The need for imaging referral guidelines:

Introduction, components, requirements, appropriateness and

decision support

Denis RemediosClinical Radiologist,

Northwick Park Hospital, UK

On behalf of the IAEA

Imaging Referral Guidelines and Clinical Decision Support

Stakeholders• Referrers- medical practitioners, non-medical

professionals• Radiological medical practitioners• Radiographers• Medical physicists• Regulators• Payers• Patients and publicQuestions:• Why?• How?• When?

Why are Referral Guidelines needed?

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Per caput annual collective dose /mSvHart et al. 2010

Guidelines: for whom?

For referring practitioners: General Practitioners, doctors-in-training & non-medically qualified health professionals

For radiology practitioners: ICRP level 2 justification

For patients: reinforcement of advice

For Healthcare organisations: decision support, planning and provision

Levels of evidence for primary research question 

Therapeutic studies—investigating the results

of treatment

Prognostic studies—investigating the effect of a patient

characteristic on the outcome of disease

Diagnostic studies—investigating a diagnostic test

Economic and decision analyses—

developing an economic or

decision model

Level I High-quality randomised controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Systematic review1 of level-I randomised controlled trials (and study results were homogeneous2)

High-quality prospective study3 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients) Systematic review1 of level-I studies

Testing of previously developed diagnostic criteria in series of consecutive patients (with universally applied reference "gold" standard) Systematic review1 of level-I studies

Sensible costs and alternatives; values obtained from many studies; multiway sensitivity analyses Systematic review1 of level-I studies

Level II Lesser-quality randomised controlled trial (eg, <80% follow-up, no blinding, or imperfect randomisation) Prospective3 comparative study4 Systematic review1 of level-II studies or level-I studies with inconsistent results

Retrospective5 study Untreated controls from a randomised controlled trial Lesser-quality prospective study (e.g., patients enrolled at different points in their disease or <80% follow-up) Systematic review1 of level-II studies

Development of diagnostic criteria on basis of consecutive patients (with universally applied reference "gold" standard) Systematic review1 of level-II studies

Sensible costs and alternatives; values obtained from limited studies; multiway sensitivity analyses Systematic review1 of level-II studies

Level III Case-control study6 Retrospective5 comparative study4 Systematic review1 of level-III studies

Case-control study6 Study of non-consecutive patients (without consistently applied reference "gold" standard) Systematic review1 of level-III studies

Analyses based on limited alternatives and costs; imperfect estimates Systematic review1 of level-III studies

Level IV Case series7 Case series Case-control study Poor reference standard

No sensitivity analyses

Level V Expert opinion Expert opinion Expert opinion Expert opinion

Dose information (from RCR iRefer, 2012)

NHS National Tariff Tariff

(£)Average

(£)Reporting

Fee(£)

MRI, one area, no contrast 154

MRI169*

26

MRI, one area, post contrast only 199

MRI, one area, pre and post contrast only 228

MRI, 2 or 3 areas, no contrast 171

MRI, 2 or 3 areas, with contrast 260

CT, one area, no contrast 105

CT131

24CT, one area, post contrast only 131

CT, one area, pre and post contrast only 152

CT, 2 or 3 areas, no contrast 132

CT, 2 areas with contrast 164

32CT, 3 areas with contrast 176

CT, More than 3 areas 223

Dexa Scans 49 49 13

Contrast fluoroscopy procedures <20 mins room usage 147159 N/A

Contrast fluoroscopy procedures >20 mins and <40 mins room usage 166

Ultrasound, scan 0-15 mins 63 US69

N/AUltrasound, scan > 15 mins 94

Nuclear Medicine Band 1 97

22823

Nuclear Medicine Band 2 151

Nuclear Medicine Band 3 302 64

Criteria for choice of investigations

For a given clinical problem, imaging modalities are listed in the following order:

