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Evidence-based radiology: why and how?

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Abstract

Purpose

To provide an overview of evidence-based medicine (EBM) in relation to radiology and to define a policy for adoption of this principle in the European radiological community.

Results

Starting from Sackett’s definition of EBM we illustrate the top-down and bottom-up approaches to EBM as well as EBM’s limitations. Delayed diffusion and peculiar features of evidence-based radiology (EBR) are defined with emphasis on the need to shift from the demonstration of the increasing ability to see more and better, to the demonstration of a significant change in treatment planning or, at best, of a significant gain in patient outcome. The “as low as reasonably achievable” (ALARA) principle is thought as a dimension of EBR while EBR is proposed as part of the core curriculum of radiology residency. Moreover, we describe the process of health technology assessment in radiology with reference to the six-level scale of hierarchy of studies on diagnostic tests, the main sources of bias in studies on diagnostic performance, and levels of evidence and degrees of recommendations according to the Centre for Evidence-Based Medicine (Oxford, UK) as well as the approach proposed by the GRADE working group. Problems and opportunities offered by evidence-based guidelines in radiology are considered. Finally, we suggest nine points to be actioned by the ESR in order to promote EBR.

Conclusion

Radiology will benefit greatly from the improvement in practice that will result from adopting this more rigorous approach to all aspects of our work.

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References

  1. Malone DE (2007) Evidence-based practice in radiology: an introduction to the series. Radiology 242:12–14

    Article  PubMed  Google Scholar 

  2. Evidence-Based Radiology Working Group (2001) Evidence-based radiology: a new approach to the practice of radiology. Radiology 220:566–575

    Article  Google Scholar 

  3. Greenhalgh T (2006) How to read a paper. The basics of evidence-based medicine, 3rd edn. Blackwell, Oxford, pp ix–xii

    Google Scholar 

  4. Greenhalgh T (2006) How to read a paper. The basics of evidence-based medicine, 3rd edn. Blackwell, Oxford, pp 1–3

    Google Scholar 

  5. Centre for Evidence-Based Medicine (2008) http://cebm.net. Accessed 24 Feb 2008

  6. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312:71–72

    CAS  PubMed  Google Scholar 

  7. Hunink MGM, Glasziou PP, Siegel JE, Weeks JC, Pliskin JS, Elstein AS, Weinstein MC (2001) Decision making in health and medicine: integrating evidence and values. Cambridge University Press, Cambridge, UK

    Google Scholar 

  8. Malone DE, Staunton M (2007) Evidence-based practice in radiology: step 5 (evaluate)—caveats and common questions. Radiology 243:319–328

    Article  PubMed  Google Scholar 

  9. Dodd JD (2007) Evidence-based practice in radiology: steps 3 and 4—appraise and apply diagnostic radiology literature. Radiology 242:342–354

    Article  PubMed  Google Scholar 

  10. van Beek EJ, Malone DE (2007) Evidence-based practice in radiology education: why and how should we teach it? Radiology 243:633–640

    Article  PubMed  Google Scholar 

  11. Hollingworth W, Jarvik JG (2007) Technology assessment in radiology: putting the evidence in evidence-based radiology. Radiology 244:31–38

    Article  PubMed  Google Scholar 

  12. Trinder L (2000) A critical appraisal of evidence-based practice. In: Trinder L, Reynolds S (eds) Evidence-based practice: a critical appraisal. Blackwell Science, Oxford, pp 212–214

    Google Scholar 

  13. Tonelli MR (1998) The philosophical limits of evidence-based medicine. Acad Med 73:1234–1240

    Article  CAS  PubMed  Google Scholar 

  14. Raymond J, Trop I (2007) The practice of ethics in the era of evidence-based radiology. Radiology 244:643–649

    Article  PubMed  Google Scholar 

  15. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J (1999) Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 318:527–530

    CAS  PubMed  Google Scholar 

  16. Acheson L, Mitchell L (1993) The routine antenatal diagnostic imaging with ultrasound study. The challenge to practice evidence-based obstetrics. Arch Fam Med 2:1229–1231

