The Vascular Laboratory Report:
Window To The Health Care System
by
Kenneth S. Rholl, MD, RVT
from
the Summer 1995 issue
The task of the noninvasive vascular laboratory is straightforward.
Patients are to be evaluated for the presence of disease, the
disease is to be quantified, and the relationship to the clinical
presentation evaluated. Findings must then be formatted in a
report so that other providers of health care can assimilate
the information for use in the management of those patients.
Simple, right? Yet many reports submitted for evaluation during
the accreditation process are substandard. Frequently, following
the generation of perfectly good data by the technologists,
there is a breakdown in the process by which the data are interpreted
and communicated to other health care professionals.
What
constitutes a complete report? The report is a medical legal
document describing the facts surrounding a patient’s visit
to a vascular laboratory. It should contain adequate information
such that a physician involved with the case can extract the
necessary information surrounding that visit, using it to appropriately
direct related health care. The information provided should
be complete enough such that a health care provider subsequently
becoming involved with that patient has adequate information
regarding the patient’s vascular status that he or she
can deliver competent related health care. This article focuses
on describing the key components of a report.
REPORT
ID
Adequate
patient identification in the way of demographics must be included.
There must be enough information to uniquely and clearly identify
the patient.
Indications
A
clear and concise description of the indication(s) for the examination
must be included. This may be as simple as one line describing
an acute anterior, left hemispheric stoke with no preceding
risk factors. Or, it may be appropriate to include a short paragraph
regarding a patient’s chronic claudication, now progressing
to rest pain with a history or multiple risk factors including
insulin dependent diabetes mellitus, hypertension, a long smoking
history and a family history. Prior related surgical and medical
histories should always be included in this section. Physical
findings may be included in this section whether noted at the
time of the examination or reported by the referring physician.
As noninvasive vascular examinations should not be performed
without the appropriate indications, there should be no case
in which this portion of the report is absent.
REPORT
BODY
The
third portion of the report includes an interpretation of the
data. The interpretation of the examination is the composition
of useful relevant information from the multiple data points
generated. This is the practice of medicine itself. As such,
the physician is primarily responsible for reporting the interpretative
portion of the examination. The Standards of the ICAVL mandate
that appropriate criteria are utilized in the interpretation
of vascular examinations, and that these criteria are verified
by the individual laboratory. Application of laboratory verified
criteria is specifically designed to promote accuracy and consistency
within each individual laboratory. The importance of this cannot
be overstated. If the information to be conveyed by the report
is to have any meaning, it must be considered consistent and
reliable within the limitations of the examination. There may
indeed be valid reasons for deviation from standard criteria.
In extracranial cerebrovascular studies for example, it has
been noted that severe occlusive disease in one carotid artery
may elevate velocities and cause overestimation of stenosis
in the contralateral vessel. It is imperative that the reasons
for deviation be included in the report so that another health
care provider is able to make informed decisions on the basis
of the report. Moreover, it is important that individual laboratories
verify the ‘altered criteria’ that they are using
and not just randomly apply the criteria to individual cases
as they see fit.
Similarly,
when there are conflicting data points, it is important that
there is a laboratory specific and verified hierarchy used in
the final interpretation. For example, stenosis estimated by
velocity criteria is frequently at odds with that measured by
sectional gray scale imaging. The inaccuracy of cross-sectional
gray scale imaging in arteries has long been known and is in
fact one of the reasons that Doppler derived data have become
dominant in the estimation of stenoses. It would therefore be
inappropriate to report a 78.9 percent stenosis noted by transverse
imaging when velocity criteria suggested a stenosis only in
the 40-59 percent category. Reporting of a stenosis limited
to a precise degree of narrowing (rather than giving an estimated
range) as above is inappropriate in any case, as there are absolutely
no quality assurance data which would support this type of reporting.
Just
as a single physician needs to be consistent in his/her use
of laboratory specific criteria, it is equally critical that
every physician within a laboratory use the same criteria in
interpreting like data. Failure to do so results in inaccurate
and conflicting reports coming from the same laboratory.
Finally,
each report should include a summary of the data and an interpretation.
This should always include the determination made regarding
the presence or absence of disease. If disease is present, its
anatomic location and a gradation of the severity of disease,
depending on the study, should always be present. Whenever possible,
comparison with prior studies should be made so that some determination
regarding progression of disease can be made. It is also appropriate
to include an assessment of the relevance of the disease to
the clinical presentation in the summary. For instance, a diabetic
patient may have presented with constant burning of the feet,
not particularly exercise related. Though his noninvasive study
may have demonstrated some mild vascular disease, the perfusion
of his lower extremities may be quite normal. Therefore, although
mild peripheral vascular disease was demonstrated, this was
not the likely cause of his symptoms, which were much more likely
secondary to a diabetic neuropathy. This is the kind of information
which the referring physician should find extremely useful in
managing his or her patients It is certainly preferable to the
type of report so often generated which simply states ‘mild
to moderate disease, left greater than right.’
SUMMARY
- Reports
from noninvasive vascular laboratories should consist of adequate
patient identification, the indications for the examination,
a concise review of the data with interpretation, and a summary
of the pertinent findings with implication of their relevance
to the clinical presentation.
- It
is imperative that when interpreting data from a vascular
examination, the physician relies on standardized criteria
which have been verified by that laboratory.
- All
physicians within a laboratory must use the same criteria
for the assessment of disease.
Top
of Page
Want
more news?
|
