PERFORMANCE E /HTO Utilization of Diagnostic Services ... · 3 | P a g e P e r f o r m a n c e E x...

1 | P a g e P e r f o r m a n c e E x c e l l e n c e - J u n e 2 0 1 3 V 2

PERFORMANCE EXCELLENCE/HTO

Utilization of Diagnostic Services

Knowledge Transfer Package

INTRODUCTION:

In early 2010, the Medical Advisory Committee (MAC), during budget consultations, identified utilization of diagnostic services (Clinical Laboratory and Diagnostic Imaging) as an area requiring further review. As a result, the CEO requested that the Health Transformation Office develop an ongoing process to review test utilization practices. The current process is outlined in Appendix A. RATIONALE:

Diagnostic Service plays an integral role in the delivery of healthcare services. In fact, nearly 85% of all clinical decisions are based on diagnostic service test data. At least 10% (not including physician payments) of the DHA budget goes to the provision of diagnostic services and the industry has experienced increases second only to the pharmaceutical industry. When discussing diagnostic service utilization, it is recognized that the situation of under utilization and over utilization exists. Studies have shown that nearly 1/3 of testing may be unnecessary and does not improve the quality of care; however, screening tests such as gynecological cytology and mammograms are far below the evidence-based national targets. When discussing behavior change models, interventions typically target predisposing, enabling and reinforcing factors, studies examining diagnostic service utilization have shown that interventions that target multiple factors are more successful than when only one factor is targeted. The CBDHA process targets multiple factors: Pre-disposing Factors: Distribution and review of test ordering guidelines by physicians. Re-enforcing Factors: Identification of the top 50% ordering physicians and comparison with their peers. Reporting the cost of testing to physicians. Appendix B. Distribution of “Do You Need That Scan” to all physicians. Appendix J

The current process is supported by MAC with the guidelines and results reviewed prior to circulation. RESULTS:

Data is available for 26 tests in the intervention (both laboratory and diagnostic imaging). We are seeing between -88.7 & +15.94% change for the 26 tests. This represents a 14.6% reduction in testing representing ~$330,366 in resources annually.


THE PROCESS IS AS FOLLOWS:

TEST IDENTIFICATION:

The HTO has been requested to provide data on one new test per month to MAC for its review. Input from the Directors and Clinical Chiefs of Laboratory Medicine and Diagnostic Imaging is used in the test selection process. Input from other Medical Departments, such as Oncology and Surgery, is also considered. GUIDELINE IDENTIFICATION:

The HTO, with assistance from diagnostic services staff, do research for available guidelines from the literature. Guideline sources are mainly medical laboratory associations, institutes, societies, etc. All guidelines are endorsed by the Clinical Chiefs of diagnostic services. See example ESR Guideline in Appendix C. A list of guidelines used to date are show in Appendix K. DATA ANALYSIS AND REPORTING:

The HTO uses NPR (Non-Procedural Representation) reports in the Meditech System’s Laboratory and Diagnostic Imaging Modules. Reports are written for specific tests and periods of times across all testing sites in the DHA and show information on the ordering physicians, the number of tests ordered and the percentage of the total tests. The NPR Reports are: Lab Services Report: Test Utilization Test Utilization Download ITS Report: Exam Utilization DI Exam Utilization Report (Download) An example of the NPR Report is shown in Appendix D.

Data from the NPR Report is imported into an Excel spreadsheet for graphing and the top 50% of physicians are anonymously reported in another spreadsheet. We now have NPR downloads of these reports so that they can be imported to an Excel spreadsheet quickly and more efficiently. This allows us to automate the analysis of the impact of the interventions on specialists vs. family physicians and changes between communities in the DHA. An example of the initial test analysis is shown in Appendix E.