    Article  CAS  PubMed  Google Scholar 

  17. No authors listed (1997) Routine ultrasound imaging in pregnancy: how evidence-based are the guidelines? Int J Technol Assess Health Care 13:475–477

    Google Scholar 

  18. No authors listed (1997) Reports from the British Columbia Office of Health Technology Assessment (BCOHTA). Routine ultrasound imaging in pregnancy: how evidence-based are the guidelines? Int J Technol Assess Health Care 13:633–637

    Google Scholar 

  19. Dixon AK (1997) Evidence-based diagnostic radiology. Lancet 350:509–512

    Article  CAS  PubMed  Google Scholar 

  20. Mukerjee A (1999) Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Magnetic resonance imaging in acute knee haemarthrosis. J Accid Emerg Med 16:216–217

    CAS  PubMed  Google Scholar 

  21. Liedberg J, Panmekiate S, Petersson A, Rohlin M (1996) Evidence-based evaluation of three imaging methods for the temporomandibular disc. Dentomaxillofac Radiol 25:234–241

    CAS  PubMed  Google Scholar 

  22. Taïeb S, Vennin P (2001) Evidence-based medicine: towards evidence-based radiology. J Radiol 82:887–890

    PubMed  Google Scholar 

  23. Arrivé L, Tubiana JM (2002) “Evidence-based” radiology. J Radiol 83:661

    PubMed  Google Scholar 

  24. Bui AA, Taira RK, Dionisio JD et al (2002) Evidence-based radiology: requirements for electronic access. Acad Radiol 9:662–669

    Article  PubMed  Google Scholar 

  25. Guillerman RP, Brody AS, Kraus SJ (2002) Evidence-based guidelines for pediatric imaging: the example of the child with possible appendicitis. Pediatr Ann 31:629–640

    PubMed  Google Scholar 

  26. Kainberger F, Czembirek H, Frühwald F, Pokieser P, Imhof H (2002) Guidelines and algorithms: strategies for standardization of referral criteria in diagnostic radiology. Eur Radiol 12:673–679

    PubMed  Google Scholar 

  27. Bennett JD (2003) Evidence-based radiology problems. Covered stent treatment of an axillary artery pseudoaneurysm: June 2003–June 2004. Can Assoc Radiol J 54:140–143

    PubMed  Google Scholar 

  28. Blackmore CC (2003) Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clin N Am 13:283–291

    Article  PubMed  Google Scholar 

  29. Cohen WA, Giauque AP, Hallam DK, Linnau KF, Mann FA (2003) Evidence-based approach to use of MR imaging in acute spinal trauma. Eur J Radiol 48:49–60

    Article  PubMed  Google Scholar 

  30. Goergen SK, Fong C, Dalziel K, Fennessy G (2003) Development of an evidence-based guideline for imaging in cervical spine trauma. Australas Radiol 47:240–246

    Article  PubMed  Google Scholar 

  31. Medina LS, Aguirre E, Zurakowski D (2003) Introduction to evidence-based imaging. Neuroimaging Clin N Am 13:157–165

    Article  PubMed  Google Scholar 

  32. Blackmore CC (2004) Critically assessing the radiology literature. Acad Radiol 11:134–140

    Article  PubMed  Google Scholar 

  33. Dodd JD, MacEneaney PM, Malone DE (2004) Evidence-based radiology: how to quickly assess the validity and strength of publications in the diagnostic radiology literature. Eur Radiol 14:915–922

    Article  PubMed  Google Scholar 

  34. Erden A (2004) Evidence based radiology. Tani Girisim Radyol 10:89–91

    PubMed  Google Scholar 

  35. Gilbert FJ, Grant AM, Gillan MGC (2004) Low back pain: influence of early MR imaging or CT on treatment and outcome—multicenter randomized trial. Radiology 231:343–351

    Article  PubMed  Google Scholar 

  36. Matowe L, Gilbert FJ (2004) How to synthesize evidence for imaging guidelines. Clin Radiol 59:63–68

    Article  CAS  PubMed  Google Scholar 

  37. Giovagnoni A, Ottaviani L, Mensà A et al (2005) Evidence based medicine (EBM) and evidence based radiology (EBR) in the follow-up of the patients after surgery for lung and colon-rectal carcinoma. Radiol Med 109:345–357

