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Tay YX, Foley S, Killeen R, Ong MEH, Chen RC, Chan LP, Mak MS, McNulty JP. Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review. Eur Radiol 2024:10.1007/s00330-024-10938-7. [PMID: 39002059 DOI: 10.1007/s00330-024-10938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/10/2024] [Accepted: 06/11/2024] [Indexed: 07/15/2024]
Abstract
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.
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Affiliation(s)
- Yi Xiang Tay
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland.
- Radiography Department, Allied Health Division, Singapore General Hospital, Singapore, Singapore.
| | - Shane Foley
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
| | - Ronan Killeen
- St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Marcus E H Ong
- Department of Emergency Medicine, Division of Medicine, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Robert Chun Chen
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Department of Neuroradiology, Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore
- National Neuroscience Institute, Singapore, Singapore
| | - Lai Peng Chan
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Department of Diagnostic Radiology, Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore
| | - May San Mak
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Department of Diagnostic Radiology, Division of Radiological Sciences, Singapore General Hospital, Singapore, Singapore
| | - Jonathan P McNulty
- Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
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Sá Dos Reis C, Gulizia M, Champendal M, De Labouchere S, Sun Z, Silva C. Plain radiography has a role to play in current clinical practice in Western Switzerland. J Med Imaging Radiat Sci 2023; 54:670-678. [PMID: 37620178 DOI: 10.1016/j.jmir.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023]
Abstract
AIM The aim of the study was to investigate the current role of conventional radiography examinations in Western Switzerland and the main clinical indications required to justify the use of this imaging examination. METHODS Ethical approval was obtained from Vaud Ethics committee (Ref 2020-00311). An online questionnaire was specifically designed and implemented on the data collection tool LimeSurvey composed of two parts: a) to characterise the participants' profile and their institutions and b) 169 projections for the different anatomical area (upper and lower limbs, pelvis, skull, spine, thorax, abdomen) were presented to collect data about the frequency and main clinical indications. Statistical analysis was performed using the software IBM SPSS® (Statistical Package for the Social Sciences) version 26. RESULTS Radiographers from 60% (26/43) of the invited institutions participated in this survey, mainly from Vaud region. The upper and lower limbs were the most commonly examined by using conventional radiography mainly for trauma and degenerative disorders. The thorax was also an anatomical area commonly explored by X-rays, so were the spine (cervical and lumbar lateral). The skull radiographs were rarely performed in clinical practice and some of the projections were not being used, namely Hirtz, Tangential Nose Bones, Worms and Caldwell's views. CONCLUSIONS Plain radiography is being used in clinical practice mainly for appendicular skeleton studies and for trauma and degenerative pathologies. Adaptations in radiographers' education and training and other healthcare professionals are needed to provide the judicious use of data that radiographs can give to better manage the patients' imaging pathway.
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Affiliation(s)
- Cláudia Sá Dos Reis
- Department of Radiologic Medical Imaging Technology, School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Switzerland.
| | - Marianna Gulizia
- Cantonal University Hospital Vaud (CHUV), Bugnon 46, 1011 Lausanne, Switzerland.
| | - Mélanie Champendal
- Department of Radiologic Medical Imaging Technology, HESAV School of Health Sciences, University of Applied Sciences and Arts Western Switzerland (HES-SO), Switzerland.
| | - Stephanie De Labouchere
- Cantonal University Hospital Vaud (CHUV), Bugnon 46, 1011 Lausanne, Switzerland; Department of Radiologic Medical Imaging Technology, HESAV School of Health Sciences, University of Applied Sciences and Arts Western Switzerland (HES-SO), Switzerland.
| | - Zhonghua Sun
- Discipline of Medical Radiation Science, Curtin Medical School, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Carina Silva
- Escola Superior de Tecnologia da Saúde de Lisboa/Instituto Politécnico de Lisboa (ESTeSL/IPL), Lisbon, Portugal; Centro de Estatística e Aplicações da Universidade de Lisboa (CEAUL), Portugal.
