Michael Hickman MIV

 Berbaum KS, el-Khoury GY, Franken EA Jr, Kathol M,

Montgomery WJ, Hesson W. Impact of clinical history
on fracture detection with radiography. Radiology. 1988;
168:507-511
 Houssami N, Irwig L, et al. The influence of clinical
information on the accuracy of diagnostic
mammography. Breast Cancer Research and Treatment.
2004; 85:223-228
 Leslie A, Jones AJ, Goddard PR. The influence of
clinical information on the reporting of CT by
radiologists. British Journal of Radiology. 2000; 73:1052-
1055
 Loy C, Irwig L. Accuracy of diagnostic tests read with
and without clinical information. JAMA. 2004;
292:1602-1609
 In favor of providing radiologist with clinical
information:
 Accuracy of the read may be improved with
additional information
 Schreiber suggested better accuracy with chest x-ray
readings when given clinical information in 1963
 In favor of not providing radiologist with
clinical information:
 Clinical information may bias the reading
 Clinical information should be incorporated into
decision making only after an unbiased read
 Accuracy: quantified in terms
of sensitivity, specificity, and
ROC curves
 Sensitivity: the proportion of
individuals with a disease who
have positive test results
 Specificity: the proportion of
individuals without a disease
who have negative test results
 Receiver operating
characteristic (ROC) curves:
test accuracy estimates for a
test at several thresholds are
joined together
 Perception: the identification
of abnormalities
 Interpretation: the attribution
of observed abnormalities to a
disease process
 Objective: Assess the effect of
knowledge of localizing symptoms
and signs on the detection of fractures
in radiographs of trauma patients.

 Materials and Methods: Seven

radiologists from University of Iowa;
40 radiographs (26 subtle fractures, 14
normal)
 Procedure: 2 sessions separated by 4
months; All 40 radiographs read, half of
radiographs shown with clinical
information in first session and vice
versa in second session. Each radiograph
read twice, once with and once without
clinical information.
 Results: Interpretations with clinical data were
more accurate than interpretations without clinical
clues.
 Improved accuracy was based on higher true-positives
rates rather than lower false-positive rates
 The most important information was location
 Discussion: “Clinical information affects detection
of radiographic abnormalities, but mechanisms of
the effect remain unclear.”
 Clinical information
 Indication of specific locations for intensive evaluation
 Clues to search for particular abnormalities
 Localizing clues facilitate the detection of subtle fractures
largely by an increase in the true-positive rate with little
to no change in false-positive rate
 Improved PERCEPTION
 1 out of 5 radiologist are sued annually for malpractice
with the largest category of suits involving missed
diagnosis, fractures most common (1988).
 Objective: Examine the influence
of knowledge of clinical
information on the accuracy of
mammography in women referred
for investigation of breast
symptoms
 Methods: 2 radiologist read 480
mammograms (240 with cancer,
240 without) first without clinical
information and then with
information a few days later.
 Clinical information: type and
site of symptoms, but without
knowledge of the level of
suspicion of cancer based on
clinical exam
 Results: Clinical information improved
radiologists ability to detect breast cancer
 Symptoms between cancer and non-cancer
patients did not substantially differ
 Clinical information “directed” the
radiologist to the area of interest which led
to improved PERCEPTION
 Specific symptom and site or quadrant of
the breast were the most crucial
 Objective: Determine whether clinical information
alters the CT report
 Method: Prospective blinded study consisted of 50
consecutive patients who had a CT performed.
Each study was read by 2 of 3 radiologists, before
and after knowledge of clinical information.
 Results: 19% of CT reports were changed after
clinical information was known; 83% of reports
became more accurate and 17% became less
accurate after the correct clinical information
was known
 CT contains a great deal of information with
multiple systems and several body areas; “The more
complex the investigation, the more important the
clinical information.”
 Objective: To determine whether diagnostic tests
are more accurate when read with clinical
information or without it.
 Study Selection: A systematic review of all articles
comparing the accuracy of tests read twice by the
same readers, once without and once with clinical
information, but otherwise under identical
conditions. Only articles that reported sensitivity
and specificity or receiver operating characteristic
(ROC) curves were included.
 16 articles met criteria
 Results: 9 out of 16 articles reported improved
areas under ROC curves, more significantly
with fabricated clinical information; 4 out of 5
articles reported improved sensitivity without
loss of specificity
 Conclusion: Clinical information improves
accuracy by improving reader’s PERCEPTION
 Clinical information improves overall accuracy
with CTs, mammography, and x-rays.
 Accuracy is improved by increasing sensitivity
without dramatically affecting specificity 
PERCEPTION
 The most crucial clinical information for the
radiologist is location of symptoms.
 Further studies should be conducted to
investigate the impact of providing clinical
information at different stages of the
perception-interpretation sequence.