regional workshop on imaging referral guidelines 13-16 december 2015, cairo, egypt 1 |1 | some...

Regional Workshop on Imaging Referral Guidelines

13-16 December 2015, Cairo, EGYPT1 |

Some reasons for unnecessary proceduresSome reasons for unnecessary procedures

Lack of awareness about radiation doses & associated risks

Insufficient access to referral guidelines at the point of care

Low confidence in clinical diagnosis & over-reliance on imaging

Consumer demand (patient's and/or family's expectations)

Self-referral, opportunistic screening, defensive medicine

Pressure from other specialists e.g. "What does the CT shows?"

Pressure from promotion and marketing of sophisticated technology

Lack of dialogue/consultation between referrers and radiologists

Non-availability of other appropriate imaging modality (e.g. US, MRI)

Fragmentation vs. continuity of health care: unnecessarily repeated examinations



Defensive medicine is a strong driving forceDefensive medicine is a strong driving force

Concerns about malpractice litigation

"…Physicians may respond to the perceived threat of litigation by ordering more referrals and more tests, some of which may be recommended by clinical guidelines and beneficial, but others might be wasteful and harmful"



Justification of radiological imagingJustification of radiological imaging

Who has to do it ?

How can it be done?



Justification in the new international radiation safety standards (BSS)

Justification in the new international radiation safety standards (BSS)

• The new BSS note that the general safety requirement on justification needs a special approach when it applies for medical exposures.

• Three levels:– General/overarching justification of the use of ionizing

radiation in medicine (level 1); – Justification for a generic clinical condition (level 2);– Justification of a radiological procedure for an

individual patient (level 3).



The level 1 of justificationThe level 1 of justification

The first level refers to the general justification of the use of ionizing radiation in medicine.

As a general approach, the use of radiation in medicine is accepted as doing more good than harm, economic and social issues being considered.

Therefore, this first level of general justification can be taken for granted.



The level 2: generic justificationThe level 2: generic justification

Justification of a particular procedure for (generic) patients with a given clinical condition, or for a group of individuals at risk to a given condition that can be detected and treated.

– This generic justification is assigned to the health authority in conjunction with appropriate professional bodies.

– Evidence-based imaging referral guidelines have been developed for different clinical conditions



The level 3: individual justificationThe level 3: individual justification

Third level- individual justification of a procedure judged to do more good than harm to a particular patient.

It is assigned to the health professionals involved in the patient's care (referring physician and radiological medical practitioner), who have to integrate the scientific evidence and values with their clinical expertise, to decide what is appropriate for an individual patient.

RISKS

BENEFITS



Roles and responsibilities in justifying at level 3?

Roles and responsibilities in justifying at level 3?

Two roles:– Radiological medical practitioner– Referring medical practitioner

Justification of medical exposure for an individual patient "shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate“ (new international BSS)



Justification of medical imaging in health screening programmes

Justification of medical imaging in health screening programmes

Justification for radiological procedures to be performed as part of a health screening programme for asymptomatic populations shall be carried out by the health authority in conjunction with appropriate professional bodies.

e.g. nationally approved mamography screening programmes



Justification of medical imaging in asymptomatic individuals

Justification of medical imaging in asymptomatic individuals

Any radiological procedure on an asymptomatic individual that is intended to be performed for the early detection of disease, but not as part of an approved health screening programme, shall require specific justification by the radiological medical practitioner and the referring medical practitioner.

The individual shall be informed of the expected benefits, risks and limitations (e.g. heart CT, lung CT, colon CT, other/s …)



Need for referral guidelinesNeed for referral guidelines

Evidence based medicine means integrating the best available clinical evidence from systematic research with the individual clinical expertise, to consider what may be applicable to or appropriate for an individual patient.

How could clinicians face in keeping abreast of all the medical advances reported in primary journals ? (i.e. to read 20 articles per day !!!)

Referral guidelines are evidence-based decision-support tools systematically developed to assist practitioners on decision about appropriate healthcare for specific circumstances/clinical conditions.



Referral Guidelines in Medical ImagingReferral Guidelines in Medical Imaging

Imaging referral guidelines (IRG) provide physicians information on which imaging procedure is most likely to yield the most informative results, and whether other modalities could be equally or more effective.

IRG are critical to support the practice of evidence-based medicine and form a foundation to guide appropriateness in prescribing diagnostic imaging services.

As decision-aiding tools for good medical practice, IRG can improve health service delivery, one of the key building blocks of health systems.



ACR - Abdominal pain in children



RCR: Abdominal

pain in children



Clinical decision support: bringing the guidelines to the point of careClinical decision support: bringing the guidelines to the point of care

Insufficient access at the point of care is a major cause of lack of adherence to imaging referral guidelines (IRG).

Bulky manuals are likely to sit on a shelf and go unused. Physicians need timely and easy access to user-friendly evidence-based IRG that are relevant to their patients.

Clinical decision support: implementation of IRG depends not only on the content, but also on the format and media.



Criteria for media selectionCriteria for media selection

Ease of preparation/production

User acceptance

Cost

Flexibility

Convenience

Durability

Mode of distribution

Local resources

Choice of media

depends on users needs and setting conditions

Referral Guidelines EffectivenessReferral Guidelines Effectiveness

Credibility – evidence-based

Practicality – end user involvement

Context – local resources, disease profiles

Endorsement – opinion leaders, stakeholders

Implementation- policy, education, CPOE …

Monitoring the use – clinical audit, report feedback

Recommendations of the Bonn Conference Recommendations of the Bonn Conference

Bonn Call for Action

10 actions to improve radiation protection in medicine in the next

decade

Bonn Call for Action

1. Enhancing implementation of justification of procedures2. Enhancing implementation of optimization of protection and safety3. Strengthening manufacturers’ contribution to radiation safety4. Strengthening RP education and training of health professionals5. Shaping & promoting a strategic research agenda for RP in medicine6. Improving data collection on radiation exposures of patients and workers7. Improving primary prevention of incidents and adverse events8. Strengthening radiation safety culture in health care9. Fostering an improved radiation benefit-risk-dialogue10.Strengthening the implementation of safety requirements (BSS) globally

hhttp://www.who.int/ionizing_radiation/about/14-2649_bonncallforaction.pdf?ua=1 ttps://rpop.iaea.org/RPOP/RPoP/Content/News/bonn-call-for-action-joint-position-statement.htm

This Training aims to enhance justification of radiological

medical procedures and will therefore contribute to the

implementation of the Bonn Call for Action in African countries

https://rpop.iaea.org/RPOP/RPoP/Content/News/bonn-call-for-action-joint-position-statement.htm

https://rpop.iaea.org/RPOP/RPoP/Content/News/bonn-call-for-action-joint-position-statement.htm



Thank you very much for your attention!

[email protected]

regional workshop on imaging referral guidelines 13-16 december 2015, cairo, egypt 1 |1 | some...

Documents

imaging referral guidelines13

level of general justification

medicine level

individual patient level

clinical guidelines

appropriate imaging

harmful regional workshop

use of radiation