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Sitareni M, Karera A, Amkongo M, Daniels E. Justification of radiological procedures: Radiographers' experiences at two public hospitals. J Med Imaging Radiat Sci 2023; 54:312-318. [PMID: 36964063 DOI: 10.1016/j.jmir.2023.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Justification is a process conducted by the radiographer in consultation with the radiologist to evaluate radiological procedures ordered by doctors. The main purpose for justifying all radiologic procedures is to assess the benefits and risks of a requested radiographic procedure and determine whether exposure will continue. Furthermore, justification helps to prevent unnecessary radiation exposure and reduce the chances of harmful effects of ionizing radiation. OBJECTIVES The study aimed to explore the experiences of radiographers regarding the justification of radiological procedures at two public hospitals in Namibia METHODS: This study made use of a qualitative, exploratory design. A total number of 13 purposefully selected radiographers from radiology departments in two tertiary public - hospitals in Namibia were interviewed using a semi-structured interview guide and audio recorder. All interviews were conducted face-to-face until data saturation was achieved. Data were analysed using Atlas.ti Windows (version 9.0 using Tesch's 8-step method of qualitative data analysis to generate themes and subthemes. FINDINGS The participants experienced an enhancement of patient care through enhanced radiation protection and optimised patient care. They also experienced defunct communication systems through deficient communication between radiographers and referrers, professional role conflict and incomplete referrals. CONCLUSION The study revealed that the justification of radiological procedures was linked to both negative and positive experiences. Enhanced patient-centred care was a positive experience related to the radiographers' job responsibilities. The defunct communication support system was a negative experience as it related to the limited availability and utilisation of communication systems that are meant to enhance and support justification by radiographers. The study recommends an in-depth study to quantify unjustified procedures in these two hospital departments. Continuous professional development focusing on justification and referral protocols must be conducted jointly between radiographers and referrers to create awareness and a platform for shared decision-making models.
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Affiliation(s)
- Martha Sitareni
- University of Namibia, Faculty of Health Sciences and Veterinary Medicine, School of Allied Health Sciences, Department of Radiography, Windhoek, Namibia
| | - Abel Karera
- University of Namibia, Faculty of Health Sciences and Veterinary Medicine, School of Allied Health Sciences, Department of Radiography, Windhoek, Namibia.
| | - Mondjila Amkongo
- University of Namibia, Faculty of Health Sciences and Veterinary Medicine, School of Allied Health Sciences, Department of Radiography, Windhoek, Namibia.
| | - Edwin Daniels
- University of Namibia, Faculty of Health Sciences and Veterinary Medicine, School of Allied Health Sciences, Department of Radiography, Windhoek, Namibia.
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Abrahams FR, Daniels ER, Niikondo HN, Amakali K. Students' knowledge, attitude and practices towards pressure ulcer prevention and management. Health SA 2023; 28:2180. [PMID: 36873786 PMCID: PMC9983280 DOI: 10.4102/hsag.v28i0.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/22/2022] [Indexed: 02/04/2023] Open
Abstract
Background Student nurses provide nursing care to patients during clinical allocation, and their competence may affect the quality of care given to the patients. Good knowledge and positive attitudes enhance early detection for prevention and management of pressure ulcers. Aim To determine undergraduate nursing students' knowledge, attitude and practices (KAP) towards prevention and management of pressure ulcers. Setting A nursing education institution in Windhoek, Namibia. Methods A quantitative, cross-sectional research design was used to conveniently sample (n = 50) student nurses and collect data using a self-administered questionnaire. Data were analysed using the statistical software programme (SPSS) version 27. Descriptive frequencies were applied, and Fishers exact test was performed. A statistical value of p < 0.05 was considered significant. Results Fifty (n = 50) student nurses consented to participate in the study. Student nurses reported good levels of knowledge (n = 35; 70%), attitude (n = 39; 78%), practices (n = 47; 94%). There was no statistically significant association between demographic variables and the level of knowledge, attitudes and practices, p > 0.05. Conclusion Student nurses have good knowledge, positive attitudes and practices on prevention and management of pressure ulcers. By the implications, the study concludes that the nursing students will competently manage the pressure ulcers occurring in the clinical setting. An observational study is recommended to assess practices in the clinical setting. Contribution The findings of this study will help to close the gap in the implementation of standard operating procedures for the prevention and management of pressure ulcers.
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Affiliation(s)
- Franco R Abrahams
- Department of General Nursing Sciences, Faculty of Health Sciences, School of Nursing, University of Namibia, Windhoek, Namibia
| | - Edwin R Daniels
- Department of Allied Health, Faculty of Health Sciences, School of Nursing, University of Namibia, Windhoek, Namibia
| | - Hileni N Niikondo
- Department of General Nursing Sciences, Faculty of Health Sciences, School of Nursing, University of Namibia, Windhoek, Namibia
| | - Kristofina Amakali
- Department of General Nursing Sciences, Faculty of Health Sciences, School of Nursing, University of Namibia, Windhoek, Namibia
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Peters S, Sukumar K, Blanchard S, Ramasamy A, Malinowski J, Ginex P, Senerth E, Corremans M, Munn Z, Kredo T, Remon LP, Ngeh E, Kalman L, Alhabib S, Amer YS, Gagliardi A. Trends in guideline implementation: an updated scoping review. Implement Sci 2022; 17:50. [PMID: 35870974 PMCID: PMC9308215 DOI: 10.1186/s13012-022-01223-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics. Results We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions. Conclusions Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact. Trial registration The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01223-6.