DATA ANALYSIS AND GUIDELINE DISTRIBUTION:

The initial data analysis and test ordering guideline are sent to MAC for review and acceptance. The data analysis and test ordering guideline, once approved by MAC, is sent to all physicians in the DHA. The top 50% of ordering physicians receive a memo (using a mail merge process) identifying their ordering practices. These memos are copied to the physician’s Chief of Service for information purposes. An example of the memo to the top 50% of physicians is shown in Appendix F. The Microsoft Word Mail

Merge tool is used to complete this process.


3 MONTH POST INTERVENTION DATA ANALYSIS:

Data is analyzed 3 months after the intervention. See attached report in Appendix G. The test ordering at 3, 6, 9 and 12 months is compared to the same period in the year prior to ensure seasonal differences in test ordering are accounted for. 3 MONTH INTERVENTION:

After review of the 3 month intervention analysis by MAC, the report and test ordering guideline are distributed to all physicians. The original top 50% of ordering physicians are notified concerning the ordering practices 3 months post guideline distribution. See memo attached in Appendix H. The Microsoft Word Mail Merge tool is used to complete this process also. DASHBOARD ANALYSIS BY MAC:

Progress at 6, 9 and 12 months, etc, is reported in a dashboard (Appendix I) and reviewed by MAC monthly. Additional analysis and interventions may be required depending on the analysis of this data.

SUMMARY:

The above initiative has been recognized by Accreditation Canada as a Leading Best Practice and has been featured in A Canada-Wide Scan of Diagnostic Services Utilization and Appropriateness, a consult prepared for the Saskatoon Health Region, in March 2011. This process has also been implemented with modifications by other organizations. It is an example of a process that has impacted ordering practices in our district health authority but is not the only initiative that organizations should consider as a part of a comprehensive utilization strategy. QUESTIONS?

If you have any questions or comments about the content of this document, please contact:

Phillip Morehouse, Director of Performance Excellence

CAPE BRETON DISTRICT HEALTH AUTHORITY

Phone: 902-567-7801 Email: [email protected]

Or

Ashley Smith, Administrative Assistant, Performance Excellence

CAPE BRETON DISTRICT HEALTH AUTHORITY

Phone: 902-567-7805 Email: [email protected]

Test Identified in Collaboration with Clinical Chief &

Director

Alternating Lab & DI

MAC Review of Utilization of Diagnostic Services

Guidelines Identified & Approved by Clinical Chief

Data Analysis & Report Written

Data Analysis & Guideline Review by MAC

Guidelines Distributed to all Physicians

Specific Ordering Data to the Top 50% Physicians

Data Analysis at 3, 6, 9, & 12 Months

Data Analysis Review by MAC

Data Reported to all Physicians

Specific Feedback to Top 50% of Physicians

Guidelines Redistributed as Necessary

Appendix A

Cost of Common

Diagnostic Imaging Tests Cost Per Test Test Total Annual Cost

General Radiography $ 47.10 BA Swallow $ 47,241.30 $109.90 BA Enema $ 89,568.50 $ 47.10 GI Series $ 78,468.60 $ 94.20 Small Bowel Follow Thru. $ 24,209.40 $ 21.98 Chest $713,866.44 $ 69.08 Portable Chest $566,456.00 $ 69.08 Lumbar Spine $354,794.88 $ 62.80 Both Hips $141,676.80 $ 50.24 Both Knees $314,954.56

Ultrasound $ 48.40 Abdomen $215,622.00 $ 36.30 Pelvis $ 61,891.50 $ 54.45 Pelvis with Trans.Vag $134,491.50 $ 36.30 Shoulders $ 11,543.40 $ 36.30 Thyroid $ 26,462.70 $ 72.60 OBS 18-20 weeks $ 75,939.60 $ 36.30 OBS Early $ 32,887.80 $ 36.30 OBS Late $ 27,914.70

Nuclear Medicine $180.80 Lumbar Bone Scan $ 84,976.00 $101.70 Whole Body Bone Scan $139,125.60 $162.72 Whole Body Joints Bone Scan $ 32,055.84 $126.56 Extremity Bone Scan $ 94,666.88

