Session Information
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose: Point-of-care (POC) musculoskeletal ultrasound (MSUS) over the past decade has increasingly been adopted to evaluate patients with rheumatic diseases. In 2011, a group of rheumatology MSUS experts developed a document on documentation, scanning conventions, and tiered-mastery designation for anatomic region views. This study aims to update consensus reflective of the current usage MSUS in rheumatology. This consensus statement will guide development of a Rheumatology MSUS fellowship curriculum and professional training in the United States.
Methods: A 3-round Delphi method study was done utilizing a 96-item questionnaire. Agreement/disagreement on documentation and scanning conventions covered 5 items each; other items included demographics; and tier designations for anatomic-regions. Comments were solicited for each question. Dissemination was done via Qualtrics®to 101 respondents, with a target participant number of 38. Respondent selection was based on: identified lead MSUS academic faculty, course instruction, certification by ACR (RhMSUS), and publication. Informed consent process was done. Questionnaire initiation and completion indicated consent. We used McNemar’s chi-square to test agreement in the paired responses for scanning and documentation. High agreement was defined as agreement of ≥ 85%. Comments were reviewed for content analysis. This study was approved by the Institutional Review Board of Loma Linda University Medical Center.
Results: 46 respondents completed all three rounds. 73% were full time academic faculty. 73% had RhMSUS certification. Table 1 shows results of levels of agreement/disagreement with the original consensus statements and with proposed alternative statements. . 4 (80%) of the documentation and 5 (100%) of the scanning convention statements reached or maintained high consensus. For the documentation statement that did not reach consensus (“A dynamic scan should be saved as a clip”), 9 out of the 39 who agreed with this statement in Round 1, disagreed with it at Round 3 and this change was statistically significant (p= 0.021). Commentary analysis showed three main themes: 1) the need for a more clinically realistic and rheumatology-specific “complete” vs “limited” scan, possibly applying these terms towards disease-specific (eg. rheumatoid arthritis) evaluation as opposed to utilizing anatomic region-based descriptions determined largely by radiologists; 2) current coding and billing constrain the “complete scan” definition.
Conclusion: Many scanning conventions from 2011 remain relevant in current practice. Documentation standards from 2011 may need revision. Current definitions of “complete” and “limited” scans may not accurately reflect relevant usage of MSUS in current rheumatology practice, and descriptions based on disease-based evaluations should instead be considered.
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Table 1. Scanning Conventions and Documentation: Levels of Agreement and Disagreement with 2011 Consensus Statement, Delphi rounds 1-3, N=46 |
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2011 Consensus Statements |
Agreement vs. Disagreement |
Proposed Alternative statement |
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Scanning Conventions |
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The radiologic anatomic position is used as a reference with palms facing forward, hence the left side of the ultrasound monitor screen is medial, cranial, ulnar or tibial. (SC1) |
44 (95.7%) vs. 2 (4.3%) |
The radiologic anatomic position can be used as a reference with palms facing forward, hence the left side of the ultrasound monitor screen is medial, cranial, ulnar or tibial or individual sonographer consistent orientation is maintained. Agreement with alternative: 14 (30.4%) Disagreement with alternative: 32 (69.6%) |
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The left side of the ultrasound monitor screen is designated anterior when a choice exists to scan posterior or anterior in the sagittal plane (for example: lateral hip). (SC2) |
40 (87%) vs. 6 (13%) |
When a choice exists to orient the probe anterior or posterior for lateral examinations, individual sonographer consistent orientation is maintained. Agreement with alternative: 8 (17.4%) Disagreement with alternative: 32 (82.6%) |
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“Longitudinal” scans imply alignment of the probe in the longitudinal axis of the structure under examination. (SC3) |
45 (97.8%) vs. 1 (2.2%) |
– |
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“Transverse” scans imply alignment of the probe transverse to the structure under examination. (SC4) |
44 (95.7%) vs. 2 (4.3%) |
– |
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“Orthogonal” scans imply that longitudinal and transverse scans have been done. (SC5) |
44 (95.7%) vs. 2 (4.3%) |
“Orthogonal” scans imply that longitudinal and transverse scans have been done to document pathology in two perpendicular planes. Agreement vs. Disagreement with alternative: 24 (52.2%) Vs. 22 (47.8%) |
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Documentation |
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All static normal scans should be documented. (D1) |
43 (93.5%) vs. 3 (6.5%) |
– |
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All abnormal scans should be documented. (D2) |
44 (95.7%) vs. 2 (4.3%) |
– |
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A dynamic scan should be saved as a clip. (D3) |
31 (67.4%) vs. 15 (32.6%) |
A dynamic scan can be saved as a clip or as static images of abnormal findings or as images of accurate procedure performance. Agreement vs. Disagreement with alternative: 33 (71.7%) vs. 13 (28.3%) |
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A complete musculoskeletal ultrasound examination of an extremity consists of real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality. (D4) |
42 (91.3%) vs. 4 (8.7%) |
A comprehensive rheumatology musculoskeletal ultrasound examination consists of real time scans of a specific region that can include examination of the muscles, tendons, joints, other soft tissue structures, and any identifiable abnormality relevant to a rheumatic differential diagnosis or a multi structure rheumatic disease assessment tool. Agreement vs. Disagreement with alternative: 30 (65.2%) vs. 16 (34.8%) |
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A limited musculoskeletal examination of an extremity looks at a specific anatomic structure in the extremity region. (D5) |
46 (100%) vs 0 |
A limited or focused musculoskeletal examination of an extremity looks at a specific anatomic structure in an extremity region. Agreement vs Disagreement with alternative: 29 (63%) vs 17 (37%) |
To cite this abstract in AMA style:
Torralba K, Nishio MJ, Thiele RG, Fairchild R, Choi K, Salto L, Cannella AC, Kissin E. Consensus Statements on Scanning Conventions and Documentation in Musculoskeletal Ultrasound [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/consensus-statements-on-scanning-conventions-and-documentation-in-musculoskeletal-ultrasound/. Accessed .« Back to 2018 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/consensus-statements-on-scanning-conventions-and-documentation-in-musculoskeletal-ultrasound/