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• W3113175239 abstract "HomeRadiologyVol. 298, No. 2 Previous CommunicationsFree AccessLetters to the EditorNight and Day: Confounding Factors Complicate Comparison and Generalizability of Radiology Error RatesR. Joshua Dym*, Howard P. Forman†, Meir H. Scheinfeld‡ R. Joshua Dym*, Howard P. Forman†, Meir H. Scheinfeld‡ Author AffiliationsDepartment of Radiology, Section of Emergency Radiology, University Hospital, Rutgers New Jersey Medical School, Newark, NJ*Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, Conn†Department of Radiology, Division of Emergency Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210 St, Bronx, NY 10467‡e-mail: [email protected]R. Joshua Dym*Howard P. Forman†Meir H. Scheinfeld‡ Published Online:Dec 15 2020https://doi.org/10.1148/radiol.2020203577MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail Editor:We read with great interest the recent article by Dr Patel and colleagues (1) published in the November 2020 issue of Radiology, and we have several relevant questions and observations.The authors found that the night shift had a significant increase in errors during its second half, but the day shift did not. However, this lack of statistical significance (albeit close) is likely due to the much lower number for the day shift (2195 vs 7895 for night) causing the study to be underpowered to demonstrate small daytime differences. In fact, the provided data demonstrated a greater increase in second-half errors for the day shift (136% relative increase) than for the night shift (48% relative increase). Worsening performance in the second half of both day and night shifts is consistent with studies showing increased error rates later in shifts (2,3). Moreover, the 13-hour night shift was 2 hours longer than the day shift in this study; longer shifts have been associated with increased errors (3). Review of overnight cases on weekday mornings (unlike daytime cases reviewed on weekend nights) might also have contributed to greater error detection and reporting.In the study, the overnight period had a seemingly low volume of one to two cases per hour (excluding chest and abdominal radiography). Accordingly, we wonder if the fellows all slept adequately during the day or whether perhaps many relied on napping during the night, which could certainly affect performance. Furthermore, we question the use of musculoskeletal or breast imaging fellows-in-training, who only interpret body CT images occasionally while on call, as a paradigm for experienced full-time emergency radiologists who interpret body CT images on a regular basis in a high-volume setting and are likely more accustomed to a semiregular daytime sleep routine.Last, overreads will always find errors, whether attending physicians overread fellows or other attending physicians (4,5). If the baseline error rate at the institution is considered, the day-night difference may not be significant.Because these data may be used by policymakers, it is important to understand the limitations of the authors’ conclusions. Furthermore, data suggesting increased errors among less experienced radiologists working overnight would argue for expanded utilization of emergency radiology specialists.Disclosures of Conflicts of Interest: R.J.D. disclosed no relevant relationships. H.P.F. disclosed no relevant relationships. M.H.S. disclosed no relevant relationships.References1. Patel AG, Pizzitola VJ, Johnson CD, Zhang N, Patel MD. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Radiology 2020. 10.1148/radiol.2020201558. Published online August 18, 2020. Link, Google Scholar2. Ruutiainen AT, Durand DJ, Scanlon MH, Itri JN. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight. Acad Radiol 2013;20(3):305–311. Crossref, Medline, Google Scholar3. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of shift, schedule, and volume on interpretive accuracy: a retrospective analysis of 2.9 million radiologic examinations. Radiology 2018;287(1):205–212. Link, Google Scholar4. Yoon LS, Haims AH, Brink JA, Rabinovici R, Forman HP. Evaluation of an emergency radiology quality assurance program at a level I trauma center: abdominal and pelvic CT studies. Radiology 2002;224(1):42–46. Link, Google Scholar5. Rosenkrantz AB, Duszak R Jr, Babb JS, Glover M, Kang SK. Discrepancy rates and clinical impact of imaging secondary interpretations: a systematic review and meta-analysis. J Am Coll Radiol 2018;15(9):1222–1231. Crossref, Medline, Google ScholarReferences1. Patel AG, Pizzitola VJ, Johnson CD, Zhang N, Patel MD. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Radiology 2020. 10.1148/radiol.2020201558. Published online August 18, 2020. Link, Google Scholar2. Krupinski EA, Schartz KM, Van Tassell MS, Madsen MT, Caldwell RT, Berbaum KS. Effect of fatigue on reading computed tomography examination of the multiply injured patient. J Med Imaging (Bellingham) 2017;4(3):035504. Medline, Google Scholar3. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of Shift, Schedule, and Volume on Interpretive Accuracy: A Retrospective Analysis of 2.9 Million Radiologic Examinations. Radiology 2018;287(1):205–212. Link, Google Scholar4. Lindgren EA, Patel MD, Wu Q, Melikian J, Hara AK. The clinical impact of subspecialized radiologist reinterpretation of abdominal imaging studies, with analysis of the types and relative frequency of interpretation discrepancies. Abdom Imaging 2014;39(5):1119–1126. Crossref, Medline, Google ScholarReferences1. Patel AG, Pizzitola VJ, Johnson CD, Zhang N, Patel MD. