June 13, 2019

Three Steps to Achieve Evidence-Based Thyroid Reporting: TI-RADS Q&A With Peter A. Rosella, MD, MRMD

In this Physician Spotlight, we talk with Peter A. Rosella, MD, MRMD — who is Magnetic Resonance Medical Director and Director of the Safe Practices Committee at University Medical Imaging, PC about implementing TI-RADS. Plus, he shares three actionable steps radiologists can take to help their organizations identify the most clinically significant malignancies, while reducing the number of biopsies performed on benign nodules.

What are the challenges your organization faced that made TI-RADS and your R-SCAN project rise to the surface to ensure appropriate imaging of thyroid nodules?
We perform a considerable number of thyroid ultrasounds at our practice, and I started to realize that we had no consistent direction for recommending follow-up care in our reports. At a CME meeting, I heard a presentation about the ACR Thyroid Imaging Reporting & Data System (TI-RADS™), and I thought that it would be a good idea to implement it into our practice to establish guidelines for reporting thyroid nodules that are discovered with ultrasound. TI-RADS also offers a lexicon to describe all thyroid nodules identified on sonography and a risk-stratification system to inform practitioners about which nodules warrant biopsy.

How did you get buy-in from the other radiologists in your practice to implement TI-RADS?
At first, the other group members were a little hesitant to take on something new, so I decided to delve into the TI-RADS criteria and the research behind it and present that information to the group. After learning about the opportunities to provide consistent guidance regarding management of thyroid nodules on the basis of their ultrasound appearance, we decided to implement this across our small group of seven radiologists. The first phase was to get radiologists’ buy-in, because it is hard to force people to comply with a new approach. But once they saw the information about the value of TI-RADS, we got 100% buy-in from our small group.

What steps did you take to implement TI-RADS throughout your practice?
One of the first actions was to educate our technologists about the new thyroid reporting standards. For years, our sonographers scanned thyroids the way they were used to doing it — likely how they learned in sonographer school. There was considerable variation among our sonographers. To help radiologists comply with the new reporting criteria used by TI-RADS, the sonographers had to assume more responsibility and change their processes. Once the sonographers and the radiologists were trained with the TI-RADS approach, our thyroid imaging and reporting became more consistent. It really has made a difference.

What changes have you seen as a result of implementing TI-RADS?
Prior to implementing TI-RADS, most of our radiology reports did not provide recommendations on what to do with the thyroid nodules we found. If anything, we would say, "This is amenable to biopsy" or "This could be followed up." Those are pretty wishy-washy recommendations, which put the follow-up back in the hands of the ordering clinician. Unfortunately, many ordering clinicians (especially primary care physicians), do not have training on how to identify the most clinically significant thyroid malignancies and were often confused about what to do with our findings. As a result, there was an overutilization of thyroid imaging and image-guided biopsies.

TI-RADS gave us the opportunity to provide evidence-based guidance to those physicians to ensure that our patients get biopsies or follow-up imaging only when necessary. Since implementing TI-RADS, the radiologists' reports have become much more definitive in their recommendations for biopsy, follow-up imaging or ignoring nodules altogether.

How have the ordering clinicians responded to the new reports?
At first, they were a little hesitant, because the reports look different, and it raises questions because they are seeing recommendations not to follow certain thyroid nodules at all. When I explained to them that the reports used evidence-based guidelines that are rooted in extensive research, they seemed to buy in. I have heard from several primary care physicians, and they really like that we are giving them solid, concrete recommendations on thyroid nodule management, including which patients should be referred to a thyroid specialist. I have not run the numbers yet, but it seems like the number of thyroid ultrasounds has increased since we have implemented TI-RADS. I hope this is because the clinicians trust our recommendations.

Have you heard any feedback from patients?
I've talked to several patients who want to know their results immediately after the imaging. Many of them have been getting a thyroid ultrasound every year for a nodule that does not meet TI-RADS criteria for follow-up or biopsy. When I tell a person that the evidence shows that nodules with certain characteristics are usually benign and do not require any follow up, there is usually a sigh of relief.

