Referral criteria and clinical decision support: radiological protection aspects for justification

Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review

OBJECTIVES

The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists.

MATERIALS AND METHODS

An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles.

RESULTS

The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences.

CONCLUSION

Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system.

CLINICAL RELEVANCE STATEMENT

There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system.

KEY POINTS

The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

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.

American College of Radiology (ACR) Appropriateness Criteria and EURO-2000 Guidelines Offer Limited Guidance for MRI Imaging of Pediatric Patients

PURPOSE

This study aims to evaluate the clinical scenarios addressed by the EURO-2000 guidelines and the ACR appropriateness criteria for referring children to MRI and assessing the referring physician compliance with both guidelines.

METHODS

In January 2022, clinical scenarios reported in the last 1000 consecutive MRI requests for children (0-16 years) in one university children's hospital and two general university hospitals in Belgium, Europe, were retrospectively matched to the EURO-2000 guidelines and ACR appropriateness criteria. The number of clinical scenarios addressed and the justification for MRI referral were independently assessed for both guidelines. Pooled data from the three centers were evaluated and then analyzed by center, body area and prescriber using McNemar's test for paired proportions and χ2-tests unpaired proportions.

RESULTS

After excluding incomplete or missing MRI requests, 2932 of 3000 requests were included in the analysis. Overall, out of 2932 clinical scenarios, 1229 (37.99%) were addressed by EURO-2000 and 1081 (36.37%) were addressed by the ACR appropriateness criteria (McNemar test, p = 0.12). The proportions of clinical scenarios covered by the two guidelines were statistically similar when comparing centers, but varied across body regions (p < 0.001) and referring physician specialty (p between 0.75 and 0.001). EURO-2000 guidelines provided better coverage for head and spine (p < 0.05), while the ACR appropriateness criteria provided broader coverage for abdomen, pelvis, and musculoskeletal system (p < 0.0001). For addressed clinical scenarios, prescriber compliance for both guidelines was excellent with > 94% of justified MRI examinations in all the centers.

CONCLUSIONS

Both the EURO-2000 guidelines and the ACR appropriateness criteria did not address two-thirds of clinical scenarios in children. Head and neck, chest and abdominal-pelvic examinations are the anatomic regions which should receive a specific attention for the future implementation of evidence-based clinical decision support tools for all referring specialists.

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.

Are referral guidelines for CT examinations addressing all clinical scenarios? A comparison of EURO-2000 Guidelines and ESR iGuide

OBJECTIVES

To investigate the proportion of clinical scenarios covered by EURO-2000 Guidelines and ESR iGuide, and assess compliance with both guidelines.

METHODS

The clinical indication on archived request forms for head, chest, abdomen-pelvis, and spine CT examinations performed in three hospitals in January 2018 was retrospectively matched with EURO-2000 Guidelines and ESR iGuide. For clinical scenarios addressed in the guidelines, the compliance with the guidelines was assessed. Analysis was performed on pooled data from the three centres and further stratified by centre, body region, and prescriber's specialisation. The differences in categorical data distributions between centres, body regions, and prescribers' specialisations were assessed with paired McNemar's χ² tests.

RESULTS

A total of 6,812 requests for 7,217 CT examinations were analysed. Sixty-five percent of clinical situations that lead to prescribing CT examinations were addressed in EURO-2000 Guidelines compared with 81% for ESR iGuide. Proportions of clinical scenarios covered by the guidelines were statistically different between centres and body regions (p < 0.001) and varied according to prescribers' specialisations (p ranging from < 0.001 to 0.531). Both EURO-2000 Guidelines and ESR iGuide encompassed more clinical scenarios in certain body regions, favouring, e.g. spine and head over abdomen and chest. The proportion of "unjustified examinations" was greater according to EURO-2000 Guidelines (46%) than ESR iGuide (23%) (p < 0.001).

