使用磁共振成像进行直肠癌的放射学报告:不同报告风格和结构之间的报告完整性的比较
Gustav Alvfeldt1, Peter Aspelin1, Lennart Blomqvist2
1Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
Acta radiologica open
|July 24, 2024
概括
对于直肠癌MRI分期的国家模板,报告的完整性从48%提高到72%. 扩展结构化报告实现了93%的完整性,突出了其对基于证据的实践的重要性.
科学领域:
- 放射学 放射学是一门学科.
- 在瘤学瘤学.
- 医疗信息学 医疗信息学
背景情况:
- 放射学报告对于指导患者治疗至关重要.
- 基于模板的报告增强了放射学报告的完整性.
- 瑞典在2014年实施了用于直肠癌MRI分期的国家报告模板.
研究的目的:
- 评估国家报告模板对MRI报告的影响.
- 为了比较模板实施前和之后的MRI报告的内容和完整性 (2010年与2016年).
- 在不同的报告风格中分析报告的完整性.
主要方法:
- 分析了来自10家医院的493份MRI报告 (2010年为243份,2016年为250份).
- 分类报告分为扩展结构化,最小化结构化和非结构化风格.
- 使用基于国家模板的定性内容分析.
主要成果:
- 报告的完整性从2010年的48%增加到2016年的72%.
- 2016年,扩展结构化报告实现了93%的完整性,最小化结构化报告达到77.5%,非结构化报告达到64%.
- 2010年的所有报告都是非结构化的;到2016年,采用了结构化的报告风格.
结论:
- 实施基于模板的报告,特别是扩展结构,对于坚持以证据为基础的实践在直肠癌分期方面至关重要.
- 国家模板显著提高了报告的完整性.
- 采用结构化报告风格是最大限度地利用国家模板的好处的关键.
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