1. Clinical effectiveness (evidence-based diagnostic/therapeutic impact)

2. Effective dose3. Cost-effectiveness

Essential for uniformity of practice

Clinical practice and clinical referral and imaging referral guidelines

• Clinical practice guidelines (‘guidelines’) are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. http://www.nus.edu.sg/irb/Articles/BMJ-Clinical%20Guidelines-Benefits%20and%20Limits.pdf

• Clinical referral guidelines/advice defines, as precisely as possible, the recommendations of the advisory group regarding the situations/conditions that should prompt specialist clinical referral. (from NICE) https://www.nice.org.uk/proxy/?sourceUrl=http%3A%2F%2Fwww.nice.org.uk%2Fmedia%2F94D%2FBE%2FReferraladvice.pdf

• Imaging referral guidelines recommend which imaging investigation is most likely to be helpful for a particular clinical scenario. Advisory not mandatory. (RCR iRefer)

Guidelines for guidelines?Appraisal of Guidelines for Research and Evaluation (AGREE) http://www.agreetrust.org/

AGREE Instrument :

1. assesses the quality of guidelines; 2. provides a methodological strategy for the

development of guidelines; 3. informs what information and how information

ought to be reported in guidelines.

Guidelines can play an important role in health policy formation and have evolved to cover topics across the health care continuum (e.g. screening, diagnosis).

Browman et al. Healthc Pap. 2003;3 http://www.ncbi.nlm.nih.gov/pubmed/12811083

Use of Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument http://www.agreetrust.org/

• health care providers before adopting its recommendations into their practice;

• guideline developers to follow a structured and rigorous development methodology, to conduct an internal assessment to ensure that their guidelines are sound, or to evaluate guidelines from other groups for potential adaptation to their own context;

• policy makers to decide which guidelines could be recommended for practice or to inform policy decisions;

• educators to help enhance critical appraisal skills amongst health professionals and to teach core competencies in guideline development and reporting.

Making the best use of clinical radiology

The Royal College of Radiologists has published guidelines for 25 years since 1989. NHS Evidence accreditation for 7th edition (2012).

Guidelines App for smartphones and tablets

RCR iRefer App distribution • Europe: UK, Ireland, France, Norway,

Sweden, Belgium, Denmark, Portugal, Spain, Switzerland, Germany, Slovakia, Netherlands, Italy, Israel

• Western Pacific: Australia, New Zealand, Singapore, Hong Kong

• Eastern Mediterranean: UAE, Kuwait, Saudi Arabia

• Africa: South Africa• Americas: Brazil

Who should justify?

Radiological medical practitionerReferring medical practitioner(In consultation with the patient for complex or high

dose procedures)For asymptomatic individuals, justification by Health

Authority and Professional Body

Transfer of responsibility or delegation?

Responsibility for justification • lies ultimately or largely with the radiological

medical practitioner who may be a cardiologist etc.

• may be transferred to another medical practitioner eg in isolated, small facilities without a radiologist

Task of justification occasionally delegated to the radiographer for low dose procedures or those within an agreed pathway eg CT for stroke. Responsibility remains with the radiologist.

Adopting and adapting referral guidelines

• Adopting validated referral guidelines is a rapid process for implementation

• Adapting allows local issues to be incorporatedCurrent version of RCR Referral Guidelines adopted

by:CroatiaIrelandJapanRussia(Malaysia)

Over 20 years , adopted and adapted by >16 countries and 1 region (Europe)

Mostly adopted and translated without adaptation

http://rcr.lucidhost.co.uk/login/

ACR Appropriateness Criteriahttps://acsearch.acr.org/docs/69483/Narrative/

Similarities between ACR and RCR referral criteriaFeatures ACR RCR

Evidence-based + +

Based on common clinical problems

159 (800 var.) 315

Cycle of review 1 yr selective 4 yrs

Expert Panels 18 16

Consensus Technique Delphi Delphi

Level of agreement for consensus

80% 75%

Involvement of other organisations

15 through consensus

100 through consultation

Dose information Rel. radiation level (= ED)

Effective dose (ED)

Publication Web, Clinical Decision Support

Paper, App and restricted web

Western Australia HA: Diagnostic Imaging Pathwayshttp://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/low-back-pain?tab=redflags#pathway

