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

Drivers for the effective use of Guidelines

European and International Legislation related to radiation protection requires effective justification of imaging tests involving radiation based on evidence-based guidance [2]. In addition there are concerns regarding increasing per capita dose from medical imaging across Europe and internationally. On the positive side, earlier access to appropriate imaging is known to affect outcomes in a number of conditions.

Production of Guidelines

There is a similar process for the production and formatting of Guidelines by those countries who presented their experience [3, 4, 5], with the exception of Western Australia [6]. Most countries displayed the Guidelines in a tabular form involving a grading system but in Western Australia the guidance was integrated into a decision-making flow-chart algorithm. All countries reported that the production of evidence-based Guidelines was resource intensive, particularly in regard to radiologist input into the process.

There was acknowledgement of duplication of effort, with the same evidence being reviewed in each individual country reaching the same or similar conclusions. The ownership and development of Guidelines by radiologists may well have an impact on the adoption of, and compliance with, Guidelines by the end-user clinician.

Challenges in evidence

The evidence base is often related to comparison of differing modalities in terms of accuracy, safety and efficiency, but there are less robust data on the impact of the use of imaging to patient outcomes. Improvements in process are often considered as a proxy for outcome. Evidence in many pathways is not always present and, if present, is not always high level, widely applicable or robust. A key factor should be the overall efficiency gains within the health system by the correct use of Guidelines.

Why don’t Guidelines work?

Solutions

Session 2, Specific Issues, addressed the perspectives of stakeholders from paediatrics, interventional radiology and nuclear medicine, as well as representatives from radiographer societies and patient groups.

Not surprisingly all speakers were strongly in favour of Guidelines although each speaker saw and described their structure, design and use with differing perspectives.

The key presentation relating to paediatrics stressed the greater sensitivity of children to radiation-induced effects and the longer period for effects to be manifested. These risks were far greater with CT and fluoroscopy, rather than radiography. Education is essential and the development and provision of specific guidelines for children is essential. Discussion centred on whether these should be stand-alone Guidelines or separate guidelines integrated into a unified publication.

Interventional radiology is a rapidly changing field hence the need for frequent updates with practice guidelines for interventional radiology not fully implemented in current diagnostic radiology guidelines.

Interventional radiologists act as clinical gatekeepers ensuring that the design of Guidelines involves multidisciplinary practice, collaboration of a large number of diverse stakeholders and robust education, not only across the healthcare community but also to patients, the public and media.

It was noted that procedural risks in interventional radiology were often far higher than radiation-related risks.

Nuclear medicine benefits from fewer procedures and Guidelines are committee driven and jointly written with clinical specialities. Interestingly technologists prepare parallel Guidelines. All requests are routinely checked and there is a strong culture of audit.

The balance between risk and benefit is pivotal, the assessment of dose alone is not helpful and justification requires knowledge of clinical circumstances. The wording of Guidelines must be carefully chosen, especially related to possible risk of misuse, criteria and appropriateness.

Key points of implementation are that Guidelines are legally required, but more importantly that they are useful, should be kept up to date, and should be used and audited and their development funded.

Radiographers were portrayed as playing a key role at the interface between patient and technology, being the pivot between referrers, patients and radiologists. They are therefore a key player in the implementation of referral guidelines.

A presentation from a general practitioner stressed that excellent communication between the patient, general practitioner and radiologist is essential. This will be facilitated by clear referral guidelines.

The patient’s perspective stressed the need for dose information, clear communication (no acronyms), the need to be sensitive to the patient’s needs, and that the patient is a member of the team—“No decision about me without me”.

The varying and diverse interpretation of “Specific Issues” demonstrates the need for a broad base of knowledge expertise and experience when designing and implementing Guidelines.

Session 3, Survey Feedback, dealt with the formulation and findings from the survey of Guidelines in Europe, conducted as an earlier part of the EC Referral Guidelines Project. Within this session workshop participants were given an opportunity to present examples of good practices from their own countries followed by enthusiastic discussion.

The survey feedback summarised the survey. It was web-based and involved multiple organisations from 30 countries. These included radiology and nuclear medicine societies and competent authorities. The questions were comprehensive and related to responsibilities, format, circulation and purpose of the referral guidelines. In addition, the survey participants were asked to share their views on barriers to implementation and their potential solutions. In establishing the survey, consideration was given to ease of understanding, completion and subsequent analysis.

The analysis provided a wealth of data. More significant information related to awareness of the legal requirement for Guidelines (60 %) and the difference between this requirement and actual availability. There was variation as to the origin of the Guidelines in each of the countries—some were based on practice within the Member State, while others were heavily or entirely based on the publications from organisations external to their country (e.g. translation of RCR guidelines). The survey provided information on a number of key elements and factors of the Guidelines including the evidence base, the grading of procedures and the associated radiation dose.

Session 4 dealt with Innovations for improvement in Guideline use. Examples of innovations in use worldwide and potential solutions drawn from other areas of medicine were discussed.

The need was identified to improve Guideline development with specific emphasis on the level of Evidence (currently approximately 30 % of Guidelines are not evidence-based). Guidelines should be informed by secondary research and particularly by systematic reviews where available. There was agreement for the need of European Guidelines, either as a synthesis of several National Guidelines or developed by European bodies.

The plan for the future should include developments to electronic requesting (computerised patient order entry, CPOE) in connection with CDS systems.

The suggestion was made for developing selected high-impact Guidelines using simple, fast and transparent software, under the leadership of medical practitioners and validated in small integrated patient groups by motivated physicians.

Web-based guidance and adequate resources are required. In addition, tablet and smart phone applications (apps) would be useful.

Guideline availability and use in Europe

Data to inform the availability of referral guidelines are not as straightforward as hoped. The survey has shown discordance of responses between some national competent authority and professional society representatives, possibly related to issues of awareness of Guideline existence and the legal requirement for Guidelines. In addition, there are issues of access to national guidelines, which may be related to format or media.

In the European survey [7], respondents in two-thirds of European countries know of the legal requirement for Guidelines nationally, and in these countries two-thirds of these have Guidelines available. Of the one-third of European countries where there is no awareness of a legal requirement, only one-third have Guidelines available. Discussion at the Workshop identified that several countries had work in progress to update or adopt Guidelines, with considerable progress since the survey took place, 4 months previously.

A further, brief, follow-up survey to ascertain the up-to-date status of Guideline availability was planned following the Workshop to enable the current work in progress to be reflected in the final report.

Guideline implementation

Workshop participants agreed that the availability of Guidelines did not equate with their use. As Guidelines cannot encompass all clinical scenarios, adherence can only be expected in up to 90 % of clinical scenarios. Participants at the Workshop reported that even where Guidelines are available, their uptake and use are limited. Reasons for this may include: sub-optimal clinician buy-in, conflicting advice from other (often clinical) guidelines, and the difficulty associated with monitoring and encouraging Guideline use.

Monitoring of Guidelines

Measures for reinforcement of Guidelines were considered essential to provide encouragement for use and to ensure sustained benefit. The European survey identified models, particularly external clinical audit as the preferred means, with a secondary role for local internal audit. Self-regulation [13, 14] by health professionals and inspection had less support.

Guideline development