How did you use R-SCAN to educate your radiology group and get buy-in?
Initially, my medical director, Dr. Eric Weinberg, suggested that this would make a great R-SCAN project. We approached Nancy Fredericks at the ACR about initiating the R-SCAN project and helping us review the data in our radiologists' reports. No one had done an R-SCAN project with thyroid before, and the ACR was very supportive of the process. Once the other radiologists in the group saw that the ACR was supporting the initiative, it gave us some additional credibility. First, we used the R-SCAN tools to collect and analyze data based on our recommendations for incidental thyroid nodule follow up, then we conducted an educational program with our radiologists about using TI-RADS for standardized reporting. After the intervention, we conducted another round of data analysis of thyroid nodule reporting to determine the impact.

What did the R-SCAN data reveal?
Before we implemented TI-RADS, there was considerable variation in the lexicon used to describe thyroid nodules and the recommendations, if any, provided for management of thyroid nodules. Prior to TI-RADS, most of our reports consisted of a mere list of every nodule in a given patient’s thyroid. Some radiologists always recommended a follow-up ultrasound in six months or one year, and biopsies were recommended based merely on the size of a given nodule. After our educational intervention and TI-RADS implementation, all of our radiologists are now in compliance with using the TI-RADS lexicon and recommendations.

What was the value of using R-SCAN to implement TI-RADS versus just doing it on your own?
The infrastructure provided by the ACR makes the process more accessible, especially when you are in a busy practice and you do not have a lot of time. In addition, the ACR worked with us to tailor this unique project specifically to our practice. The R-SCAN web portal was essential in helping us collect, organize and analyze our data both before and after our educational intervention.

What educational strategies did you use to gain buy-in from the other radiologists in your practice?
Since there are only seven of us, I initially approached each of my partners to brief them about TI-RADS and provide background materials. Then, I held a formal, one-hour education lecture where I reviewed the reasoning behind TI-RADS, its lexicon and its nodule scoring criteria. I also presented multiple cases. Together, we decided how we would describe and score the presented nodules and what we would recommend based on TI-RADS. Initially, a couple of the radiologists were hesitant about implementing TI-RADS into their practice. When these radiologists saw the consistency that TI-RADS provides, we gained their trust. Even though all of us agree that it takes us a little bit longer to interpret and report thyroid ultrasounds now with the TI-RADS system, we feel like we are making a difference. We are helping physicians make appropriate follow-up decisions, and we are helping patients get the care they need.

What are three things every radiologist who conducts thyroid ultrasounds can do to make a difference in patient care?

  1. Educate yourself about TI-RADS, because it is a different approach than what you are used to doing. It takes some time to gain buy-in, because the evidence supports not reporting or following nodules with certain characteristics. Getting over the mental hurdle of accepting something new and complying with it fully, requires both education and confidence.

  2. Make sure your technologists are trained. It is the responsibility of the radiologist to make sure the technologists are up-to-date and educated about the latest guidelines and methods. Regardless of whether you do the education yourself or you send your technologists elsewhere, they need to learn about TI-RADS and they may need to change the way they scan. There is a steep learning curve.

  3. Get the support of everybody in your group, and make sure everyone is on the same page with use of the lexicon and the recommendations. TI-RADS implementation should be all or none. This process will be uncomfortable and take effort, and it could require some extra infrastructure. But to improve, we must often step out of our comfort zone. Turning to the ACR and using R-SCAN can certainly help with practice quality improvement. I am a little biased, but I am glad that my practice went through the process of using R-SCAN and implementing TI-RADS, and I am glad we had the support of the ACR in getting it done.

Peter A. Rosella, MD, MRMD

Peter A. Rosella, MD, MRMD, is an associate professor of clinical imaging sciences at the University of Rochester Medical Center, in Rochester, NY. He is also a staff radiologist at the university’s affiliate outpatient practice, University Medical Imaging, PC (UMI). At UMI, Dr. Rosella is the Magnetic Resonance Medical Director, Director of the Safe Practices Committee and Assistant
Director of the Advanced MR Fellowship program.

Dr. Rosella’s interests include all aspects of MRI and patient safety. He is invested in medical student, resident, fellow and community/patient education. Dr. Rosella also provides MR safety and contrast safety education for both the radiology residents and the department of anesthesia. He has given numerous lectures in the community at local libraries, colleges and high schools. In addition to overseeing the TI-RADS initiative at UMI, Dr. Rosella is involved in CT radiation dose reduction, structured reporting, artificial intelligence and contrast safety initiatives.