictors of adherence to Fleischner
Society surveillance guidelines. J Comput Assist Tomogr 2014;38:89-95. 22. American College of Radiology. Imaging 3.0 case study: reducing variability. Available at: https://www.acr.org/w/media/ACR/ Documents/PDF/Economics/Imaging3/ CaseStudies/2015/QualityAndSafety/ ReducingVariability/Imaging3_Reducing Variability_October2015.pdf. Accessed May 19, 2016.
23. Beaman AL, Klentz B, Diener E, et al. Selfawareness and transgression in children: two field studies. J Pers Soc Psychol 1979;37:1835-46. 24. Clark TJ, Flood TF, Maximin ST, et al. Lung CT Screening Reporting and Data System speed and accuracy are increased with the use of a semiautomated computer application. J Am Coll Radiol 2015;12: 1301-6.
Toshimasa J. Clark, MD, and Glenn Coats, MD, are from the University of Colorado Denver, Aurora, Colorado. The authors have no conflicts of interest related to the material discussed in this article. Toshimasa J. Clark, MD: University of Colorado Denver, 12401 E 17th Avenue, MS L954, Aurora, CO 80045; e-mail: [email protected].
4
Journal of the American College of Radiology Volume - n Number - n - 2016