Imaging referral guidelines in Europe: now and in the future-EC Referral Guidelines Workshop Proceedings

Impact of point-of-care clinical decision support on referrer behavior, imaging volume, patient radiation dose exposure, and sustainability

OBJECTIVES

When referring patients to radiology, it is important that the most appropriate test is chosen to avoid inappropriate imaging that may lead to delayed diagnosis, unnecessary radiation dose, worse patient outcome, and poor patient experience. The current radiology appropriateness guidance standard at our institution is via access to a standalone web-based clinical decision support tool (CDST). A point-of-care (POC) CDST that incorporates guidance directly into the physician workflow was implemented within a subset of head and neck cancer specialist referrers. The purpose of this audit was to evaluate the imaging pathway, pre- and post-implementation to assess changes in referral behavior.

METHODS

CT and MRI neck data were collected retrospectively to examine the relationship between imaging referrals pre- and post-POC CDST implementation. Effective radiation dose and estimated carbon emissions were also compared.

RESULTS

There was an overall reduction in absolute advanced imaging volume by 8.2%, and a reduction in duplicate CT and MRI imaging by 61%, p < 0.0001. There was also a shift in ordering behavior in favor of MRI (OR [95% CI] = 1.50 [1.02-2.22], p = 0.049). These changes resulted in an effective radiation dose reduction of 0.27 mSv per patient, or 13 equivalent chest x-rays saved per patient, p < 0.0001. Additionally, the reduction in unnecessary duplicate imaging led to a 13.5% reduction in carbon emissions, p = 0.0002.

CONCLUSIONS

Implementation of the POC CDST resulted in a significant impact on advanced imaging volume, saved effective dose, and reduction in carbon emissions.

CRITICAL RELEVANCE STATEMENT

The implementation of a point-of-care clinical decision support tool may reduce multimodality ordering and advanced imaging volume, manifesting in reduced effective dose per patient and reduced estimated carbon emissions. Widespread utilization of the point-of-care clinical decision support tool has the potential to reduce imaging wait times.

KEY POINTS

• Implementation of the point-of-care clinical decision support tool reduced the number of patients who simultaneously had a CT and MRI ordered for the same clinical indication compared to a standalone web-based clinical decision support tool. • The point-of-care clinical decision support tool reduced the absolute number of CT/MRI scans requested compared to the standalone web-based clinical decision support tool. • Utilization of the point-of-care clinical decision support tool led to a significant reduction in the effective dose per patient compared to the standalone web-based clinical decision support tool.

Innovative advances in pediatric radiology: computed tomography reconstruction techniques, photon-counting detector computed tomography, and beyond

In pediatric radiology, balancing diagnostic accuracy with reduced radiation exposure is paramount due to the heightened vulnerability of younger patients to radiation. Technological advancements in computed tomography (CT) reconstruction techniques, especially model-based iterative reconstruction and deep learning image reconstruction, have enabled significant reductions in radiation doses without compromising image quality. Deep learning image reconstruction, powered by deep learning algorithms, has demonstrated superiority over traditional techniques like filtered back projection, providing enhanced image quality, especially in pediatric head and cardiac CT scans. Photon-counting detector CT has emerged as another groundbreaking technology, allowing for high-resolution images while substantially reducing radiation doses, proving highly beneficial for pediatric patients requiring frequent imaging. Furthermore, cloud-based dose tracking software focuses on monitoring radiation exposure, ensuring adherence to safety standards. However, the deployment of these technologies presents challenges, including the need for large datasets, computational demands, and potential data privacy issues. This article provides a comprehensive exploration of these technological advancements, their clinical implications, and the ongoing efforts to enhance pediatric radiology's safety and effectiveness.

Service evaluation of radiographer-led vetting and protocoling of Computed Tomography (CT) scan requests in a Singapore public healthcare institution

INTRODUCTION

A service improvement project involving the vetting and protocoling of Computed Tomography (CT) scan requests by qualified CT radiographers was initiated in 2018.

AIM

This study provides a comprehensive evaluation of how a radiographer-led initiative aims to ensure that the CT scan requests received by the Radiology department are clinically appropriate, which in turn will reduce interruptions to the interpretation and reporting of imaging examinations by radiologists, who might otherwise be required to attend to clinically inappropriate and wrongly protocolled CT scan requests.