Canadian Association of Radiologists: adopt, adapt and translate http://www.car.ca/uploads/standards%20guidelines/car-fr-referralguidelines-d-20121011.pdf

Austrian Referral Guidelines: adopt and translate http://orientierungshilfe.vbdo.at/

EC Referral Guidelines 2000

articlestoryarticlestory Europe: EuroSafe Imaging Campaign. Collaborative efforts for Radiation Protection

USA Guidance for appropriate imaginghttp://www.acr.org/Quality-Safety/Appropriateness-Criteria

USA: Guidelines and clinical decision support

ACR- Clinical Decision Support

Clinical decision support for imaging referral guidelines in Europe ESR iGuide

Radiology, http://pubs.rsna.org/doi/abs/10.1148/radiol.2511081174

Christopher L. Sistrom; Pragya A. Dang; Jeffrey B. Weilburg; Keith J. Dreyer; Daniel I. Rosenthal; James H. Thrall; Radiology  2009, 251, 147-155.DOI: 10.1148/radiol.2511081174© RSNA, 2009

CT requests with Clinical Decision Support

Targeted CDS can reduce utilisation of lumbar MRI, head MRI and sinus CT.

Rand: MID report for Imaging and CDS 2014 http://www.rand.org/content/dam/rand/pubs/research_reports/RR700/RR706/RAND_RR706.pdf

Rand: MID report for Imaging and CDS http://www.rand.org/content/dam/rand/pubs/research_reports/RR700/RR706/RAND_RR706.pdf

Uptake“Approximately two-thirds of clinicians in the sample placed fewer than 20 orders”

Reduction in utilisation“largest decrease in the percentage of rated orders was for orders for CT and MRI of the lumbar spine, which decreased by 8 and 15%”. Overall 5%.

Coverage“percentage of orders that were successfully rated by DSSs ranged from as little as 17 percent for Convener D to a high of 58 percent for Convener A” Average c. 30%.

USA: Protecting Access to Medicare Act 2014

The bill sought to authorize a short-term Medicare SGR patch that extends authorization for physician reimbursement under Medicare under current law through March 31, 2015. The bill prevents a scheduled 24 percent reduction in Medicare physician reimbursement rates.

It also mandates that starting January 1, 2017, physicians ordering advanced diagnostic imaging exams (CT, MRI, nuclear medicine and PET) must consult government- approved, evidence-based appropriate-use criteria, namely through a CDS system. Physicians furnishing advanced imaging services will only be paid if claims for reimbursement confirm that the appropriate-use criteria was consulted, which CDS mechanism was used, and whether the exam ordered adhered or did not adhere to an acceptable CDS rating. It’s important to note that physicians ordering advanced diagnostic imaging services do not have to adhere to the appropriate-use criteria; however, they must confirm that the guidelines have been consulted.

Consultation of appropriate-use criteria is required prior to the ordering of advanced diagnostic imaging services in the physician office, hospital outpatient, and emergency department settings. Exams for inpatients and emergency services as defined under the Emergency Medical Treatment and Active Labor Act (EMTALA) will be exempt. Hardship exclusions, such as a lack of access to high speed Internet, will be allowed, presumably on a case-by-case basis.

The U.S. Department of Health and Human Services (HHS) through CMS is authorized to deem various accepted appropriate-use criteria by November 15, 2015.

Canadian Association of RadiologistsManitoba Demonstration Project in Physician Demand-Side Control forDiagnostic Imaginghttp://www.car.ca/uploads/about/manitoba%20i%20project_final%20report.pdf

Manitoba Demonstration Project: Why Such Limited Impact?

Low impact (5% accept rate) could be the result of several factors:

1. Insufficient guideline coverage of actual practice

• Would additional guidelines increase impact?

2. Good existing DI appropriateness at demonstration site

• Would guidelines be more useful for generalists (e.g. family

practitioners) rather than specialists?