CONCLUSIONS

Both EURO-2000 Guidelines and ESR iGuide do not address numerous common clinical scenarios. The proportions of scenarios addressed differ according to the centre, body region, and prescribers' specialisation. Any estimation of compliance with referral guidelines is therefore of relative significance.

KEY POINTS

• ESR iGuide performs better than earlier EURO-2000 Guidelines for the coverage of all possible clinical scenarios leading to CT referrals. • Differences in coverage of clinical scenarios by both referral guidelines are observed for different body regions and/or prescribers' subspecialties. • As referral guidelines are incomplete, any estimation of justified or unjustified CT requests is of relative significance.

Perceptions of radiographers regarding establishing a self-regulatory body for radiation safety in Eswatini

INTRODUCTION

Eswatini remains one of the countries in Southern Africa without a regulating authority for radiation safety in the radiography departments. Quality control (QC) tests and radiation protection practices are unmonitored. This study sought to explore radiographers' perceptions regarding establishing a self-regulatory body that will formulate, implement and monitor compliance of standardised guidelines for radiation safety.

METHODS

A qualitative, exploratory and descriptive research approach was undertaken. Radiographers currently registered and practicing in Eswatini were purposively selected and invited to participate. Data was collected using semi-structured interviews. Audiotapes and field notes were used. Audio taped interviews were transcribed verbatim and then analyzed using qualitative content analysis.

RESULTS

Six themes emerged from the analysis of data, namely; a) awareness of the need for QC tests, b) radiation protection and safety in the radiography departments, c) radiographers' responsibility towards radiation protection, d) education and training in radiation safety for radiographers and other stakeholders, e) support from governmental and management structures and f) the need for the self-regulatory body in the radiography departments.

CONCLUSION

The study demonstrated that there is awareness among radiographers in Eswatini that radiation safety practices are necessary in the radiography departments. Continuous education and training were deemed as imperative to improve radiation safety in the radiography departments. There is also support for the idea of establishing the self-regulatory body.

IMPLICATIONS FOR PRACTICE

The need for monitoring structures in order to ensure radiation safety in the radiography departments is highlighted in this study. Government officials and hospital management are crucial in ensuring radiation safety in radiography departments.

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.

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.

Overdiagnosis and overimaging: an ethical issue for radiological protection

AIMS AND OBJECTIVES

This study aimed to analyse the key factors that influence the overimaging using X-ray such as self-referral, defensive medicine and duplicate imaging studies and to emphasize the ethical problem that derives from it.

MATERIALS AND METHODS

In this study, we focused on the more frequent sources of overdiagnosis such as the total-body CT, proposed in the form of screening in both public and private sector, the choice of the most sensitive test for each pathology such as pulmonary embolism, ultrasound investigations mostly of the thyroid and of the prostate and MR examinations, especially of the musculoskeletal system.

RESULTS

The direct follow of overdiagnosis and overimaging is the increase in the risk of contrast media infusion, radiant damage, and costs in the worldwide healthcare system. The theme of the costs of overdiagnosis is strongly related to inappropriate or poorly appropriate imaging examination.

CONCLUSIONS

We underline the ethical imperatives of trust and right conduct, because the major ethical problems in radiology emerge in the justification of medical exposures of patients in the practice. A close cooperation and collaboration across all the physicians responsible for patient care in requiring imaging examination is also important, balancing possible ionizing radiation disadvantages and patient benefits in terms of care.

Education and training as a strategy to improve justification of medical imaging referrals in emergency departments

Diagnostic imaging pathways are developed to ensure that medical imaging examinations are appropriately selected and referred by clinicians with the aim of justifying the use of imaging modalities for clinical diagnosis. Failing to comply with the imaging pathways or guidelines results in exposing patients to unnecessary ionising radiation due to malpractice of imaging referrals. This editorial provides a comment on a recent study reporting very high percentage of general x-ray imaging referrals which did not or partially met the imaging pathways in an emergency department.