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De Roo B, Bacher K, Verstraete K. Cervical and lumbar spine imaging after traffic and occupational accidents: Evaluation of the use of imaging techniques, cumulative radiation dose and associated lifetime cancer risk. Eur J Radiol 2022; 151:110293. [DOI: 10.1016/j.ejrad.2022.110293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/31/2022] [Indexed: 11/15/2022]
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Gransjøen AM, Thorsen K, Lysdahl KB, Wiig S, Hofmann BM. Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period. Acta Radiol Open 2021; 10:2058460120988171. [PMID: 33796335 PMCID: PMC7975584 DOI: 10.1177/2058460120988171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/27/2020] [Indexed: 12/01/2022] Open
Abstract
Background An ever-increasing technological development in the field of radiology urges
a need for guidelines to provide predictable and just health services. A
musculoskeletal guideline was developed in Norway in 2014, without active
implementation. Purpose To investigate the impact of active guideline implementation on the use of
musculoskeletal diagnostic imaging most frequently encountered in general
practice (pain in the neck, shoulders, lower back, and knees). Material and Methods The total number of outpatient radiological examinations across modalities
registered at the Norwegian Health Economics Administration between January
2013 and February 2019 was assessed using an interrupted time series
design. Results A 12% reduction in the total examination of Magnetic Resonance Imaging
shoulder and knee, and x-ray lower back and shoulder was found at a
significant level (p = 0.05). Stratified analysis (Magnetic
Resonance Imaging examination as one group and x-ray examinations as the
other) showed that this reduction mainly was due to the reduction in the use
of Magnetic Resonance Imaging examinations (shoulder and knee) which was
reduced by 24% at a significant level (p = 0.002), while
x-ray examinations had no significant level change
(p = 0.71). No other statistically significant changes were
found. Conclusion The impact of the implementation on the use of imaging of the neck, shoulder,
lower back, and knee is uncertain. Significant reductions were demonstrated
in the use of some examinations in the intervention county, but similar
effects were not seen when including a control group in the analysis. This
indicates a diffusion of the implementation, or other interventions or
events that affected both counties and occurred in the intervention
period.
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Affiliation(s)
- Ann M Gransjøen
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
| | | | - Kristin B Lysdahl
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Bjørn M Hofmann
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway.,Center for Medical Ethics, University of Oslo, Blindern, Oslo
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8
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Elshami W, Abuzaid MM, Tekin HO. Effectiveness of Breast and Eye Shielding During Cervical Spine Radiography: An Experimental Study. Risk Manag Healthc Policy 2020; 13:697-704. [PMID: 32636688 PMCID: PMC7335279 DOI: 10.2147/rmhp.s257185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose This study assessed the effectiveness of breast and eye shielding and measured the radiation dose to radiosensitive tissues (eyes and breasts) due to scatter radiation during cervical spine X-ray radiography examinations. Methods Using an anthropomorphic phantom, the scattered radiation dose was measured before and after the placement of the lead shield over the eyes and breasts in the anteroposterior (AP) and left lateral projection. A regression formula was utilized to determine the exposure. Mean values and standard deviation of breasts and eyes doses were calculated. The paired two sample t-test was used to compare the recorded dose before and after shielding placement. Results Radiation shielding of eyes and breasts during AP cervical spine X-ray decreased radiation dose to the breasts by 99.9% and to the left and right eye by 91% and 89%, respectively. For the left lateral cervical spine X-ray, the radiation dose decreased by 26% and 31% for the left and right eye, respectively, and by 23% and 99% for the left and right breast, respectively. A significant difference was noted comparing the dose before and after the implementing shielding on the eye and breast. Conclusion According to the results presented, the dose is significantly reduced, especially considering that they are not in the area of interest but are exposed to scatter radiation.
