Pi is 1546144015000691

ORIGINAL ARTICLE

Survey-Based AssessmenUnderstanding of Their OExaminations

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ergation, as well as experiences, satisfaction, and preferences regarding

that provision of information to patients is among the Radiologists can contribute to shared decision making

dality of the ex-ed, any use ofd potential radi-f understanding

the examination. 2015 American College of Radiology1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2015.02.006 549standing includes awareness of the moamination, the body part being imagintravenous or other contrast agents, anation exposure. Obtaining this level oinvolves providing patients with sufcfor any questions to be answered by avider who is knowledgeable regarding

Department of Radiology, NYU Langone Medical Center, New York,New York.

The authors have no conicts of interest to disclose.

Corresponding author and reprints: Andrew B. Rosenkrantz, MD, MPA,Department of Radiology, Center for Biomedical Imaging, NYU LangoneMedical Center, 660 First Ave, New York, NY 10016; e-mail: [email protected] opportunityhealth care pro-most critical steps for achieving shared decision making by ensuring that patients have a strong understanding ofthe imaging examinations they undergo. Such under-Results: A total of 176 surveys were completed by patients awaiting CT (n 45), MRI (n 41), ultrasound (n 46), and nuclearmedicine (n 44) examinations. A total of 97.1% and 97.8% of patients correctly identied the examination modality and the bodypart being imaged, respectively. A total of 45.8% correctly identied whether the examination entailed radiation; 51.1% and 71.4% ofpatients receiving intravenous or oral contrast, respectively, correctly indicated its administration. A total of 78.6% indicated that theordering physician explained the examination in advance; among these, 72.1% indicated satisfaction with the explanation. A total of21.8% and 20.5% indicated consulting the Internet, or friends and family, respectively, to learn about the examination. An overallunderstanding of the examination was reported by 70.8%. A total of 18.8% had unanswered questions about the examination, mostcommonly regarding examination logistics, contrast-agent usage, and when results would be available. A total of 52.9% were interestedin discussing the examination with a radiologist in advance. Level of understanding was greatest for CT and least for nuclear medicineexaminations, and lower when patients had not previously undergone the given examination.

Conclusions: Patients knowledge of their imaging examinations is frequently incomplete. The ndings may motivate initiatives toimprove patients understanding of their imaging examinations, enhancing patient empowerment and contributing to patient-centeredcare.

Key Words: Patient communication, patient-centered care, survey, radiologists, radiology practice

J Am Coll Radiol 2015;12:549-555. Copyright 2015 American College of Radiology

INTRODUCTIONShared decision making by patients and physicians con-tributes to patients experiencing reduced anxiety as wellas greater satisfaction, engagement, sense of control, andparticipation in their own care [1-5]. Past studies report

[6], and that the process entails having patients that are asknowledgeable as possible regarding their management[1]. In addition, in studies of a range of medical condi-tions, patients have been observed to want greaterknowledge regarding their care [4,7,8].Andrew B. Rosenkrantz, MD, MPA, Eric R. Flagg,

Abstract

Purpose: To perform a survey-based assessment of patients knospectives regarding communication of such information.

Methods: Adult patients were given a voluntary survey before undquestions addressed knowledge of various aspects of the examincommunication of such knowledge.t of Patientswn Imaging

D

dge of radiologic imaging examinations, including patients per-

oing an outpatient imaging examination at our institution. Survey

extremity); whether the examination was for follow-up of

Patients Knowledge of Radiologic ImagingHowever, reaching this goal may be challenging giventhat the physicians who order radiologic tests are typicallynot the same physicians who perform and interpret thetests; this situation creates a potential gap in patientcommunication that may result in a decit in their un-derstanding of these areas. For instance, past studies showthat patients have incomplete knowledge regarding radi-ation exposure and risk from CT [9,10].

To provide greater insight into patients knowledge ofradiologic testing, we administered a prospective survey tooutpatients undergoing imaging examinations at ourinstitution. We report ndings from this assessment ofpatients knowledge regarding radiologic imaging exami-nations, including their perspectives on the communica-tion of such information. The results of this survey,including factors identied to be associated with patientsunderstanding of imaging examinations, could be used toguide future initiatives to improve patient awareness.

METHODSOur institutional review board approved this HIPAA-compliant prospective study. All subjects provided writteninformed consent. Adult outpatients undergoing radiologicimaging examinations at our institution were given avoluntary survey while in the waiting area before the start ofthe scheduled examination. Questions were related toknowledge of specic aspects of their examination, as well astheir experience in being educated about the examinationbefore their appointment. Most questions required either ayes or no response or a rating of 1 to 5 in a Likert-typeformat; a small number of free-response items wereincluded. Each individual question was optional.