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Radiology 2020. 10.1148/radiol.2020201558. Published online August 18, 2020. Link, Google Scholar2. Ruutiainen AT, Durand DJ, Scanlon MH, Itri JN. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight. Acad Radiol 2013;20(3):305–311. Crossref, Medline, Google Scholar3. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of shift, schedule, and volume on interpretive accuracy: a retrospective analysis of 2.9 million radiologic examinations. Radiology 2018;287(1):205–212. Link, Google Scholar4. Yoon LS, Haims AH, Brink JA, Rabinovici R, Forman HP. Evaluation of an emergency radiology quality assurance program at a level I trauma center: abdominal and pelvic CT studies. Radiology 2002;224(1):42–46. Link, Google Scholar5. Rosenkrantz AB, Duszak R Jr, Babb JS, Glover M, Kang SK. Discrepancy rates and clinical impact of imaging secondary interpretations: a systematic review and meta-analysis. J Am Coll Radiol 2018;15(9):1222–1231. Crossref, Medline, Google ScholarResponseMaitray D. Patel , Victor J. Pizzitola, C. Daniel JohnsonMaitray D. Patel , Victor J. Pizzitola, C. Daniel JohnsonAuthor AffiliationsDepartment of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054e-mail: [email protected]We agree multiple factors influence interpretation errors; sorting these confounding factors is complicated. Nevertheless, we believe our observation of increased radiologist night error rate has generalizable underpinnings (1).Fatigue contributes to radiology interpretation error (2,3). Our data showing increased errors in the second half of both day and night assignments support this premise. Yet, the fact that fatigue also occurs during the day has no bearing on our results showing the latter half of the night shift had the highest error rate by far.High work volume contributes to radiology interpretation error (3). The idea that low night volume contributes to error relies on postulating diminished radiologist alertness from circadian misalignment; no one contends that low work volume contributes to increased error in the day. Some of our fellows pursued napping when volume was low at night, others did not, and we could not study the impact of night naps. If emergency radiologists have schedules truly minimizing circadian misalignment, the influence of this one factor on night error should decrease. However, it remains an important consideration when the night radiologist is not so aligned.Radiologist expertise relative to study difficulty contributes to interpretation error (4). By using resources to use emergency radiologists for final interpretation or over read in the middle of the night instead of pursuing morning subspecialty review has drawbacks. Concerns regarding the use of the experience of less-expert fellows as a paradigm for emergency radiologists are legitimate but ironic from a subspecialty perspective. The diagnostic challenges in off-hour studies at Mayo Clinic Arizona for emergency and hospital patients are as or more difficult than those we encounter in outpatients. For any practice that emphasizes subspecialization to promote quality, the notion that these urgent patients are better served by emergency radiologist interpretation not subsequently reviewed by subspecialists is incongruous. If outcomes are just as good without subspecialty interpretation, why not have all studies—day and night, regardless of subspecialty focus—interpreted by emergency radiologists?Yes, the subject is complicated, solutions have trade-offs, and our study has important limitations. Those realities do not invalidate our observation that radiologists make more errors at night. Disclosures of Conflicts of Interest: M.D.P. disclosed no relevant relationships. V.J.P. disclosed no relevant relationships. C.D.J. disclosed no relevant relationships.References1. Patel AG, Pizzitola VJ, Johnson CD, Zhang N, Patel MD. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Radiology 2020. 10.1148/radiol.2020201558. Published online August 18, 2020. Link, Google Scholar2. Krupinski EA, Schartz KM, Van Tassell MS, Madsen MT, Caldwell RT, Berbaum KS. Effect of fatigue on reading computed tomography examination of the multiply injured patient. J Med Imaging (Bellingham) 2017;4(3):035504. Medline, Google Scholar3. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of Shift, Schedule, and Volume on Interpretive Accuracy: A Retrospective Analysis of 2.9 Million Radiologic Examinations. Radiology 2018;287(1):205–212. Link, Google Scholar4. Lindgren EA, Patel MD, Wu Q, Melikian J, Hara AK. The clinical impact of subspecialized radiologist reinterpretation of abdominal imaging studies, with analysis of the types and relative frequency of interpretation discrepancies. Abdom Imaging 2014;39(5):1119–1126. Crossref, Medline, Google ScholarArticle HistoryPublished online: Dec 15 2020Published in print: Feb 2021 FiguresReferencesRelatedDetailsCited ByResponse to Reflection on the Evaluation of Radiologists' Performance during Off-Hours ShiftsMaitray D. Patel, Victor J. Pizzitola, C. 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