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Affiliation(s)
- Wiam Elshami
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Mohamed M Abuzaid
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - H O Tekin
- Medical Diagnostic Imaging Department, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
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De Roo B, Hoste P, Stichelbaut N, Annemans L, Bacher K, Verstraete K. Belgian multicentre study on lumbar spine imaging: Radiation dose and cost analysis; Evaluation of compliance with recommendations for efficient use of medical imaging. Eur J Radiol 2020; 125:108864. [DOI: 10.1016/j.ejrad.2020.108864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 10/25/2022]
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Yates M, Oliveira CB, Galloway JB, Maher CG. Defining and measuring imaging appropriateness in low back pain studies: a scoping review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:519-529. [PMID: 31938944 DOI: 10.1007/s00586-019-06269-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 10/28/2019] [Accepted: 12/24/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE Patients with low back pain (LBP) rarely have serious underlying pathology but frequently undergo inappropriate imaging. A range of guidelines and red flag features are utilised to characterise appropriate imaging. This scoping review explores how LBP imaging appropriateness is determined and calculated in studies of primary care practice. METHODS This scoping review builds upon a previous meta-analysis, incorporating articles identified that were published since 2014, with an updated search to capture articles published since the original search. Electronic databases were searched, and citation lists of included papers were reviewed. Inclusion criteria were studies assessing adult LBP imaging appropriateness in a primary care setting. Twenty-three eligible studies were identified. RESULTS A range of red flag features were utilised to determine imaging appropriateness. Most studies considered appropriateness in a binary manner, by the presence of any red flag feature. Ten guidelines were referenced, with 7/23 (30%) included studies amending or not referencing any guideline. The method for calculating the proportion of inappropriate imaging varied. Ten per cent of the studies used the total number of patients presenting with LBP as the denominator, suggesting most studies overestimated the rate of inappropriate imaging, and did not capture where imaging is not performed for clinically suspicious LBP. CONCLUSION Greater clarity is needed on how we define and measure imaging appropriateness for LBP, which also accounts for the problem of failing to image when indicated. An internationally agreed methodology for imaging appropriateness studies would ultimately lead to an improvement in the care delivered to patients. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Mark Yates
- The Centre for Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Cutcombe Road, SE5 9RJ, London, UK.
| | - Crystian B Oliveira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - James B Galloway
- The Centre for Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Cutcombe Road, SE5 9RJ, London, UK
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
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Logan GS, Pike A, Copsey B, Parfrey P, Etchegary H, Hall A. What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews. PLoS One 2019; 14:e0225414. [PMID: 31805073 PMCID: PMC6894771 DOI: 10.1371/journal.pone.0225414] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/03/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Since 2000, guidelines have been consistent in recommending when diagnostic imaging for low back pain should be obtained to ensure patient safety and reduce unnecessary tests. This systematic review and meta-analysis was conducted to determine the pooled proportion of CT and x-ray imaging of the lumbar spine that were considered appropriate in primary and emergency care. METHODS Pubmed, CINAHL, The Cochrane Database of Systematic Reviews and Embase were searched for synonyms of "low back pain", "guidelines", and "adherence" that were published after 2000. Titles, abstracts, and full texts were reviewed for inclusion with forward and backward tracking on included studies. Included studies had data extracted and synthesized. Risk of bias was performed on all studies, and GRADE was performed on included studies that provided data on CT and x-ray separately. A random effect, single proportion meta-analysis model was used. RESULTS Six studies were included in the descriptive synthesis, and 5 studies included in the meta-analysis. Five of the 6 studies assessed appropriateness of x-rays; two of the six studies assessed appropriateness of CTs. The pooled estimate for appropriateness of x-rays was 43% (95% CI: 30%, 56%) and the pooled estimate for appropriateness of CTs was 54% (95% CI: 51%, 58%). Studies did not report adequate information to fulfill the RECORD checklist (reporting guidelines for research using observational data). Risk of bias was high in 4 studies, moderate in one, and low in one. GRADE for x-ray appropriateness was low-quality and for CT appropriateness was very-low-quality. CONCLUSION While this study determined a pooled proportion of appropriateness for both x-ray and CT imaging for low back pain, there is limited confidence in these numbers due to the downgrading of the evidence using GRADE. Further research on this topic is needed to inform our understanding of x-ray and CT appropriateness in order to improve healthcare systems and decrease patient harms.
