以临床需求为导向的卵巢-附件肿瘤“3+X定”结构化报告的应用研究  

Application study of clinically needs-oriented ovarian-adnexal tumors“3+X diagnosis”structured report

作　　者：杨庆玲 彭锐 马丽娜 袁蕾 吕艳红 刘淑娟 宦怡 郑敏文 任静 YANG Qing-ling;PENG Rui;MA Li-na;YUAN Lei;LV Yan-hong;LIU Shu-juan;HUAN Yi;ZHENG Min-wen;REN Jing(Xijing Hospital,Air Force Medical University,Xi'an 710032,China)

机构地区：[1]空军军医大学西京医院,陕西西安710032

出　　处：《中国临床医学影像杂志》2024年第7期490-493,497,共5页Journal of China Clinic Medical Imaging

基　　金：陕西本科教育教学改革研究重点项目(23BZ089);空军军医大学教学研究重点课题(2023JXYJ003)。

摘　　要：目的:探讨卵巢-附件肿瘤“3+X定”结构化报告(Structured reports,SR)在临床的应用价值。方法:本研究以临床需求为导向,提出“3+X定”影像诊断思路:在定位、定量、定性这“3定”基础上,针对不同系统不同疾病不定项增加诸如定期、定效等“X定”,并结合卵巢-附件肿瘤最新诊疗指南,设计研发了卵巢-附件肿瘤的“3+X定”SR。回顾性分析2022年5月—2023年12月,我院12名妇科医生对放射科最终提交的339份卵巢-附件肿瘤MRI“3+X定”SR和自由文本式报告(Free text reports,FTR)在术语的规范性、回答关键临床问题、指导临床决策、为手术方案提供有效信息、获取有效信息的便捷性、对报告的信任度和报告整体质量方面的满意度。同时,比较24名放射科医生对两种卵巢-附件肿瘤MRI报告模板在便利性、实用性和诊断信心方面的满意度。采用Likert五分量表法填写调查问卷,满意度间比较采用Wilcoxon符号秩检验,P<0.05为结果有统计学意义。结果:妇科医生认为,相较于传统FTR,“3+X定”SR使用术语更加规范、更好地回答了关键临床问题、指导临床决策、为手术方案提供了更多有效信息,从报告中获取有效信息更便捷(P<0.05)。此外,妇科医生对“3+X定”SR的信任度更高,认为其整体质量明显高于FTR(P<0.001)。24名放射科医生认为“3+X定”SR在便利性、实用性和诊断信心方面的满意度均显著高于FTR(P<0.001)。结论:与传统的FTR相比,“3+X定”SR更受妇科医生和放射科医生欢迎,具有更好的临床应用价值。Objective:To explore the clinical application value of ovarian-adnexal tumors“3+X diagnosis”structured reports(SR).Methods:This study has proposed a“3+X diagnosis”imaging diagnostic thinking guided by clinical needs.“3 diagnosis”included diagnosis of position,quantity and quality,while“X diagnosis”were added according to different systems and diseases,which included diagnosis of cancer staging and therapeutic effects.Combined with the latest diagnostic and treatment guidelines for ovarian-adnexal tumors,a“3+X diagnosis”SR of ovarian-adnexal tumors was designed and developed.The satisfaction of 339 ovarian-adnexal tumor MRI“3+X diagnosis”SR and free text reports(FTR)submitted by the radiology department was counted by 12 gynecologists in our hospital from May 2022 to December 2023,which included that standardized terminology,answered key clinical questions,guided clinical decision-making,provided effective information for surgical plans,the convenience of obtaining effective information,the level of trust in the report and the overall quality of the report.Meanwhile,the satisfaction of 24 radiologists with the convenience,practicality,and diagnostic confidence of two types of ovarian-adnexal tumor MRI report templates was collected.The survey questionnaire was filled out by the Likert five scale,and Wilcoxon signed rank test was used to compare satisfaction levels.P<0.05 indicates statistical significance of the results.Results:Gynecologists believed that compared to traditional FTR,“3+X diagnosis”SR used more standardized terminology,better answered key clinical questions,guided clinical decision-making,provided more effective information for surgical plans,and was more convenient to obtain effective information from reports(P<0.05).In addition,gynecologists had a higher level of trust in“3+X diagnosis”SR,and they believed that its overall quality was significantly higher than FTR(P<0.001).24 radiologists believed that the satisfaction of“3+X diagnosis”SR in terms of convenienc

关 键 词：卵巢肿瘤 磁共振成像 研究报告 

分 类 号：R737.31[医药卫生—肿瘤] R445.2[医药卫生—临床医学]