Influence of observer experience and training on proficiency in coronary CT angiography interpretation

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Abstract

Purpose

To assess the influence of experience and training on the proficiency in coronary CT angiography (CCTA) interpretation of practitioners with different levels of experience.

Methods and materials

Nine radiologist and cardiologist observers with varying prior CCTA experience ranging from novice to expert independently analyzed two case series of 50 catheter-correlated CCTA studies for coronary artery stenosis (0%, ≤49%, 50–74%, 75–99%, or 100%). Results of the first case series were unblinded and presented along with catheter angiography results to each reader before proceeding to the second series. Diagnostic accuracy on a per-segment basis was compared for all readers and both case series, respectively.

Results

Correlation coefficients between CCTA and catheter angiography initially ranged between good (r = 0.87) and poor (r = 0.26), depending on reader experience, and significantly (p < 0.05) improved in the second case series (range: r = 0.42 to r = 0.91). Diagnostic accuracy was significantly (p < 0.05) higher for more experienced readers (range: 96.5–97.8%) as compared to less experienced observers (range: 90.7–93.6%). After completion of the second case series for less experienced readers sensitivity and PPV significantly (p < 0.05) improved (range: 62.7–67.8%/51.4–84.1%), but still remained significantly (p < 0.05) lower as compared to more experienced observers (range: 89.8–93.3%/80.6–93.3%).

Conclusion

The level of experience appears to be a strong determinant of proficiency in CCTA interpretation. Limited one-time training improves proficiency in novice readers, but not to clinically satisfactory levels.

Introduction

Contrast-enhanced ECG-synchronized coronary CT angiography (CCTA) is the most promising method for direct non-invasive detection of coronary artery stenosis [1], [2], [3], [4], [5], [6] and the use of this test for non-invasive evaluation of patients with atypical or acute chest pain has substantially risen in recent years. Consequently, results of CCTA increasingly direct patient management.

Because of the limited exposure of most practitioners to CCTA interpretation during their graduate medical education, several forays in recent years have aimed at establishing standards of proficiency and educational curricula for CCTA interpretation [7], [8], [9]. Guidelines and proficiency requirements differ between countries and between medical disciplines. Criteria for the demonstration of advanced proficiency diverge between specialties; however, a common entry requirement for initial certification of proficiency in CCTA interpretation, which is shared between radiology and cardiology pathways in the US and Europe, is the mentored review of 50 contrast medium-enhanced cardiac CT cases [10], [11].

There is a scarcity of evidence regarding the influence of experience and training of practitioners on their proficiency [12], i.e. their ability to independently render CCTA interpretations of a quality commensurate with the clinical use of this test to effectively, safely, and meaningfully contribute to patient management according to the current state of the art. Accordingly, the aim of this study was to assess the influence of observer experience and the effect of one-time limited training on 50 cardiac CT cases on the proficiency in CCTA interpretation of practitioners with different levels of experience.

Section snippets

Materials and methods

Our human research committee approved this study and all participating patients gave written informed consent.

Patient CCTA data sets

The final case series consisted of 100 CCTA data sets of 53 male and 47 female patients with a mean age of 65 years (range 48–75 years). The average heart rate was 66 bpm (range 45–89 bpm) at the time of CCTA acquisition, with an average scan time of 15.3 s (range: 13.2–17.8 s). Globally, all 100 CCTA studies were considered of diagnostic quality. In all patients, 64-slice CCTA and conventional coronary catheter angiography had been performed within 24 h. Mean time spent on each patient series was

Discussion

This investigation sought to quantify the influence of experience and training on the proficiency in CCTA interpretation of practitioners with different levels of experience. The results objectify in a systematic manner the intuitive notion that the level of experience is the strongest determinant of proficiency in CCTA interpretation. The results also show that limited one-time training improves proficiency - particularly in less-experienced readers -, but not to clinically satisfactory levels.

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    These authors contributed equally to this work and would like to share first-authorship.

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