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Affiliation(s)
| | - Andrea Pike
- Primary Healthcare Research Unit, Memorial University, St. John’s, NL, Canada
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Patrick Parfrey
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Amanda Hall
- Faculty of Medicine, Memorial University, St. John’s, NL, Canada
- Primary Healthcare Research Unit, Memorial University, St. John’s, NL, Canada
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Gransjøen AM, Lysdahl KB, Hofmann BM. Geographical variations in the use of diagnostic imaging of musculoskeletal diseases in Norway. Acta Radiol 2019; 60:1153-1158. [PMID: 30417668 DOI: 10.1177/0284185118812204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ann Mari Gransjøen
- Department of Health Sciences, Norwegian University of Science and Technology in Gjøvik (NTNU), Gjøvik, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, Norway and University of South-Eastern Norway, Kongsberg, Norway
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De Roo B, Stichelbaut N, Hoste P, Verstraete K, Bacher K. The effective and collective dose to patients undergoing abdominopelvic and trunk computed tomography examinations: A Belgian multicentre study. Eur J Radiol 2019; 111:81-87. [DOI: 10.1016/j.ejrad.2018.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 12/18/2018] [Accepted: 12/23/2018] [Indexed: 10/27/2022]
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Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J 2018; 18:2266-2277. [PMID: 29730460 DOI: 10.1016/j.spinee.2018.05.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/13/2018] [Accepted: 05/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear. PURPOSE This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed. DESIGN This is a systematic review and meta-analysis. PATIENT SAMPLE The sample comprised patients with LBP presenting to primary care. OUTCOME MEASURES Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures. METHODS MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system. RESULTS Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology. CONCLUSIONS Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.
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Affiliation(s)
- Hazel J Jenkins
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia; Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, NSW, 2109, Australia.
| | - Aron S Downie
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, NSW, 2109, Australia; The University of Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Chris G Maher
- The University of Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Niamh A Moloney
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
| | - John S Magnussen
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
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Gransjøen AM, Wiig S, Lysdahl KB, Hofmann BM. Development and conduction of an active re-implementation of the Norwegian musculoskeletal guidelines. BMC Res Notes 2018; 11:785. [PMID: 30390703 PMCID: PMC6215611 DOI: 10.1186/s13104-018-3894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/27/2018] [Indexed: 11/10/2022] Open
Abstract
Objective Significant geographical variations in the use of diagnostic imaging have been demonstrated in Norway and elsewhere. Non-traumatic musculoskeletal conditions is one area where this has been demonstrated. A national musculoskeletal guideline was implemented in response by online publishing and postal dissemination in Norway in 2014 by national policy makers. The objective of our study was to develop and conduct an intervention as an active re-implementation of this guideline in one Norwegian county to investigate and facilitate guideline adherence. The development and implementation process is reported here, to facilitate understanding of the future evaluation results of this study. Results The consolidated framework for implementation research guided the intervention development and implementation. The implementation development was also based on earlier reported success factors in combination with interviews with general practitioners and radiologists regarding facilitators and barriers to guideline adherence. A combined implementation strategy was developed, including educational meetings, shortening of the guideline and easier access. All the aspects of the implementation strategy were adapted towards general practitioners, radiological personnel and the Norwegian Labor and Welfare Administration. Sixteen educational meetings were held, and six educational videos were made for those unable to attend, or where meetings could not be held. Electronic supplementary material The online version of this article (10.1186/s13104-018-3894-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ann Mari Gransjøen
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.
| | - Siri Wiig
- Faculty of Health Sciences, SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholmsgate 41, 4036, Stavanger, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, PO Box 235, 3603, Kongsberg, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.,Center for Medical Ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway
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16
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Gransjøen AM, Wiig S, Lysdahl KB, Hofmann BM. Barriers and facilitators for guideline adherence in diagnostic imaging: an explorative study of GPs' and radiologists' perspectives. BMC Health Serv Res 2018; 18:556. [PMID: 30012130 PMCID: PMC6048703 DOI: 10.1186/s12913-018-3372-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 07/09/2018] [Indexed: 12/20/2022] Open
Abstract
Background Diagnostic imaging has been a part of medicine for the last century. It has been difficult to implement guidelines in this field, and unwarranted imaging has been a frequent problem. Some work has been done to explain these phenomena separately. Identifying the barriers to and facilitators of guideline use has been one strategy. The aim of this study is to offer a more comprehensive explanation of deviations from the guideline by studying the two phenomena together. Methods Eight general practitioners and 10 radiologists from two counties in Norway agreed to semi-structured interviews. Topics covered in the interviews were knowledge of the guideline, barriers to and facilitators of guideline use, implementation of guidelines and factors that influence unwarranted imaging. Results Several barriers to and facilitators of guideline use were identified. Among these are lack of time, pressure from patients, and guidelines being too long, rigid or unclear. Facilitators of guideline use were easy accessibility and having the guidelines adapted to the target group. Some of the factors that influence unwarranted imaging are lack of time, pressure from patients and availability of imaging services. Conclusion There are similarities between the perceived barriers for guideline adherence and the perceived factors that influence unwarranted imaging. There may be a few reasons that explains the deviation from guidelines, and the amount of unwarranted imaging. Electronic supplementary material The online version of this article (10.1186/s12913-018-3372-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ann Mari Gransjøen
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.