METHOD

Outpatient CT scan requests received from July to October 2021 were vetted and protocolled by a qualified CT-trained radiographer for parameters which included the appropriateness of the clinical indication, adequacy of patient preparation for the scan, as well as the suitability of the requested examination protocol pertaining to the need for contrast media, multiple contrast-enhanced imaging phases, and the appropriateness of the scan range.

RESULTS

Poor patient preparation and insufficient or inaccurate clinical indications were the most common findings during the vetting process (71%). Out of the 64 CT scan requests with protocol errors, 77% were attributed to contrast media type errors. The odds of incorrect CT scan requests increased with the requesting clinician's rank, while there was no such significant correlation with the clinical specialty of the requesting clinician or the CT scan type.

CONCLUSION

The meticulous vetting of imaging requests helps to ensure that limited imaging hardware resources are allocated to more clinically appropriate cases, correct protocols are applied to requested imaging scans, and that patients undergoing imaging are adequately prepared, thereby enhancing overall patient care.

IMPLICATIONS FOR PRACTICE

Vetting of imaging requests by radiographers, who are capable to make appropriate clinical decisions related to their enhanced level of practice ensures patient safety and optimisation of Radiology resources.

Referral guidelines for medical imaging in children: an ESR-EuroSafe Imaging survey on availability, awareness and use in clinical practice among European radiologists

OBJECTIVES

Justification of medical exposures from medical imaging is fundamental to radiation protection. Referral guidelines are intended to help physicians decide when an imaging study is justified. For two decades, referral guidelines have been a legally binding requirement for European Union member states. Recently, the European Society of Radiology (ESR) developed iGuide tool, which provides evidence-based referral guidance for imaging inclusive of children. The aim of this survey was to assess the availability, use and familiarity of referral guidelines for medical imaging in children and knowledge about the availability of ESR iGuide among ESR member radiologists.

METHODS

Over a 2-month period (15 September-15 November 2019), 33,257 ESR member radiologists were invited to respond to an anonymised web-based questionnaire, which consisted of 12 multiple-choice questions.

RESULTS

In total, 2067/33,257 responses (6.3%) were received from 52 countries. A total of 1068 out of 2067 (51.7%) respondents were aware that imaging referral guidelines are a legal requirement. One thousand five (48.6%) of all respondents did not know whether dedicated guidelines for imaging in children were available, and only 653 (31.2%) were aware of the mainstays of the available guidelines. Similarly, just 746 (36.1%) of all respondents were aware of ESR iGuide availability and features.

CONCLUSIONS

The information gathered confirms that effective and widespread adoption of imaging referral guidelines is lacking, especially in children. Further work is required to improve uptake and awareness.

KEY POINTS

• Justification of medical exposures is fundamental to radiation protection and evidence-based referral guidelines are crucial for practical implementation of this principle. • About half of survey respondents are aware that the availability of imaging referral guidelines is a legal requirement, despite this being mandated since 1997. • The information gathered from this survey confirms that, especially in children, an effective and widespread adoption of imaging referral guidelines is lacking.

Improving justification of medical exposures using ionising radiation: considerations and approaches from the European Society of Radiology

This discussion paper has been produced within the context of the European Society of Radiology EuroSafe Imaging initiative and considers primarily the issues and challenges associated with justification of medical exposures using ionising radiation for individual patient diagnostic imaging procedures. It addresses both regulatory requirements and practical considerations and discusses approaches that are intended to improve justification.

The effect of interventions on appropriate use of lumbar spine radiograph and CT examinations in young adults and children: a three-year follow-up

BACKGROUND

According to international guidelines, radiological examinations of the lumbar spine are of limited value and do not improve clinical outcome unless there are clinical red flags present suggesting serious pathology. Nevertheless, the utilization of lumbar spine imaging remains high.

PURPOSE

To follow up the effects of active referral guideline implementation and education on the number and appropriateness of lumbar spine radiographs and computed tomography (CT) examinations in young patients and to evaluate whether the appropriate radiographs have more significant findings.

