Factors Impacting the Use of Terminology to Convey Diagnostic Certainty in Radiology Reports

Abstract

Background: Variable use of phrases expressing diagnostic uncertainty can lead to ambiguous radiology reports, a concern for information processing. Objective: This study aimed to quantify the usage of phrases conveying diagnostic certainty for abdominal imaging findings and assess factors that impact use of phrases with “good agreement” between radiologists and referring providers. Methods: This retrospective, Institutional Review Board-Approved study included all diagnostic reports generated by the Abdominal Radiology Division at an academic medical center July-September 2016. We assessed the use of 16 diagnostic certainty phrases using information retrieval from the Impression section of radiology reports. Phrases with good provider agreement for conveying the level of certainty are defined as “good agreement” phrases - including “diagnostic of”, “represents” and “unlikely.” We assessed the impact of imaging modality, trainee contribution to report generation, and individual radiologists. Results: In 5,598 radiology reports, 2,071 (37%) contained diagnostic certainty phrases, 119 (6%) of which were “good agreement” phrases. There was a significant difference between how frequently “good agreement” phrases were used in Magnetic Resonance Imaging (MRI), Computed Tomography (CT) and X-ray reports (p=0.0003). There was a significant variation among attending radiologists on the use of “good agreement” phrases (p<0.0019). There was no difference in the use of “good agreement” phrases in reports generated by attending radiologists alone compared to reports with trainees. Conclusion: Although phrases to convey diagnostic certainty were commonly used in radiology reports, the use of phrases with a good agreement was uncommon. Standardizing terminology to convey diagnostic certainty may reduce ambiguity in radiology reports and generate more accurate information processing tools.