Before distributing the surveys to patients, supervisorsfor the individual imaging modalities reviewed the ques-tionnaire with their respective staff members and pro-vided clarications and modications regarding thequestions. Subsequently, front-desk staff members foreach modality were solicited to distribute the surveys toconsecutive patients presenting for examinations duringweekday daytime hours, over a span of approximately 3weeks. The survey typically required

those who did, versus did not, consult with friends andfamily; P .020).

A total of 70.8% (121 of 171) of patients reportedhaving a complete or near-complete understanding oftheir examination. Reponses to this question were signif-icantly associated with modality (lowest frequency fornuclear medicine examinations; P .001) and whetherthe patient had previously undergone the given examina-tion (lower frequency if they had not previously under-gone the examination; P .002). In comparison, 18.8%(32 of 170) indicated having unanswered questionsregarding the examination. Responses to this question

undergone the examination; P .025). Table 1 summa-explained the examination in advance. Responses to this

Fig 1. Bar graph showing percentages of patients who wereable to correctly respond to questions regarding variousaspects of their scheduled radiologic examination. For intra-venous and oral contrast, the numbers in parentheses reectthe number of patients undergoing CT or MRI who receivedthe given agent. For other measures, the numbers in pa-rentheses reect the number of survey respondents.question were not signicantly associated with any vari-able, although they showed nonsignicant associationswith exam modality (lowest frequency for nuclear medi-cine examinations; P .080) and body region imaged(lowest frequency for musculoskeletal exams; P .097).Furthermore, among those who indicated that the refer-ring physician had explained the examination in advance,72.1% (98 of 136) indicated that that they were satisedor very satised with the explanation. Responses to thisquestion showed a signicant association with modality(lowest frequency for nuclear medicine examinations;P .008) and a nonsignicant association with bodyregion imaged (lowest frequency for musculoskeletal ex-aminations; P .055).

A total of 21.8% (38 of 174) of patients reported thatthey consulted the Internet to learn about their exami-nation. Responses to this question were not signicantlyassociated with any variable, although they showed anonsignicant association with patient age (lower age forthose who did, versus did not, consult the Internet; P .056). A total of 34.9% (61 of 175) of patients reportedconsulting with family or friends to learn about theirexamination. Responses to this question were signi-cantly associated with only patient age (lower age for

Journal of the American College of RadiologyRosenkrantz, Flagg n Patients Understanding of Imagingrizes the topics of the unanswered questions.A total of 52.9% (90 of 170) of patients were inter-

ested or very interested in having the opportunity todiscuss the examination with a radiologist in advance ofthe examination. Responses to this question showed asignicant association with whether the exam was per-formed for follow-up of a known cancer (lower frequencyif performed for follow-up of a known cancer; P .040)and a nonsignicant association with modality (highestfrequency in nuclear medicine examinations; P .098).

Fig. 2 summarizes the previously described surveyresponses. Table 2 provides additional informationregarding the distribution of survey responses by studyvariable.

Cronbachs alpha was 0.728, indicating good internalconsistency of psychometric survey items.

DISCUSSIONWe performed a prospective survey-based assessment of pa-tients knowledge of their scheduled imaging examinations.

Table 1. Topics of patients unanswered questions regardingtheir imaging examinations

Topic nGeneral explanation of the examinations logistics 8Use of contrast agents 7When the patient would be able to obtain the test results 5The reason for the examination 4The expected duration of the examination 4Potential radiation exposure 3Which body part was being imaged 1

Note: Values for n reect the fact that some patients listed >1unanswered question.were signicantly associated with modality (highest fre-quency for nuclear medicine examinations; P .001) andwhether the patient had previously undergone the givenexamination (lower frequency if they had not previously551

ithpaA reassuring nding is that the overwhelming majorityof patients correctly identied the imaging modalitybeing used and the body part being imaged. However,patients less reliably understood other aspects of theirexaminations. Approximately half of patients incor-rectly identied whether their examination entailedradiation exposure, and a substantial fraction of patientswere unaware that they would be receiving intravenousor oral contrast agents. These gaps in knowledge candiminish patients satisfaction with their imagingexperience and limit patients ability to effectivelyengage in shared decision making regarding undergoingsuch testing.

Patients incomplete knowledge of imaging examina-tions relates in part to the traditional radiology workowin which radiologists generally do not order examinationsor interact with patients before examinations. Althoughordering physicians may seem well positioned to performthis role, ordering physicians may have an incompleteunderstanding of the examinations themselves or,depending on the circumstances, may not have sufcient

Fig 2. Bar graph showing percentages of patients agreeing wexamination. Number of respondents for each item is given inopportunity to review the examination with the patient atthe time of ordering. Our data support this possibility, asthe ordering physician failed to explain the examinationin >20% of cases, and even when doing so, the patientwas not satised with the explanation in >25% of cases.