3. Need for stronger clinical engagement about DI appropriateness

• Would more attention to demonstrating the “need” for guideline

adherence, influencing physician knowledge and attitudes lead

to more practice change?

4. Timing of advice

• Was this intervention placed “too late” in decision-making

process (after physician commitment to a course of action)?

Australia & New Zealand: Inclusive approach to imaging guidelines and decision support

UAE: Suggestions for next stepsIAEA Workshop on Patient Referral Guidelines, Sept. 2014

1. Adopt and adapt Imaging Referral Guidelines for use in the UAE

2. Encourage Clinician Champions to promote guideline introduction & use

3. Governmental endorsement and support for guideline availability & use

4. Educational initiatives for medical under-graduates & doctors in training, also CPD*

5. Clinical audit facilitation and training for monitoring guideline availability and use

Collaboration of Portuguese-speaking countries

Afrosafe campaign 2015AFROSAFE’s main objective is to address issues arising from radiation protection in medicine in Africa. This campaign is based on the Bonn Call-for-Action, 2013. The vision of AFROSAFE is: All radiation-based medical procedures in Africa appropriate and safely performed. AFROSAFE plans to achieve its goals through supporting adherence to policies, strategies and activities for the promotion of radiation safety.

Imaging referral guidelines: areas for consideration to help local implementation

• Imaging referral guidelines- what is available• Format- tabular or flow chart algorithm• Media- print copy, web-based, app-based for

tablets/smart phones, clinical decision support CDS• Barriers• Monitoring- audit, workflow, regulatory inspection• Tools for implementation- awareness campaigns,

education, CDS• Long term goals- reduced utilisation, effective

diagnostics, radiation safety culture, collective corporate responsibility for safety

Monitoring of guideline use in workflow

1. Clinic-radiological meetings (MDT meetings)Can influence:

i. Future imaging choices in the individual case

ii. Imaging referral behaviour.2. Educational messages in reports esp. to GPs

Sustained 20% reduction in referral possible “Lumbar imaging for low back pain without suggestion of serious underlying conditions does not improve clinical outcomes. See M04 http://www.rcr.ac.uk:2059/adult/#Tpc151

http://www.nice.org.uk/guidance/CG88/chapter/1-Guidance ”

3. Through CDS- dashboard can give ratings of appropriateness

Metrics esp. for Economic benefit?

Value of test not the same as the cost

Benefit to a health organisation within the constraints of resources

Essential to measure outcome for clinical guidance & patient protocols

6. Societal benefit

5. Patient outcome

4. Therapeutic i

mpact

3. Diagnostic i

mpact

2. Diagnostic efficacy

1. Technical efficacy

The efficacy of diagnostic imagingFryback and Thornbury Med

Decis Making 1991;11:88 http://www.ncbi.nlm.nih.gov/pubmed/1907710

Evidence for referral guidelinesFollowing RCR guidelines, overall referrals fell

13% BMJ. 1993 Jan 9;306(6870):110-1

RCGP Randomised controlled trial showed fewer referrals and better conformance Oakeshott, Kerry, Williams. Br J Gen Pract. 1994 Sep;44:427-8.

Randomised trial with an educational reminder messages in reports is effective in reduction by up to 20% & does not affect quality of referrals. Eccles , Steen , Grimshaw , Thomas , McNamee , Soutter, Wilsdon , Matowe , Needham , Gilbert.   The Lancet, 2001; 357: 1406 – 1409.

Over 12 consecutive months no evidence of the effect of the intervention wearing off Ramsay, Eccles, Grimshaw, Steen. Clin Radiol. 2003 Apr;58(4):319-21

Emerging evidence to show 2-20% improvement in conformance with clinical decision support tools.

Imaging Referral Guidelines: needs, components and clinical decision support

1. Awareness of value of appropriate imaging… referrers and patients

2. Adopting and adapting of guidelines to facilitate appropriate imaging

3. CDS in workflow simple & effective4. Clinical audit for monitoring,

identifying outliers, & feedback… Awareness, appropriateness & audit