MATERIAL AND METHODS

Referral guidelines for spine examinations and info pocket cards on radiation protection were distributed to referring practitioners. Educational lectures were provided annually. The number of lumbar spine radiographs and CT examinations on patients aged <35 years was analyzed before and three years after the interventions. Appropriateness and findings of 313 radiographs and appropriateness of 117 CT scans of the lumbar spine were assessed.

RESULTS

The number of lumbar spine radiographs and CT scans decreased significantly after the interventions and the level remained unchanged during the follow-up (-33% and -72%, respectively, P < 0.001). Appropriateness improved significantly in radiographs from 2005 to 2009 (65% vs. 85%) and in CT scans already from 2005 to 2007 (23% vs. 63%). Radiographs that were in accordance with the guidelines had more significant findings compared to radiographs that were not; in young adults, this was 56% versus 21% (P < 0.001).

CONCLUSION

A combination of interventions can achieve a sustained reduction in the number of lumbar spine examinations and improve appropriateness. Inappropriate lumbar spine radiographs do not seem to contain significant findings that would affect patient care.

Diagnostic imaging: Doing the right thing

Inappropriate diagnostic imaging (DI) is a burgeoning issue and embraces its overuse and its misapplication. The obverse problem is one of underuse - that is when patients who should undergo imaging fail to do so. This article attempts to define these problems, examines the causes and effects and suggests some potential solutions.

National audit on the appropriateness of CT and MRI examinations in Luxembourg

OBJECTIVES

In Luxembourg, the frequency of CT and MRI examinations per inhabitant is among the highest in Europe. A national audit was conducted to evaluate the appropriateness of CT and MRI examinations according to the national referral guidelines for medical imaging.

METHODS

Three hundred and eighty-eight CT and 330 MRI requests corresponding to already performed examinations were provided by all radiology departments in Luxembourg. Four external radiologists evaluated the clinical elements for justification present in each request. They consensually assessed the appropriateness of each requested examination with regard to the national referral guidelines and their clinical experience.

RESULTS

The appropriateness rate (AR) was higher for MRI requests than for CT requests (79% vs. 61%; p < 0.001). AR was higher for requests referred by medical specialists rather than by general practitioners, both for CT requests (70% vs. 37%; p < 0.001) and MRI requests (83% vs. 64%; p = 0.002). For CT, AR was higher when the requests concerned paediatric rather than adult patients (82% vs. 58%; p < 0.001), when the radiology departments were equipped with both CT and MRI units rather than with only CT units (65% vs. 47%, p = 0.004) and when the requests concerned head-neck (79%), chest (77%) and chest-abdominal-pelvic (81%) areas rather than spinal (28%), extremity (51%) and abdominal-pelvic (63%) areas (p < 0.001).

CONCLUSIONS

The appropriateness of CT and MRI in Luxembourg is not satisfactory and collective efforts to improve should be continued. The focus should be on general practitioners and on spinal CT examinations.

Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis

OBJECTIVES

Obtain summary estimates of sensitivity and specificity for imaging modalities for chronic pancreatitis (CP) assessment.

METHODS

A systematic search was performed in Cochrane Library, MEDLINE, Embase and CINAHL databases for studies evaluating imaging modalities for the diagnosis of CP up to September 2016. A bivariate random-effects modeling was used to obtain summary estimates of sensitivity and specificity.

RESULTS

We included 43 studies evaluating 3460 patients. Sensitivity of endoscopic retrograde cholangiopancreatography (ERCP) (82%; 95%CI: 76%-87%) was significant higher than that of abdominal ultrasonography (US) (67%; 95%CI: 53%-78%; P=0.018). The sensitivity estimates of endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and computed tomography (CT) were 81% (95%CI: 70%-89%), 78% (95%CI: 69%-85%), and 75% (95%CI: 66%-83%), respectively, and did not differ significantly from each other. Estimates of specificity were comparable for EUS (90%; 95%CI: 82%-95%), ERCP (94%; 95%CI: 87%-98%), CT (91%; 95% CI: 81%-96%), MRI (96%; 95%CI: 90%-98%), and US (98%; 95%CI: 89%-100%).

CONCLUSIONS

EUS, ERCP, MRI and CT all have comparable high diagnostic accuracy in the initial diagnosis of CP. EUS and ERCP are outperformers and US has the lowest accuracy. The choice of imaging modality can therefore be made based on invasiveness, local availability, experience and costs.

