African Regional Workshop on Imaging Referral Guidelines Setting the scene: Objectives &

Overview

Denis RemediosClinical Radiologist,

Northwick Park Hospital, UKOn behalf of the IAEA

African Regional Workshop on Imaging Referral Guidelines: Cairo, 13-16 December 2015

With thanks to:

International Atomic Energy Agency

World Health Organization

Egyptian Atomic Energy Authority

Acknowledgement:

The need for radiation protectionDiagnostic radiology in USA

accounts for as much radiation than natural causes (15% in 1980 to 48% in 2006)

NCRP 160 http://www.ncrponline.org/CT exams have increased at

10% pa in USA from 3-80 million since 1980

44% of CT exams not justified in USAHadley JL, Agola J, Wong P. AJR 2006; 186: 937-942 http://www.ncbi.nlm.nih.gov/pubmed/16554560

Low level of knowledge of dose; only 1:3 doctors received formal training in radiation protectionSoye & Paterson. BJR 81 (2008),725-729 http://bjr.birjournals.org/cgi/content/abstract/81/969/725

“Awareness, Appropriateness & Audit”Triple Ahttp://www.ncbi.nlm.nih.gov/pubmed/21343316

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Joint Position Statement by the IAEA and WHO

Criteria for choice of investigationsInvestigations are recommended according to the following criteria:1. Clinical effectiveness

(evidence-based diagnostic/therapeutic impact)

2. Effective dose (effective low or no dose investigations preferred)

3. Cost-effectiveness (cheaper equally effective investigation preferred)

Essential for uniformity of practice

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The Basic Safety Standards and “Justification”

Appropriate Imaging

• “The best test first”• Investigation should answer the clinical question

posed• Must be a justified investigation: benefit>>risk• Recommendations should give latitude for

equipment and expertise• Appropriate imaging should take into account

over-utilisation of imaging in some member states but under-utilisation of imaging in others

• Cost savings come from avoidance of unhelpful investigations

Justification and clinician involvement: IssuesOverloaded knowledge base

Medical and technical advancesCompetition for inclusion in curricula/CPD

Time challengedFastest test with shortest wait best?

Mixed messagesDifferent guidance from different sources?

Patient expectationsHistorical or geographical biasUnreliable evidence base from the web

Justification and clinician involvement : challengesDissemination of Referral Guidelines

Widely and freely available to end-users “If they haven’t heard it you haven’t said it” McLuhan

Implementation of guidance decision support tools?

“We shape our tools and thereafter our tools shape us” McLuhan

Uptakeneed buy-in by users and preferably ownership

“Computers can do better than ever what needn’t be done at all. Making sense is still a human monopoly” McLuhan

Monitoringclinical audit, feedback and education

“We drive into the future using only our rearview mirror ” McLuhan

Justification and clinician involvement: possible solutionsEducation Undergraduate and Continuing

Professional Development. Requests not orders

Referral Guidelines

from a trusted source, in line with clinical guidance, +/- clinical decision support

Monitor with clinical audit

Local internal audit (bottom up)External audit (top down)

External control

by payerslegislation

African Regional Workshop on Imaging Referral Guidelines: Overview

Day 1 Setting the scene- why do we need referral guidelines, what are they, who should use them, what improvements may we get?

Day 2 Current status- what measures are in place in African countries; what good practices can be shared

Day 3 Strategies for improvement- existing, wanted and needed. Visit to the National PACS.

Day 4 The way forward- recommendations for national and international help

Break out Groups, Day 2 and Day 3

• To enable all participants to share experiences and good practices

• 2 streams, one in the French language, one in English

• Chairman and Rapporteur for each group• Chair will lead structured discussion• Rapporteur will feedback to all participants and

provide a framework for recommendations

Group 1: Barriers and solutions to appropriate imaging

Group 2: Strategies and tools for adopting/adapting, implementing, using and monitoring Imaging Referring Guidelines

African Regional Workshop on Imaging Referral Guidelines: Objectives

1. Understand benefits of imaging referral guidelines 2. Guideline implementation: Adopting and adapting

for appropriate imaging3. Introduction to methods for monitoring / audit of

appropriate imagingSecondary objectives are: a. To strengthen justification in diagnostic imaging;b. Reduction in unnecessary radiation dose to

patients.c. To promote awareness among referrers,

radiologists, radiographer and regulators. Clinical champions.

d. To address country-specific problems.Awareness, Appropriateness and Audit

Referrers, Radiologists, Radiographer and Regulators