Challenges to the adopting and adapting of referral guidelines, maintenance of guidelines and

future directions

Denis RemediosClinical 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

http://rcr.lucidhost.co.uk/login/

ACR Appropriateness Criteriahttps://acsearch.acr.org/docs/69483/Narrative/

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

Justification and clinician involvement: Issues

Overloaded knowledge baseMedical 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

articlestoryarticlestory Europe: EuroSafe Imaging Campaign. Collaborative efforts for Radiation Protection

EC Guidelines study: potential barriers to distribution

National Radiology Society

National Nuclear Medicine Society

Competent Authority (Regulatory/ Advisory

Body)

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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

%

EC Guidelines study: Suggested solutions to barriers

National Radiology So-ciety

National Nuclear Medicine Society

Competent Authortiy (Regulatory/ Advisory

Body)

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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

%

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

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

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

Tips for guideline complianceGuidelines 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. Speed- sub-second “screen flips”2. Anticipate needs, deliver in real time3. Fit into users’ workflow4. Little things make a big difference5. Recognise physicians resist stopping6. Changing direction better than stopping7. Simple interventions work best8. Ask for additional info only if essential9. Monitor impact, get feedback, respond10. Manage & maintain knowledge-based system

Analysis of 70 randomised controlled trials identified 4 features to improve clinical practice—

1. CDS automatically as part of clinician workflow, 2. CDS at the time & location of decision making, 3. actionable recommendations provided, and 4. computer based

An effective system must minimise clinicians’ effort to receive and act on system recommendations

Improving clinical practice using clinical decision support (CDS) systems: a systematic review Kensaku Kawamoto et al BMJ 2005;330:765

http://www.bmj.com/content/330/7494/765

Rand report, 2104 http://www.rand.org/content/dam/rand/pubs/research_reports/RR700/RR706/RAND_RR706.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 M04 http://www.rcr.ac.uk:2059/adult/#Tpc151

http://www.nice.org.uk/guidance/CG88/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 benefit

5. Patient outcome

4. Therapeutic impact

3. Diagnostic impact

2. Diagnostic efficacy

1. Technical efficacy

The efficacy of diagnostic imagingFryback and Thornbury Med

Decis Making 1991;11:88 http://www.ncbi.nlm.nih.gov/pubmed/1907710

>90% Appropriateness through radiologists’ amendment of 12% CT requests and 9% MRI requests

UK: Appropriate imaging through vetting (authorisation) The radiologist as gatekeeper http://www.ncbi.nlm.nih.gov/pubmed/25037149

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

target

articlestoryarticlestoryFigure 12

RCR Audit of appropriate imaging. Clinical Radiology 2014 69, 1039-1044DOI: (10.1016/j.crad.2014.05.109)

RCR National audit of appropriate imaging: Education & promoting a radiation safety

culture• Imaging request (for

opinion) not order• Referrer not prescriber• 4Rs : 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

articlestoryarticlestoryClinical decision support in Europe and the UK:

work in progress

RCR imaging referral guidelines: the future

8th 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 versionRCR committed to a CDS solution taking into account

advice from end users:Patient focus with other guidance within a care pathwayEasy access at 1 click or lessIn work flow preferably through GP information systemsIn concordance with other guidance (GP has c.80

guidelines)

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

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Combining imaging and clinical advice

http://www.aomrc.org.uk/general-news/choosing-wisely.html

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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-radiogCommunication with referrersRegulation

AwarenessAppropriate

ImagingClinical audit

EfficiencyEducationEvidence-basedpractice

Evidence for referral guidelinesFollowing 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 , McNamee , 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) OECDhttp://icebergfinanza.finanza.com/files/2012/08/health_public_private_total_expenditure_gdp_oecd_4.png

Healthcare rankings: Commonwealth fund 2014http://www.commonwealthfund.org/~/media/images/publications/fund-report/2014/june/davis_mirror_2014_es1_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… 4Rs

Referrer, radiologist, radiographer & regulator