Challenges to the adopting and adapting of referral

Challenges to the adopting and adapting of referral guidelines, maintenance of guidelines and future directions Denis Remedios Clinical Radiologist, Northwick Park Hospital, UK On behalf of the IAEA

Challenges to guidelines implementation and maintenance • Clinician acceptance “buy-in” and use • Competing guidance • Ease of use • Format and distribution • Tabular /flowchart / narrative • Print / web / app • Resources for development and maintenance • Financial • Manpower • Support / endorsement from regulatory authorities and national ministries • Monitoring for improvement

ACR Appropriateness Criteria https: //acsearch. acr. org/docs/69483/Narrative/

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

Justification and clinician involvement: Issues Overloaded knowledge base Medical and technical advances Competition for inclusion in curricula/CPD Time challenged Fastest with shortest wait best? Mixed messages Different guidance from different sources? Patient expectations Historical or geographical bias Unreliable evidence base from the web

Justification and clinician involvement : challenges Dissemination of Referral Guidelines Widely and freely available to end-users “If they haven’t heard it you haven’t said it” Mc. Luhan Implementation of guidance decision support tools? “We shape our tools and thereafter our tools shape us” Mc. Luhan Uptake need 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” Mc. Luhan Monitoring clinical audit, feedback and education “We drive into the future using only our rearview mirror ” Mc. Luhan

Justification and clinician involvement: possible solutions Education Referral Guidelines Monitor with clinical audit External control Undergraduate and Continuing Professional Development. Requests not orders from a trusted source, in line with clinical guidance, +/- clinical decision support Local internal audit (bottom up) External audit (top down) by payers legislation

Europe: Euro. Safe Imaging Campaign. Collaborative efforts for Radiation Protection

EC Guidelines study: potential barriers to distribution Limitation of resource (human) Limitation of resource (financial) Translation/language barriers Dissemination / distribution barriers Awareness, access and acceptability Limited involvement of referring clinicians in the development process Conflicting Guidelines from multiple sources Lack of support or endorsement by ministries of health 80 70 % 60 70 64 54 50 50 50 39 40 29 30 20 63 61 36 44 39 52 51 47 44 39 29 30 28 22 14 52 48 44 61 17 22 26 25 19 10 0 National Radiology Society National Nuclear Medicine Society Competent Authority (Regulatory/ Advisory Body) Overall 30

EC Guidelines study: Suggested solutions to barriers Clinical decision support systems (for automated, non-mandatory change of clinican-requested modality according to rules based on Guidelines) Provision of Guidelines through electronic requesting systems (computerised order entry) as a future development Education (undergraduate, specialist and continuing professional education) Involvement of referring clinicians Other (please specify below) 100 89 90 80 80 70 72 70 60 % 50 50 66 53 54 48 52 69 73 76 70 64 64 56 66 58 57 40 30 20 10 0 National Radiology Society National Nuclear Medicine Competent Authortiy Society (Regulatory/ Advisory Body) Overall

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

http: //www. nhmrc. gov. au/_files_nhmrc/file/nics/material_resources/Identifying %20 Barriers%20 to%20 Evidence%20 Uptake. pdf

http: //www. nhmrc. gov. au/_files_nhmrc/file/nics/material_resources/Identifying %20 Barriers%20 to%20 Evidence%20 Uptake. pdf

Tips for guideline compliance Guidelines that are acceptable to all specialties will improve compliance and reduce unnecessary paediatric skull radiographs Johnson K, Williams SC, Balogun M, Dhillon MS. Clin Radiol. 2005 Aug; 60(8): 936. Psychological research shows that the more precisely behaviours are specified, the more they are likely to be carried out Specifying what, who, when, where, and how will assist implementation Susan Michie, Marie Johnston. BMJ 2004; 328: 343 -345

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Speed- sub-second “screen flips” Anticipate needs, deliver in real time Fit into users’ workflow Little things make a big difference Recognise physicians resist stopping Changing direction better than stopping Simple interventions work best Ask for additional info only if essential Monitor impact, get feedback, respond Manage & maintain knowledge-based system