    PubMed  Google Scholar 

  38. Medina LS, Blackmore CC (2006) Evidence-based imaging, 1st edn. Springer, New York

    Google Scholar 

  39. Medina LS, Blackmore CC (2007) Evidence-based radiology: review and dissemination. Radiology 244:331–336

    Article  PubMed  Google Scholar 

  40. Royal College of Radiologists Working Party (1998) Making the best use of a department of clinical radiology: guidelines for doctors, 4th edn. The Royal College of Radiologists, London

    Google Scholar 

  41. No authors listed (2004) Proceedings of the second ALARA conference. February 28, 2004. Houston, Texas, USA. Pediatr Radiol 34(Suppl 3):S162–S246

    Google Scholar 

  42. Prasad KN, Cole WC, Haase GM (2004) Radiation protection in humans: extending the concept of as low as reasonably achievable (ALARA) from dose to biological damage. Br J Radiol 77:97–99

    Article  CAS  PubMed  Google Scholar 

  43. Semelka RC, Armao DM, Elias J Jr, Huda W (2007) Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging 25:900–909

    Article  PubMed  Google Scholar 

  44. Council of the European Union (1997) Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation with medical exposure, and repealing Directive 84/466/Euratom. J Eur Commun L 180:22–27 (http://europa.eu.int/eurlex/en/dat/1997/en_397L0043.htlm)

    Google Scholar 

  45. Barr HJ, Ohlhaber T, Finder C (2006) Focusing in on dose reduction: the FDA perspective. AJR Am J Roentgenol 186:1716–1717

    Article  PubMed  Google Scholar 

  46. FDA Radiological Health Program (2008) Available via: http://www.fda.gov/cdrh/radhealth/index.html. Accessed 24 Feb 2008

  47. White SJ, Ashby D, Brown PJ (2000) An introduction to statistical methods for health technology assessment. Health Technol Assess 4(i–iv):1–59

    Google Scholar 

  48. Hillman BJ, Gatsonis CA (2008) When is the right time to conduct a clinical trial of a diagnostic imaging technology? Radiology 248:12–15

    Article  PubMed  Google Scholar 

  49. Fineberg HV, Bauman R, Sosman M (1977) Computerized cranial tomography. Effect on diagnostic and therapeutic plans. JAMA 238:224–227

    Article  CAS  PubMed  Google Scholar 

  50. Fryback DG, Thornbury JR (1991) The efficacy of diagnostic imaging. Med Decis Making 11:88–94

    Article  CAS  PubMed  Google Scholar 

  51. Thornbury JR (1994) Clinical efficacy of diagnostic imaging: love it or leave it. AJR Am J Roentgenol 162:1–8

    CAS  PubMed  Google Scholar 

  52. Mackenzie R, Dixon AK (1995) Measuring the effects of imaging: an evaluative framework. Clin Radiol 50:513–518

    Article  CAS  PubMed  Google Scholar 

  53. Thornbury JR (1999) Intermediate outcomes: diagnostic and therapeutic impact. Acad Radiol 6(suppl 1):S58–S65

    Article  PubMed  Google Scholar 

  54. Sunshine JH, Applegate KE (2004) Technology assessment for radiologists. Radiology 230:309–314

    Article  PubMed  Google Scholar 

  55. Brealey SD, DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team (2007) Influence of magnetic resonance of the knee on GPs’ decisions: a randomised trial. Br J Gen Pract 57:622–629

    PubMed  Google Scholar 

  56. Oei EH, Nikken JJ, Ginai AZ, From the Program for the Assessment of Radiological Technology (ART Program) et al (2009) Costs and effectiveness of a brief MRI examination of patients with acute knee injury. Eur Radiol 19(2):409–418

    Article  PubMed  Google Scholar 

  57. Ouwendijk R, de Vries M, Stijnen T, from the Program for the Assessment of Radiological Technology et al (2008) Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial. AJR Am J Roentgenol 190:1349–1357