Prevalence of unjustified emergency department x-ray examination referrals performed in a regional Queensland hospital: A pilot study

INTRODUCTION

The underpinning principles of radiation protection are justification, optimisation and limitation. Each medical imaging referral that uses ionising radiation must balance the justification of exposure to radiation against the benefits of the examination. Scrutiny of justification is the role of radiographers, for general radiography, and is usually performed using the clinical details provided on the referral. International studies report up to 77% of medical imaging examinations are unjustified or inappropriate. In regional Queensland, justification seems to involve a subjective assessment and enforcement is ad hoc. This study aimed to determine the number of unjustified emergency department x-ray examinations performed in a regional Queensland hospital.

METHODS

An audit of the clinical details provided on x-ray referrals and in the medical records was performed on x-ray examinations undertaken within an 11-day period. Justification was determined by compliance with the Government of Western Australia's diagnostic imaging pathways.

RESULTS

Of the 186 referrals assessed, 75.3% were categorised as not having complied with the imaging pathway and were considered unjustified. When the clinical details in the patient's medical record were reviewed, in conjunction with the referral, the unjustified rate reduced to 49.2% of examinations.

CONCLUSION

Results demonstrate a lack of information transfer by referring clinicians and a lack of compliance with justification requirements for imaging by medical imaging staff. Improved communication regarding the need for imaging, and the refusal of referrals that are not justified, will ensure that patients are only exposed to radiation when clear benefit has been demonstrated.

Are physicians aware enough of patient radiation protection? Results from a survey among physicians of Pavia District- Italy

Background

Radiological practices are the first anthropic sources of ionizing radiation exposure of the population. However, a review of recent publications underlines inadequate doctors’ knowledge about doses imparted in medical practices and about patient protection that might explain unnecessary radiological prescriptions. We investigated the knowledge of the physicians of Pavia District (Italy) on the risk of radiation exposure.

Methods

A cross sectional study was performed involving the Medical Association of Pavia District. Data were collected with a self-administered questionnaire, available on-line with private login and password.

Results

Four hundred nineteen physicians fulfilled the questionnaire; 48% of participants reported training about radiation protection. The average percentage of correct answers on the knowledge on ionizing radiation was 62.29%, with a significantly higher result between radiologist. Around 5 and 13% of the responders do not know that, respectively, ultrasonography and magnetic resonance do not expose patients to ionizing radiations. Only 5% of the physicians properly identified the cancer risk rate associated to abdomen computed tomography.

Conclusions

The findings show a quite good level of the general knowledge about ionizing radiations, higher that reported in literature. Nevertheless, we believe the usefulness of training on the risk linked to radiation exposure in medicine for physicians employed in every area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2358-1) contains supplementary material, which is available to authorized users.

Current global and Korean issues in radiation safety of nuclear medicine procedures

In recent years, the management of patient doses in medical imaging has evolved as concern about radiation exposure has increased. Efforts and techniques to reduce radiation doses are focussed not only on the basis of patient safety, but also on the fundamentals of justification and optimisation in cooperation with international organisations such as the International Commission on Radiological Protection, the International Atomic Energy Agency, and the World Health Organization. The Image Gently campaign in children and Image Wisely campaign in adults to lower radiation doses have been initiated in the USA. The European Association of Nuclear Medicine paediatric dosage card, North American consensus guidelines, and Nuclear Medicine Global Initiative have recommended the activities of radiopharmaceuticals that should be administered in children. Diagnostic reference levels (DRLs), developed predominantly in Europe, may be an important tool to manage patient doses. In Korea, overexposure to radiation, even from the use of medical imaging, has become a public issue, particularly since the accident at the Fukushima nuclear power plant. As a result, the Korean Nuclear Safety and Security Commission revised the technical standards for radiation safety management in medical fields. In parallel, DRLs for nuclear medicine procedures have been collected on a nationwide scale. Notice of total effective dose from positron emission tomography-computed tomography for cancer screening has been mandatory since mid-November 2014.