Improving clinical practice using clinical decision support (CDS) systems: a systematic review Kensaku Kawamoto et al BMJ 2005; 330: 765 Analysis of 70 randomised controlled trials identified 4 features to improve clinical practice— 1. 2. 3. 4. CDS automatically as part of clinician workflow, CDS at the time & location of decision making, actionable recommendations provided, and computer based An effective system must minimise clinicians’ effort to receive and act on system recommendations http: //www. bmj. com/content/330/7494/765

Rand report, 2104 http: //www. rand. org/content/dam/rand/pubs/research_reports/RR 700/RR 706/RAND_RR 706. pdf

Manitoba Demonstration Project

Clinical decision support for referral guidance Benefits • • • Improvement in appropriateness of requests up to 84% Limited reduction in targeted utilisation Some improvement in uniformity Barriers • • • Incomplete coverage- 19 -35% of scenarios Low uptake- typically 5% No overall effect on utilisation Time consuming to use Gaming to improve rating

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 M 04 http: //www. rcr. ac. uk: 2059/adult/#Tpc 151 http: //www. nice. org. uk/guidance/CG 88/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 The efficacy of diagnostic imaging benefit Fryback and Thornbury Med 5. Patient Decis Making 1991; 11: 88 http: //www. ncbi. nlm. nih. gov/pubmed/1907710 outcome 4. Therapeutic impact 3. Diagnostic impact 2. Diagnostic efficacy 1. Technical efficacy

UK: Appropriate imaging through vetting (authorisation) The radiologist as gatekeeper http: //www. ncbi. nlm. nih. gov/pubmed/25037149 >90% Appropriateness through radiologists’ amendment of 12% CT requests and 9% MRI requests

RCR National audit of appropriate imaging: GP requested CT investigations % retrospectively appropriate (Kind courtesy of Mr Karl Drinkwater, RCR Audit Officer) target

Figure 12 of appropriate imaging: RCR National audit Education & promoting a radiation safety culture • • • RCR Audit of appropriate imaging. Clinical Radiology 2014 69, 1039 -1044 DOI: (10. 1016/j. crad. 2014. 05. 109) Imaging request (for opinion) not order Referrer not prescriber 4 Rs : referrer, radiologist, radiographer, regulator. Corporate responsibility for quality and safety: clinical governance Delegation of task of justification (but not responsibility) from radiologist to radiographer for low dose or protocol driven procedures

Clinical decision support in Europe and the UK: work in progress

RCR imaging referral guidelines: the future 8 th edition in preparation Focus on general practice and emergency care with early involvement of GPs and emergency physicians Individual health assessment and screening addressed in line with Bonn call RCR committed to an accessible version RCR committed to a CDS solution taking into account advice from end users: Patient focus with other guidance within a care pathway Easy access at 1 click or less In work flow preferably through GP information systems In concordance with other guidance (GP has c. 80 guidelines)

Wasteful imaging http: //www. aomrc. org. uk/doc_download/9793 protecting-resources-promoting-value. html

Combining imaging and clinical advice http: //www. aomrc. org. uk/general-news/choosing-wisely. html

Imaging and clinical guidelines: uniformity

Integrating approaches of clinical governance (from Scally G , and Donaldson L J BMJ 1998; 317: 61 -65) Team working: Radiol-radiog Communication with referrers Regulation Awareness Appropriate Imaging Clinical audit Efficiency Education Evidence-based practice

Evidence for referral guidelines Following 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 , Mc. Namee , 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.

EC pan-European dose estimation project: Per-capita effective doses in Europe

Health expenditure as % of GDP (2007) OECD http: //icebergfinanza. com/files/2012/08/health_public_private_total_expenditure_gdp_oecd_4. png

Healthcare rankings: Commonwealth fund 2014 http: //www. commonwealthfund. org/~/media/images/publications/fundreport/2014/june/davis_mirror_2014_es 1_for_web. jpg? h=511&w=740&la=en

Imaging Referral Guidelines and CDS: how to make imaging more appropriate 1. Radiologists as gatekeepers… aided by radiographers. Allow request amending. 2. Referrer acceptance eg integration with clinical practice guidelines 3. Regulator’s support needed. 4. Clinical audit for monitoring, identifying outliers, & feedback… 5. Radiation safety culture… 4 Rs Referrer, radiologist, radiographer & regulator