    Article  PubMed  Google Scholar 

  58. Kuhl CK, Träber F, Schild HH (2008) Whole-body high-field-strength (3.0-T) MR imaging in clinical practice. Part I. Technical considerations and clinical applications. Radiology 246:675–696

    Article  PubMed  Google Scholar 

  59. Jordan HS, Bert RB, Chew P, Kupelnick B, Lau J (2003) Magnetic resonance spectroscopy for brain tumors. Agency for Healthcare Research and Quality, Rockville, p 109

    Google Scholar 

  60. Möller-Hartmann W, Herminghaus S, Krings T et al (2002) Clinical application of proton magnetic resonance spectroscopy in the diagnosis of intracranial mass lesions. Neuroradiology 44:371–381

    Article  PubMed  Google Scholar 

  61. Soares HP, Kumar A, Daniels S et al (2005) Evaluation of new treatments in radiation oncology: are they better than standard treatments? JAMA 293:970–978

    Article  CAS  PubMed  Google Scholar 

  62. Hunink MG, Krestin GP (2002) Study design for concurrent development, assessment, and implementation of new diagnostic imaging technology. Radiology 222:604–614

    Article  PubMed  Google Scholar 

  63. Jarvik JG (2002) Study design for the new millennium: changing how we perform research and practice medicine. Radiology 222:593–594

    Article  PubMed  Google Scholar 

  64. Launois R (2003) Economic assessment, a field between clinical research and observational studies. Bull Cancer 90:97–104

    PubMed  Google Scholar 

  65. Plevritis SK (2005) Decision analysis and simulation modeling for evaluating diagnostic tests on the basis of patient outcomes. AJR Am J Roentgenol 185:581–590

    PubMed  Google Scholar 

  66. Otero HJ, Rybicki FJ, Greenberg D, Neumann PJ (2008) Twenty years of cost-effectiveness analysis in medical imaging: are we improving? Radiology 249:917–925

    Article  PubMed  Google Scholar 

  67. Hunink MG (2008) Cost-effectiveness analysis: some clarifications. Radiology 249:753–755

    Article  PubMed  Google Scholar 

  68. Sardanelli F, Di Leo G (2008) Biostatistics for radiologists. Springer, Milan, pp 165–179

    Google Scholar 

  69. Kelly S, Berry E, Roderick P et al (1997) The identification of bias in studies of the diagnostic performance of imaging modalities. Br J Radiol 70:1028–1035

    CAS  PubMed  Google Scholar 

  70. Sica GT (2006) Bias in research studies. Radiology 238:780–789

    Article  PubMed  Google Scholar 

  71. Reid MC, Lachs MS, Feinstein AR (1995) Use of methodological standards in diagnostic test research. Getting better but still not good. JAMA 274:645–651

    Article  CAS  PubMed  Google Scholar 

  72. Bossuyt PM, Reitsma JB, Bruns DE et al (2003) Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Radiology 226:24–28

    Article  PubMed  Google Scholar 

  73. Smidt N, Rutjes AW, van der Windt DA et al (2005) Quality of reporting of diagnostic accuracy studies. Radiology 235:347–353

    Article  PubMed  Google Scholar 

  74. Wilczynski NL (2008) Quality of reporting of diagnostic accuracy studies: no change since STARD statement publication—before-and-after study. Radiology 248:817–823

    Article  PubMed  Google Scholar 

  75. Moher D, Schulz KF, Altman DG (2001) The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 357:1191–1194

    Article  CAS  PubMed  Google Scholar 

  76. Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P, CONSORT Group (2008) Methods and processes of the CONSORT Group: example of an extension for trials assessing nonpharmacologic treatments. Ann Intern Med 148:W60–W66

    PubMed  Google Scholar 

  77. Moher D, Cook DJ, Eastwood S et al (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses. Lancet 354:1896–1900

    Article  CAS  PubMed  Google Scholar 

  78. Atkins D, Best D, Briss PA, for the GRADE working group et al (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490 (http://www.bmj.com/cgi/content/full/328/7454/1490)