CT $ 45.96 Head $202,729.56 $ 43.50 Spine $ 70,818.00 $ 69.16 Chest $151,252.92 $ 90.91 Chest/Abdomen/Pelvis $176,729.04 $ 83.66 Abdomen/Pelvis $332,966.80

MRI $124.50 Brain $ 37,848.00 $120.00 Lumbar Spine $ 55,320.00 $105.00 Joints (Shoulders & Knees) $104,685.00

Appendix B

Cost of Common Laboratory Medicine Tests

Cost Per Test Test Total Annual Cost

$5.80 CBC $ 978,303.40

$0.46 CREAT $ 76,151.16

$1.39 LYTES $ 179,383.67

$1.74 TSH $ 110,919.78

$0.46 GLUCOSE $ 49,103.16

$0.46 PT $ 38,845.62

$0.46 OT $ 39,195.68 $5.80 HGB A1C $ 178,686.40

$0.46 ALK PHOS $ 31,443.76

$4.64 INR $ 297,934.40

$4.64 URINE $ 341,852.00

$1.74 BUN $ 85,301.76 $1.74 FERRITIN $ 46,271.82

$0.46 TOTAL BIL $ 22,849.58 $0.46 TRIG $ 26,981.30

$0.46 CHOL $ 26,968.42 $0.46 HDL $ 26,869.98

$0.46 LDH $ 21,165.98 $1.74 B12 $ 34,415.46 $0.46 ALBUMIN $ 20,321.88

$0.46 CALCIUM $ 15,677.26

$9.28 Specimen Collection $2,918,005.52

CLP 023

REVISED: MARCH 2001

Guideline for the Ordering of Erythrocyte Sedimentation Rate (ESR)

The Ontario Association of Medical Laboratories’ (OAML) guidelines are intended to provide community physicians with information on the appropriate use of Erythrocyte Sedimentation Rate (ESR) tests. The guidelines represent the consensus thinking of a panel of experts in the field. Guidelines are, by their nature, general in focus and cannot apply in every clinical situation. They do not serve as a substitute for sound clinical judgement. These guidelines are appropriate at the time of writing and are applicable in most clinical situations.

1. Background The Erythrocyte Sedimentation Rate (ESR) is a laboratory test which should be ordered in only a few clinical situations. 2. Limitations There is no evidence to support the use of the ESR as a screening test in asymptomatic individuals. The test should not be ordered in this situation. 3. Indications Evaluation of the ESR is accepted as a diagnostic adjunct in Temporal Arteritis and Polymyalgia Rheumatica and may be used to monitor the activity of these conditions. The ESR is a component of some clinical indices of Rheumatoid Arthritis and may be used to follow the activity of this condition or other connective tissue disorders. The ESR may be used to monitor patients with treated Hodgkin’s Disease and to monitor certain infections such as Tuberculosis and Osteomyelitis. 4. Interpretation Slightly elevated ESR results must be interpreted with caution, particularly in patients with negative physical examinations. Extensive diagnostic work-ups are not indicated. A markedly elevated ESR is

often present in patients with significant infectious, inflammatory and malignant disease but, is rarely the sole indicator of the presence of such diseases. 5. Recommendations: It is recommended that the ESR not be used as a screening test in asymptomatic patients. In specific clinical situations, ESR is a relevant test for diagnosis and disease monitoring. Test results must be interpreted with caution. 6. References:

1. Constantino, B.T., Erythrocyte Sedimentation Rate: What Technologists Need to Know, CJMT, Vol. 56, P. 161-169 (1994)

2. Green, C.J., Friesen, K.D., et al. The Erythrocyte Sedimentation Rate – An Examination of the Evidence. B.C. Medical Journal, Vol. 36, No. 2, P. 108-112, February 1994.

