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Structured reporting of MRI of the shoulder – improvement of report quality?

European Radiology volume 27, pages 4110–4119 (2017)Cite this article

Abstract

Objectives

To evaluate the effect of structured reports (SRs) in comparison to non-structured narrative free text (NRs) shoulder MRI reports and potential effects of both types of reporting on completeness, readability, linguistic quality and referring surgeons’ satisfaction.

Methods

Thirty patients after trauma or with suspected degenerative changes of the shoulder were included in this study (2012–2015). All patients underwent shoulder MRI for further assessment and possible surgical planning. NRs were generated during clinical routine. Corresponding SRs were created using a dedicated template. All 60 reports were evaluated by two experienced orthopaedic shoulder surgeons using a questionnaire that included eight questions.

Results

Eighty per cent of the SRs were fully complete without any missing key features whereas only 45% of the NRs were fully complete (p < 0.001). The extraction of information was regarded to be easy in 92% of the SRs and 63% of the NRs. The overall quality of the SRs was rated better than that of the NRs (p < 0.001).

Conclusions

Structured reporting of shoulder MRI improves the readability as well as the linguistic quality of radiological reports, and potentially leads to a higher satisfaction of referring physicians.

Key Points

• Structured MRI reports of the shoulder improve readability.

• Structured reporting facilitates information extraction.

• Referring physicians prefer structured reports to narrative free text reports.

• Structured MRI reports of the shoulder can reduce radiologist re-consultations.

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Abbreviations

CI 95%:

Confidence interval

MSK:

Musculoskeletal

NRs:

Narrative free text reports

SRs:

Structured reports

std:

Standard deviation

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Author information

Author notes

    Affiliations

    1. Department of Clinical Radiology, Ludwig-Maximilians-University (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany

      Sebastian Gassenmaier, Marco Armbruster, Wieland H. Sommer & Nora N. Sommer

    2. Department of Knee, Hip and Shoulder Surgery, Schön Klinik München Harlaching, Munich, Germany

      Florian Haasters

    3. Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University (LMU), Campus Innenstadt, Munich, Germany

      Florian Haasters & Tobias Helfen

    4. Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim - Heidelberg University, Heidelberg, Germany

      Thomas Henzler

    5. Ambulatory Health Care Center Radiology & Nuclear Medicine, Fürth, Germany

      Sedat Alibek

    6. Department of Diagnostic Radiology, Friedrich-Alexander University, Erlangen-Nuremberg, Germany

      Sedat Alibek

    7. Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

      Dominik Pförringer

    Authors
    1. Sebastian Gassenmaier
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    2. Marco Armbruster
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    8. Wieland H. Sommer
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    Corresponding author

    Correspondence to Sebastian Gassenmaier.

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    Guarantor

    The scientific guarantor of this publication is Professor Wieland H. Sommer.

    Conflict of interest

    The authors of this manuscript declare relationships with the following companies: QMedify GmbH. Wieland H. Sommer and Marco Armbruster are co-founders of the website www.smart-radiology.com (by Smart Reporting GmbH), an online platform for structured reporting.

    Funding

    The authors state that this work has not received any funding.

    Statistics and biometry

    One of the authors has significant statistical expertise.

    No complex statistical methods were necessary for this paper.

    Informed consent

    Written informed consent was waived by the institutional review board.

    Ethical approval

    Institutional review board approval was obtained.

    Methodology

    • retrospective

    • diagnostic study

    • performed at one institution

    Additional information

    Sebastian Gassenmaier and Marco Armbruster contributed equally to this work.

    Electronic supplementary material

    Below is the link to the electronic supplementary material.

    ESM 1

    Example of a structured report. The figure shows an example of a structured report used in our study. The report was translated from German and had to be edited due to language reasons and with regard to content for the protection of the patient’s anonymity. (DOC 31 kb)

    ESM 2

    Corresponding narrative free text report to ESM 1. The figure shows the corresponding non-structured narrative free text report used in our study. The report was translated from German and had to be edited due to language reasons and with regard to content for the protection of the patient’s anonymity. (DOC 24 kb)

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    Cite this article

    Gassenmaier, S., Armbruster, M., Haasters, F. et al. Structured reporting of MRI of the shoulder – improvement of report quality?. Eur Radiol 27, 4110–4119 (2017). https://doi.org/10.1007/s00330-017-4778-z

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    • DOI: https://doi.org/10.1007/s00330-017-4778-z

    Keywords

    • Radiology
    • MRI
    • Quality improvement
    • Medical informatics
    • Shoulder