Accordingly, the nding that approximately 20% ofpatients had unanswered questions regarding their ex-amination is not surprising. These unanswered questionspertained to a spectrum of procedural aspects of the ex-amination, including overall logistics, radiation exposure,use of contrast agents, and the time needed for examcompletion and reporting of results. Such items are fullywithin the purview of radiologists who could readilyexplain these matters to patients. However, opportunities

552for interactions of this nature rarely occur between radi-ologists and patients in todays typical imagingenvironment.

Despite such issues, most patients felt that they un-derstood their examination. This sense of awarenessmay berelated to initiatives by patients to learn more about theirexamination from alternate sources. For instance, consid-erable fractions of patients reported using the Internet orfamily and friends as sources of supplemental information.Such efforts by patients indicate their desire to becomemore fully educated about their care, via, for instance,investigating details of their imaging examinations.Although excellent information potentially may be ob-tained through the Internet or family and friends, radiol-ogists are nonetheless uniquely positioned to providecomprehensive and accurate information regarding radio-logic testing, given their training and expertise in the area.

In view of the above ndings, the fact that a largefraction of patients were interested in meeting with theradiologist before their examination may be an expectednding. Through such an encounter, the radiologist can

various statements regarding their scheduled radiologicrentheses.explain the examination experience, provide reliable in-formation regarding radiation and contrast usage, andanswer remaining questions. A considerably higher frac-tion of patients expressed a desire to meet with theradiologist than reported a lack of understanding of theexamination or had unanswered questions. Thus, patientsmay have a general expectation that all physiciansparticipating in their care will be available for consulta-tion, or patients may simply be at greater ease once theyhave had direct human interaction with the doctorinterpreting their images. Such ndings are consistentwith past studies that report a desire by patients to receivemore information regarding radiologic testing directlyfrom their health care providers [10,12,13]. Finally, our

Journal of the American College of RadiologyVolume 12 n Number 6 n June 2015

Table 2. Distribution of responses to survey items, by studyvariables

Survey Item Study VariableExam explained inadvance

ModalityCT: 86.7 (39/45)MRI: 80.5 (33/41)Ultrasound: 81.8 (36/44)Nuclear medicine: 65.1 (28/43)

Body region imagedThoracoabdominal: 77.3 (75/97)Head: 86.6 (46/53)Musculoskeletal: 65.2 (15/23)

Satised withexplanation


Body region imagedThoracoabdominal: 69.9 (51/73)Head: 82.6 (38/46)Musculoskeletal: 52.9 (9/17)

Used Internet to learnabout exam

Patient age (y)Did use the Internet: 45.9 14.4Did not: 52.0 18.0

Asked friends orfamily about exam

Patient age (y)Did ask friends or family:46.5 16.5

Did not: 52.9 17.5Achievedunderstanding ofexam


Patient imaging historyHad previously undergone givenexam: 84.4 (54//64)

Had not previously undergonegiven exam: 61.5 (67/109)

Unansweredquestions aboutexam


Patient imaging historyHad previously undergone givenexam: 24.1 (26/108)

Had not previously undergonegiven exam: 9.7 (6/62)

Interested indiscussing examwith radiologist inadvance

Exam indicationFor follow-up of known cancer:34.5 (10/29)

Not for follow-up of knowncancer: 56.7 (80/141)

(continued)

Journal of the American College of RadiologyRosenkrantz, Flagg n Patients Understanding of Imagingdata do not make clear why patients undergoing imagingto follow-up on a known cancer were less likely to wish tomeet with the radiologist before the examination.Possibly, such patients have already had discussionsregarding the examination with their oncologist. Alter-natively, or in addition, they may have been eager toexpedite the examination to the extent possible in orderto alleviate anxiety.

Patients responses varied among the imaging mo-dalities. In general, patients indicated the highest level ofawareness for CT and the lowest level of awareness fornuclear medicine examinations, and signicant differ-ences were found among modalities in terms of satisfac-tion with referring physician explanations, sense ofunderstanding, and having unanswered questions. Thesendings likely reect differences in the degree ofcomplexity of the examinations and familiarity with thevarious modalities among referring physicians. The rela-tively low level of knowledge regarding nuclear medicineexaminations highlights a particular need to ensure pro-vision of appropriate information to patients undergoingsuch studies. Despite the variation, 40% of patients foreach modality were interested in meeting with the radi-ologist in advance, indicating the potential value of uni-versally providing such an opportunity within a radiologypractice.

