Reading Room

Article Summary
Idiopathic Interstitial Pneumonia:
What is the effect of a multidisciplinary approach to diagnosis?

Flaherty KR, King TE, Raghu G, et al. Am J Respir Crit Care Med. 2004;170:904-910.

Discussion

• The diagnosis of idiopathic pulmonary fibrosis represents a distinct clinical challenge and requires a careful and thorough assessment of clinical, radiologic, and pathologic findings. Accordingly, the current ATS/ERS Consensus Statement recommends an integrated diagnostic approach that is characterized by close and ongoing collaboration between clinicians, radiologists, and pathologists.¹
• While the value of multidisciplinary collaboration seems intuitive, the effect of such an approach on the ultimate diagnosis has not been previously assessed. In the current study, Flaherty, et al, sought to quantify the impact of sequential increases in multidisciplinary interaction on the final diagnosis and the level of diagnostic confidence for the diagnosis of interstitial lung disease.
  

Study Design

• Participants included 3 expert clinicians, 2 expert radiologists, and 2 expert pathologists, all from university hospitals After independently reviewing the HRCTs of 58 suspected cases of idiopathic interstitial pneumonia, clinicians and radiologists were first asked to provide their initial diagnosis and level of diagnostic confidence (Step 1).
  
• Clinical information was then provided for each case, and participants were asked to repeat their selections of the most likely diagnosis and indicate the level of diagnostic confidence (Step 2). Clinicians and radiologists were then permitted to discuss the clinical and radiologic findings and asked to once again record their individual diagnosis and confidence level (Step 3).
  
• Pathologists in the following stage provided their interpretation of the surgical lung biopsies. Following a group discussion of the clinical, radiologic, and pathologic findings, individual diagnoses and level of confidence from clinicians, radiologists, and pathologists were recorded (Step 4). Finally, group discussion of cases followed in an attempt to reach a consensus diagnosis for each patient; consensus diagnoses could not be reached in all cases so participants again recorded their individual diagnoses and level of confidence (Step 5).

Results/Discussion:

• Investigators observed a significant correlation between multidisciplinary interaction, ie, discussion of cases among clinicians, radiologists, and pathologists, and diagnostic agreement and level of confidence
• The greatest change in diagnosis occurred among radiologists after pathologists provided interpretations of the biopsies
• The greatest improvement in diagnostic agreement among clinicians occurred after discussing clinical and HRCT features with radiologists
• A change in the final diagnosis was particularly likely to occur for patients with atypical clinical or radiologic findings
• Providing clinical and radiologic information to pathologists resulted in an alternative diagnosis in 19% of cases
• A limitation of the study was the use of participants with significant expertise in the field of interstitial lung disease who may not be accessible to practicing community pulmonologists

Implications/Recommendations:

• Whenever possible, clinicians should review the actual HRCT with radiologists instead of relying on reported findings
• A surgical lung biopsy may not be necessary when the clinical and radiologic findings are consistent with a confident diagnosis of IPF
• Atypical clinical or radiologic findings should prompt the clinician to consider a surgical lung biopsy, since reaching a consensus diagnosis is most influenced by the histopathologic pattern
• Flexibility and cooperation among clinicians, radiologists, and pathologists are key factors for arriving at a consensus diagnosis in patients with interstitial lung disease

Reference

1. American Thoracic Society, European Respiratory Society. American Thoracic Society/ European Respiratory Society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2002;165:277-304.

Article link

Click here for a direct link to the article abstract