| | - Siri Wiig
- Faculty of Health Studies, University of Stavanger, Kjell Arholmsgate 41, 4036, Stavanger, Norway
| | - Kristin Bakke Lysdahl
- Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Pilestredet 46, 0167, Oslo, Norway.,Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, PO Box 235, 3603, Kongsberg, Norway
| | - Bjørn Morten Hofmann
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.,Center for medical ethics, University of Oslo, PO Box 1130 Blindern, 0318, Oslo, Norway
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Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med 2018; 33:1142-1154. [PMID: 29728892 PMCID: PMC6025666 DOI: 10.1007/s11606-018-4435-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 08/10/2017] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs). METHODS The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results. RESULTS The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]). DISCUSSION Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.
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Vilar-Palop J, Hernandez-Aguado I, Pastor-Valero M, Vilar J, González-Alvarez I, Lumbreras B. Appropriate use of medical imaging in two Spanish public hospitals: a cross-sectional analysis. BMJ Open 2018; 8:e019535. [PMID: 29549204 PMCID: PMC5857681 DOI: 10.1136/bmjopen-2017-019535] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the appropriateness of medical imaging examinations involving radiation and to estimate the effective radiation dose and costs associated. DESIGN Cross-sectional retrospective study. SETTING Two Spanish public tertiary hospitals. PARTICIPANTS 2022 medical imaging tests were extracted from the radiology information system in February and March of 2014. MRI and ultrasound examinations were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Five outcomes were set independently by at least two researchers according to four guidelines: (1) appropriate; (2) inappropriate; (3) inappropriate due to repetition, if the timing to carry out next diagnostic tests was incorrect according to guidelines; (4) not adequately justified, if the referral form did not include enough clinical information to allow us to understand the patient's clinical condition; and (5) not included in the guidelines, if the referral could not be matched to a clinical scenario described in the guidelines. We estimated the prevalence of the five categories according to relevant clinical and sociodemographic variables and the effective radiation dose and costs for each category. RESULTS Approximately half of the imaging tests were deemed as appropriate (967, 47.8%) while one-third (634, 31.4%) were considered inappropriate. 19.6% of the effective dose and 25.2% of the cost were associated with inappropriate tests. Women were less likely than men to have an imaging test classified as appropriate (adjusted OR 0.70,95% CI 0.57 to 0.86). Imaging tests requested by general practitioners were less likely to be considered appropriate than those requested by central services (adjusted OR 0.60, 95% CI 0.38 to 0.93). Mammography and CT were more likely to be appropriate than conventional X-rays. CONCLUSION There was a significant frequency of inappropriateness, which resulted in a high percentage of associated effective radiation dose. Percentage of inappropriateness depends on sociodemographic and clinical characteristics such as sex, age, referral physician and medical imaging test.
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Affiliation(s)
| | - Ildefonso Hernandez-Aguado
- Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Spain
- Department of Public Health, History of Science and Gynecology, Miguel Hernández University, Alicante, Spain
| | - María Pastor-Valero
- Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Spain
- Department of Public Health, History of Science and Gynecology, Miguel Hernández University, Alicante, Spain
| | - José Vilar
- Radiology Department, Peset Hospital, Valencia, Spain
| | | | - Blanca Lumbreras
- Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Spain
- Department of Public Health, History of Science and Gynecology, Miguel Hernández University, Alicante, Spain
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O'Sullivan JW, Albasri A, Nicholson BD, Perera R, Aronson JK, Roberts N, Heneghan C. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open 2018; 8:e018557. [PMID: 29440142 PMCID: PMC5829845 DOI: 10.1136/bmjopen-2017-018557] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. OBJECTIVE To identify overuse and underuse of diagnostic tests in primary care. DESIGN Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. RESULTS We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively. CONCLUSIONS There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER CRD42016048832.
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Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Ali Albasri
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Rafael Perera
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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