Purpose or Case Report: Two major insurance companies have recently enacted policies requiring outpatient advanced imaging at free-standing imaging facilities for adults. Examining the potential clinical and economic implications of non-subspecialized interpretations in children is important. We evaluated the rate of major discrepancies and changes in management arising from second interpretations by a dedicated pediatric facility.
Methods & Materials: A retrospective and prospective analysis of CTs and MRs presenting for over-read by a pediatric radiologist was performed. For the prospective review, a standardized dictation template was implemented to track disagreements. A board-certified radiologist identified cases with major discrepancies as defined by those that were likely to change surgical or medical management. A chart review was performed to identify changes in clinical course and outcomes based on the second interpretation.
Results: 1397 patients were referred to our pediatric hospital for second interpretation following an outside facility interpretation. 3.6% of all patients (18/574 patients from retrospective review and 32/823 patients from prospective analysis) had major discrepancies between the outside report and the pediatric subspecialty interpretation. Of all major discrepancies, 31 were body cases (chest, abdomen, or pelvis), 13 were neuroradiology cases (head or neck), and 6 were musculoskeletal cases (spine or joint). Second interpretations changed surgical management for 14 patients, with 4 patients receiving a necessary surgery and 10 patients avoiding an unnecessary surgery. Medical management changed for 36 patients. Eleven of the cases with major discrepancies involved an incorrect diagnosis related to appendicitis. Examples of other serious missed findings included secondary reads that lead to diagnoses of meningoencephalitis, Crohn’s disease, herpes encephalitis, intracranial hemorrhage, pulmonary embolism, and ovarian teratoma.
Conclusions: Pediatric subspecialty interpretations altered the surgical or medical management in 3.6% of referrals, which compares with a 0.4% rate of level 3 and 4 errors from the ACR RADPEER database. This supports the case for performing and interpreting these studies at a facility with dedicated pediatric radiologists. Since changes in reimbursement related to hospital-based cross-sectional imaging are driven by costs, the potential long-term adverse economic impact of non-subspecialized interpretations suggested by our study needs to be carefully considered.