Responses were received from representatives of all 30 countries surveyed. Eighty responses were received:
32 from national radiological societies (some countries had more than one national society)
20 from national nuclear medicine societies
28 from national competent authorities
Regarding the radiological societies, multiple responses were received from The Netherlands (two) and Romania (three). No response was received from Cyprus.
Regarding the national nuclear medicine societies, three responses were received from The Netherlands. No response was received from Bulgaria, Estonia, Finland, France, Ireland, Lithuania, Luxembourg, Norway, Poland, Portugal, Slovakia or Slovenia.
Regarding the national competent authorities, two responses were received from Spain, but none from Italy, Hungary and Latvia.
In the analysis, all the responses received were taken into account using the majority response (rounding up) for those countries with multiple responses.
Availability of imaging referral guidelines in European countries
Sixty-one percent of responders said that there was a legal requirement for Guidelines including radiation dose. Five responders were uncertain as to the existence of such legislation. It was confirmed at a later date that all EU member states had such a requirement.
Most respondents report that the responsibility for making Guidelines available has been transferred to ministries of health. There was some discordance between national societies and competent authorities’ responses to the question about the transfer of responsibility for making Guidelines available.
The majority of respondents (76 %) did not think that Guidelines must exist in order for insurance companies in their country to pay for an imaging investigation. Respondents indicated that most imaging requests are made by medical practitioners. Respondents report that general practitioners make more requests for plain radiographs, contrast radiography, and ultrasound (US), and fewer for computed tomography (CT), magnetic resonance imaging (MRI), interventional radiology and nuclear medicine examinations compared with hospital specialists.
Respondents indicated that the most common modality for which a patient could self-present was US, followed by plain radiography and MRI.
Twenty radiology societies, 12 nuclear medicine societies and eight competent authorities responded that there were nationally recognised imaging referral guidelines including radiation dose available.
Analysis by country showed that representatives in 70 % of European countries were aware of the legal requirement for guidelines and respondents in 60 % of countries were aware of the presence of referral guidelines [2, 4–24] (see Table 1).
Only 12 of the 20 radiological societies and 9 of the 12 nuclear medicine societies which have nationally recognised imaging referral guidelines including radiation dose answered the subsequent questions concerning specifically the content of these Guidelines. The replies for this section on guideline methodology may not be fully representative of the 30 European countries as only 23 responses from 17 countries were received out of 52 professional society representatives (and a total of 80 respondents including competent authority representatives).
Preference for source of Guidelines to be used in Europe
The great majority of states have recommended European or national Guidelines (see Fig. 1).
Where “other” was chosen as the question response, the specified other options for the preference of the source of Guidelines included:
“The professional societies are responsible for drawing up the referral guidelines.”
“Our government would most probably accept competent international guidelines and the Croatian Society of Radiology is currently trying to introduce Royal College of Radiologists’ guidelines in our clinical practice modified according to our situation.”
“Current regulation does not [recommend any guidelines] but new draft regulation and guidelines recommend European Guidelines.”
“European guidelines are to be recommended in new legislation.”
“If National guidelines are not available then European ones are implemented.”
“American guidelines (US).”
Development of Guidelines
Guidelines were reported (by respondents from just 14 countries) to be developed nationally in half of the countries and modified or adopted with modifications from another source in the others (see Fig. 2).
There was a good concordance between radiology and nuclear medicine societies for two countries (France and UK), which provided radiological and nuclear medicine guidance within the same publication.
The year of the first edition of the Guidelines varied from 1989 to 2005 for radiological societies and from 1998 to 2011 for nuclear medicine societies. The approximate duration of the review cycle has varied between countries from 3-4 years to >6 years.
In the majority of countries (67 % for radiology and 90 % for nuclear medicine), the source of funding for the development of the Guidelines was the Ministry of Health or other governmental department.
Imaging modalities included in Guidelines
The imaging modalities involving ionising radiation (radiography and nuclear medicine) were included in the great majority of Guidelines (83-92 %), whereas the non-ionising radiology modalities (US, MRI) were present in only 75 % of Guidelines.
Guidance for children and for pregnant women
The majority of National Guidelines include separate guidance for children (67 % for radiology and 80 % for nuclear medicine) and pregnant women (83 % for radiology and 78 % for nuclear medicine).