    Article  PubMed  Google Scholar 

  79. Schünemann HJ, Oxman AD, Brozek J, for the GRADE Working Group et al (2008) Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 336:1106–1110

    Article  PubMed  Google Scholar 

  80. Field MJ, Lohr KN, eds (1992) Guidelines for clinical practice: from development to use. National Academy, Washington DC

  81. Lohr KN (1992) Reasonable expectations: from the Institute of Medicine. Interview by Paul M Schyve. QRB Qual Rev Bull 18:393–396

    CAS  PubMed  Google Scholar 

  82. Hurwitz B (1999) Legal and political considerations of clinical practice guidelines. BMJ 318:661–664

    CAS  PubMed  Google Scholar 

  83. Shekelle PG, Woolf SH, Eccles M, Grimshaw J (1999) Clinical guidelines: developing guidelines. BMJ 318:593–596

    CAS  PubMed  Google Scholar 

  84. Schmidt HG, van der Arend A, Moust JH, Kokx I, Boon L (1993) Influence of tutors’ subject-matter expertise on student effort and achievement in problem-based learning. Acad Med 68:784–791

    Article  CAS  PubMed  Google Scholar 

  85. Royal College of Radiologists (2007) Making the best use of clinical radiology services (MBUR), 6th edn. http://www.rcr.ac.uk/content.aspx?PageID=995. Accessed 21 June 2009

  86. American College of Radiologists (2009) Guidelines available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx. Accessed 21 June 2009

  87. Canadian Association of Radiologists (2009) Guidelines available at: http://www.car.ca/content.aspx?pg=Guidelines&spg=home&lang=E&lID=. Accessed 21 June 2009

  88. European Society of Radiology (2009) Guidelines available at: http://www.myesr.org/cms/website.php?id=%2Fen%2Fsearchresults.htm&cx=014135113606645554273%3Aigwz0kdufju&cof=FORID%3A11&sa=Search&q=guidelines#1545. Accessed 21 June 2009

  89. Cabana MD, Rand CS, Powe NR et al (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465

    Article  CAS  PubMed  Google Scholar 

  90. Tigges S, Sutherland D, Manaster BJ (2000) Do radiologists use the American College of Radiology musculoskeletal appropriateness criteria? AJR Am J Roentgenol 175:545–547

    CAS  PubMed  Google Scholar 

  91. The European Network for the Assessment of Imaging in Medicine (EuroAIM) (2009) http://www.eibir.org/cms/website.php?id=/de/index/newfilename/newfilename.htm. Accessed 21 June 2009

  92. Appraisal of Guidelines Research and Evaluation (AGREE) http://www.agreecollaboration.org/instrument/. Accessed 21 June 2009

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Acknowledgement

We sincerely thank Professor Yves Menu (Department of Radiology, Saint Antoine Hospital, Paris) for his suggestions regarding the subsection “EBR at the ECR”.

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Authors and Affiliations

  1. Dipartimento di Scienze Medico-Chirurgiche, Unità di Radiologia, IRCCS Policlinico San Donato, Università degli Studi di Milano, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy

    Francesco Sardanelli & Giovanni Di Leo

  2. Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands

    Myriam G. Hunink & Gabriel P. Krestin

  3. Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands

    Myriam G. Hunink

  4. Program for Health Decision Science, Harvard School of Public Health, Boston, MA, USA

    Myriam G. Hunink

  5. Aberdeen Biomedical Imaging Centre, University of Aberdeen, Aberdeen, AB25 2ZD, UK

    Fiona J. Gilbert

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  1. Francesco Sardanelli
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  2. Myriam G. Hunink
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  3. Fiona J. Gilbert
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  4. Giovanni Di Leo
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  5. Gabriel P. Krestin
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Correspondence to Francesco Sardanelli.

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Sardanelli, F., Hunink, M.G., Gilbert, F.J. et al. Evidence-based radiology: why and how?. Eur Radiol 20, 1–15 (2010). https://doi.org/10.1007/s00330-009-1574-4

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