Completeness and accuracy of malignancy history in abdominal CT order requisitions and final radiology reports

To evaluate the prevalence of malignancy history documentation in CT abdomen or abdomen/pelvis (CT AP) order requisitions and inclusion in final radiology reports, when not included in the order requisition. Influence of exam type, radiologist subspecialty, and patient characteristics on documentation rates was evaluated.

This retrospective cross-sectional study was conducted at a large academic healthcare system. All patients with a malignancy history who underwent CT AP from 1/1/23-1/31/23 were identified. Data were reviewed for malignancy documentation in both radiology order requisition and final reports, using multivariable logistic regression to assess documentation rates by patient setting and control for exam, radiologist, and patient covariates.

Among 1,858 CT APs, 51% included malignancy history in the order requisition, and 71.3% in the final report. Documentation was more likely in the order requisition in outpatient vs. emergency department (ED) settings (OR 10.5; p<0.001) and inpatient vs. ED (OR 1.51; p=0.050), younger patients (OR 0.98 per year; p<0.001), and those of non-Black race (Other race OR 2.06 and White OR 1.36, respectively; p<0.001 and p=0.011). Documentation in final radiology reports, when initially omitted in the order requisition, was more likely during business hours (OR 1.41; p=0.039), outpatient and inpatient settings (ORs 1.90 and 1.70, respectively; p-value 0.013 and p-value 0.019), with younger patients (OR 0.99; p=0.009), and less likely in White patients compared to Black (OR 0.50; p<0.001).

Malignancy history is frequently omitted in initial CT AP order requisitions but is often added by radiologists in final reports, correlated with the imaging timing, setting, and patient demographics.