Focus of Guidelines on clinical presentations or indications for procedures
Most radiological Guidelines focus on clinical presentations, whereas most nuclear medicine guidelines focus on indications for procedures. Most of the radiological societies’ Guidelines and the nuclear medicine societies’ Guidelines cover multiple groups of diseases and medical conditions for adults, including: breast, cancer, cardiovascular, chest, gastrointestinal, neurological, trauma and urogenital. Guidelines for children cover fewer clinical conditions.
The radiological societies’ Guidelines included between 200 to 500 clinical conditions or diagnostic problems, and the nuclear medicine societies’ Guidelines between 16 and 300.
Use of evidence levels and recommendations
Very few Guidelines have included recognised evidence levels (six radiology, three nuclear medicine) and grading recommendation using a recognised system (four radiology, one nuclear medicine).
Radiation dose, strength of evidence and grading of recommendations were considered in most Guidelines. Cost effectiveness and availability of equipment or expertise were far less frequently taken into consideration.
Two radiological societies graded their recommendations (France and UK). Both used the grades of recommendation as defined by The Oxford Centre for Evidence-Based Medicine—Evidence levels and grades of recommendations, 2009 . In the French Society of Radiology Guidelines there were 62 grade A recommendations, 618 grade B recommendations and 209 grade C recommendations. In the RCR Guidelines from the UK there were 74 grade A recommendations, 633 grade B recommendations and 166 grade C recommendations.
Use of a recognised process of consensus
Delphi process was used in three radiological societies’ Guidelines (Finland, France, UK). Expert meeting for consensus was used by four radiological societies and five nuclear medicine societies.
Use of recognised sources for radiation dose and costs
Radiation dose was obtained from recognised sources in eight radiological and nine nuclear medicine societies.
Format of Guidelines
Regarding the format and dissemination of the National Guidelines (Fig. 3), almost all Guidelines are available in a downloadable digital version. The great majority of Guidelines are available in a web version. Very few have a tablet or smart phone version.
Distribution of Guidelines
The majority of Guidelines are routinely circulated to providers of the service, general practitioners, emergency department clinicians and specialists/hospital doctors. Only a few of these Guidelines are routinely circulated to non-healthcare professionals, medical students, funders and the public.
Reinforcement of Guidelines
Reinforcement of Guidelines is advocated through periodical reminders in half and through educational message by most of the radiological societies.
Guidelines are also used for education and academic research.
Wishes for the use of Guidelines in Europe
For the remaining items in the survey, respondents were asked to rate agreement on a seven-point balanced Likert scale regarding preferences for European Guideline development, format, media, barriers and their solutions, and methods for monitoring. There were 28 responses from radiology societies, 18 from nuclear medicine societies and 27 from competent authorities. All responses were taken into account. Positive responses rated 5-7 on a seven-point scale were taken as agreement and consensus considered strong where there was agreement by at least 75 % of respondents.
European preferences for Guidelines
Eighty-two percent of radiology societies and 78 % of competent authorities support European Guidelines developed by a combination of multiple national Guidelines agreed by consensus. This is also supported to a lesser extent by nuclear medicine societies (61 %). Seventy-five percent of radiology societies support Pan-European Guidelines developed centrally (see Fig. 4).
Most societies and competent authorities support tabular and flowchart format for the Guidelines (see Fig. 5).
Media and mode for distribution
Most societies and competent authorities support an open web version for distribution mode. Seventy-five percent of radiology societies support provision of Guidelines through electronic requesting systems as a future development (see Fig. 6).
Potential barriers/challenges to the effective distribution of Guidelines
Resource limitation, limited awareness and limited clinician involvement are common barriers to the effective distribution of Guidelines (see Fig. 7).
Suggestions of solutions to barriers limiting the availability of Guideline use
Education and involvement of referring clinicians are mostly proposed by competent authorities as potential solutions to overcome the barriers limiting the availability of Guidelines (see Fig. 8).
Preferred methods for monitoring Guideline use
All respondents and particularly competent authorities strongly support local internal and external clinical audits to monitor Guideline use (see Fig. 9).