KEY POINTS

• EUS, ERCP, MRI and CT have high diagnostic sensitivity for chronic pancreatitis • Diagnostic specificity is comparable for all imaging modalities • EUS and ERCP are outperformers and US has the lowest accuracy • The choice of imaging can be made based on clinical considerations.

The Rate of Magnetic Resonance Imaging in Patients with Deep Brain Stimulation

BACKGROUND

For Parkinson's disease (PD), essential tremor (ET), and dystonia patients with deep brain stimulation (DBS) implants, magnetic resonance imaging (MRI) requires additional safety considerations due to potentially hazardous interactions.

OBJECTIVE

A propensity-matched cohort of DBS-implanted patients was analyzed to determine the likelihood of needing MRI.

METHODS

Patients with new DBS full-system implants (n = 576) were identified in the Truven Health MarketScan® Commercial Claims and Medicare Supplemental Databases (2009-2012). Patients diagnosed with PD, ET, or dystonia and no DBS implant were identified (DBS-indicated patients: n = 11,216). The DBS-indicated patients were continuously enrolled for 4 years and matched for age, gender, and propensity score based on comorbid conditions to DBS-implanted patients (n = 4,878 and 543, respectively). A Kaplan-Meier survival curve of time to first MRI was extrapolated to 10 years.

RESULTS

An estimated 56-57% of DBS-indicated patients need an MRI within 5 years and 66-75% within 10 years after implantation. While 92% of DBS-implanted patients' MRI after implantation was of the head, for DBS-indicated patients, 62% of MRIs were of the body, potentially unrelated to the primary diagnosis.

CONCLUSIONS

This analysis highlights the projected utilization of MRI in the DBS population for head and full-body images.

Imaging Guidelines for Enhancing Justifications for Radiologic Studies

Justification in the field of radiology refers to the appropriate use of radiologic imaging modalities, and may be achieved by establishing clinical imaging guidelines (CIGs). Recently, CIGs have been shown to be useful in selecting the proper medical imaging modality, resulting in the reduction of inappropriate radiologic examinations, thereby enhancing justifications. However, the development of CIGs is both time-consuming and difficult as the methodology of evidence-based medicine should be adhered to. Thus, although the radiologic societies in developed countries such as the United Kingdom and USA are already developing and implementing CIGs in their clinical practices, CIGs are not yet readily available in many other countries owing to differences in medical circumstances and resources. In this review, we assess the role and limitations of CIGs by examining the current status of CIGs in developed countries, and also describe the specific efforts made to establish CIGs in Korea.

National audit of appropriate imaging

AIMS

To audit the availability of imaging referral guidelines; vetting by radiologists of GP-initiated CT and MRI requests; and the achievement of appropriate imaging using retrospective assessment as a surrogate.

MATERIALS AND METHODS

A web-based questionnaire was distributed to imaging departments in the UK seeking awareness of guideline availability; the percentage of consecutive general practitioner (GP)-requested computed tomography (CT) and magnetic resonance imaging (MRI) investigations that showed evidence of vetting; and the percentage of procedures where retrospective assessment showed the investigation to be appropriate according to imaging referral guidelines.

RESULTS

Replies were received from 88 departments covering 1700 of 2700 (63%) consultant radiologists practising in the UK. Regarding the availability of guidelines, approximately a third of respondents were not aware of guidelines being available to all radiologists and radiographers. The 68% level of availability (58/88 departments) is well below the standard of 100%. In keeping with the target of 95%, vetting of CT requests was shown in 1815/1890 (96%) and MRI in 1181/1250 (95%). Appropriateness of CT examinations was shown in 1746/1870 (93%) and MRI in 1154/1215 (95%), well above the target of 90%. The most common reason for an inappropriate investigation for both MRI and CT was the inability to affect patient management.

CONCLUSIONS

Although awareness of referral guidelines availability was limited at 68%, well below the 100% standard, the meticulous vetting of requests (shown in 95-96%) with the amendment or return of inappropriate requests (9-12%) enables a high level of appropriate imaging (93-95%) for GP-requested CT and MRI, thus making the best use of clinical radiology.