We hope that our ndings serve as motivation forfuture initiatives by radiology departments to enhancepatient-centered care. One direct means of addressing theidentied gap is for radiologists to be routinely available

Table 2. Continued

Survey Item Study VariableModalityCT: 47.7 (21/44)MRI: 59.0 (23/39)Ultrasound: 41.3 (19/46)Nuclear medicine: 65.9 (27/41)

Note: Values are % (n of total), or mean SD. Data are provided for alldistributions that had a signicance level of P < .1.to meet with patients in person before their scheduledexamination, if desired by the patient. Such an approachmay borrow elements from a recently implementedradiology consultation service [14] in which radiologistsmet with patients after their examinations to review theimages. Indeed, a future investigation could use thequestionnaire employed in this study to assess the impactof a prospective brief educational session before imagingexaminations to improve patients knowledge of their

553

implement in practices that perform a high volume of

n Patients understanding was greatest for CT andremote interpretations for offsite imaging. One possibilityto address such workow concerns is to focus these effortson patients who have not previously undergone the givenexamination, as such patients in our study had less of anunderstanding of the exam and were more likely to havequestions.

In addition to the above considerations, IT and digitalmedia should be used to provide patients with easy accessto complete information. For instance, a practice couldprovide videos on its Website that portray the experienceof undergoing a given examination, establish a mecha-nism for patients to electronically submit questions inadvance regarding an upcoming examination, or postresponses to its most commonly received questions on itswebsite for the benet of other patients. However,traditional communication with the radiologist remainsan important component of any comprehensive solutiongiven the various levels of patients digital literacy [15].Through a committed effort to address the challenge, aradiology practice can achieve greater patient awareness,which in turn can contribute to heightened patientempowerment and participation in decision making fortheir own care.

A number of limitations of this study warrantmention. First, the data contained an inherent selectionbias given that survey completion was optional, and pa-tients level of understanding may have inuenced theirdecision to participate. In addition, the survey was con-ducted at a single large tertiary care academic medicalcenter serving primarily an insured and communicativeoutpatient population. Trends may have been different inother practice settings. Furthermore, we do not havesubsequent clinical data to demonstrate an actual impactof patients various knowledge levels on outcomes andquality of care. Finally, the survey assessed only patientspreference to meet with a radiologist before the exami-nation. Interest in meeting with a radiologist to reviewresults after the examination was not assessed.

CONCLUSIONSWe have identied key areas of incomplete knowledge bypatients regarding their scheduled radiologic examina-tions, including knowledge of radiation exposure and usetests. An additional benet of in-person encounters is thatthey may better position radiologists to tailor imagingprotocols to address patients concerns and cancelpotentially inappropriate examinations. However, thissolution may create workow challenges or be difcult to554least for nuclear medicine examinations. In addi-tion, level of understanding was lower when pa-tients had not previously undergone the givenexamination.

n A total of 52.9% of patients were interested in anopportunity to discuss the examination with aradiologist in advance, including 40% of patientsfor each modality evaluated (CT, MRI, ultrasound,and nuclear medicine).

n Radiology practices should consider offering radi-ologist consultations before examinations, in com-bination with solutions utilizing IT and digitalmedia, to address these gaps in patients knowledgeand thereby enhance patient empowerment andpatient-centered care.had remaining unanswered questions while await-ing the test.of contrast agents. Examinations were not explainedconsistently to patients in advance, or were not explainedsatisfactorily, by referring physicians, and patients notuncommonly reported having incomplete understandingas well as remaining unanswered questions about theirscheduled examinations. A small majority of patientswere interested in meeting with the radiologist before theexamination to discuss the test. Incomplete understand-ing was most pronounced for nuclear medicine exami-nations and for patients who had not previouslyundergone the given examination. These ndings maymotivate initiatives by radiology practices to improvepatients understanding of their imaging examinations,thereby enhancing patient empowerment and contrib-uting to patient-centered care.

TAKE-HOME POINTS

n In a survey of outpatients awaiting radiologic im-aging, 45.8% correctly identied whether the ex-amination entailed radiation; 51.1% and 71.4% ofpatients who were scheduled to receive intravenousor oral contrast, respectively, were aware that itwould be administered.

n A total of 78.6% of patients indicated that theordering physician explained the examination inadvance. Among these, 72.1% indicated satisfactionwith the explanation.

n A total of 21.8% and 20.5% of patients indicatedconsulting the Internet or friends and family,respectively, to learn about the examination; 18.8%Journal of the American College of RadiologyVolume 12 n Number 6 n June 2015

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Credits awarded for this enduring activity are designated SA-CME by the Americanlify toward fullling requirements for Maintenance ofong Learning and Self-assessment. Scan the QR codevisit http://bit.ly/ACRSACME.Journal of the American College of RadiologyRosenkrantz, Flagg n Patients Understanding of ImagingBoard of Radiology (ABR) and quaCertication (MOC) Part II: Lifelto access the SA-CME activity or555

Survey-Based Assessment of Patients Understanding of Their Own Imaging ExaminationsIntroductionMethodsResultsPatients Knowledge of Radiologic Imaging ExaminationsPatients Experience in Communication Regarding Radiologic Imaging Examinations

DiscussionConclusionsTake-Home PointsReferences

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