3. Saade, H.C., The Erythrocyte Sedimentation Rate, Southern Medical Journal, Vol. 91, No. 3, P. 220-225 (1998)

The Ontario Association of Medical Laboratories The Ontario Association of Medical Laboratories (OAML) represents the community-based laboratory sector in Ontario.

Its mission is to promote excellence in the provision of laboratory services and, as an essential component of the health care system, to contribute to shaping the future of health care in Ontario.

The OAML encourages the highest level of professional and ethical integrity and technical excellence among laboratory owners, operators and staff in the provision of laboratory services for the benefit of the people of Ontario. Guidelines for Clinical Laboratory Practice The OAML, through its Quality Assurance of Clinical Laboratory Practice Committee, co-ordinates the development and dissemination, implementation and evaluation of Guidelines for Clinical Laboratory Practice. This guideline, in its original form, was developed jointly by the Ontario Association of Medical Laboratories and the Ontario Medical Association and was issued in August 1994. A re-formatted issue was distributed in November 1995. The current re-issue has been revised as to content and supersedes the previously issued CLP003. Approved guidelines are distributed to Community-based Laboratories and by them to their client physicians. There may be additional educational materials produced, if it is thought that they might be useful, and these are distributed with the guideline.

The comments of end users are essential to the development of guidelines and will encourage adherence. You are strongly encouraged to submit your comments on this or on any other OAML Guideline to: Chair Quality Assurance of Clinical Laboratory Practice e Committee Ontario Association of Medical Laboratories 5160 Yonge Street, Suite 710 North York, Ontario M2N 6L9 Tel: (416) 250-8555 Fax: (416) 250-8464 E-mail: [email protected] Internet: www.oaml.com

© 2001 OAML CLP023 Issued: March 2001

Print Date [Feb 19, 2000 ] Cape Breton Healthcare Complex Page [ 1]

Print Time [ 10:52 am ] CAPE BRETON REGIONAL

Doctor Doctor Doctor [BOTH ]

---------------------------------------------------------------------------------------------------

Start Date [ Jan 01, 2009 ] 099.0098 - ERYTHROCYTE SEDIMENTATION RATE

End Date [Dec 30, 2009 ]

Running

Order Site Doctor Count Percent Percent

---------------------------------------------------------------------------------------------------

CBR Dr. Yellow 1987 9.58 9.58

CBR Dr. Blue 1175 5.66 15.24

CBN Dr. Red 985 4.75 19.99

CBR Dr. Pink 909 4.38 24.37

CBR Dr. Purple 870 4.19 28.56

CBR Dr. Orange 729 3.51 32.07

CBN Dr. Black 611 2.94 35.01

CBN Dr. White 399 1.92 36.93

CBN Dr. Beige 369 1.78 38.71

CBN Dr. Aqua 338 1.63 40.34

CBR Dr. Teal 324 1.56 41.90

CBW Dr. Green 292 1.40 43.30

CBN Dr. Grey 286 1.37 44.67

CBR Dr. Brown 284 1.37 46.04

CBR Dr. Olive 275 1.32 47.36

CBG Dr. Gold 268 1.29 48.65

CBR Dr. Sliver 265 1.27 49.92

CBN Dr. Lavender 264 1.27 51.19

CBW Dr. Bronze 242 1.16 52.35

CBG Dr. Plum 238 1.14 53.49

CBG Dr. Grey-Blue 225 1.08 54.57

CBG Dr. Navy 217 1.04 55.61

CBN Dr. Taupe 209 1.00 56.61

This report is an EXAMPLE Only and does not contain actual data.

Appendix D

March 12, 2010; Page 1 of 2 HTO

Utilization of Diagnostic Services- DHA

UTILIZATION OF DIAGNOSTIC SERVICES

ESR Analysis Initial Analysis

Reports are available which allow our organization to view ordering patters of physicians ordering laboratory tests.

Modifications have been requested so that the same information can be obtained for Diagnostic Imaging Reports.

This information went to the Medical Advisory Committee [MAC] on March 9, 2010. It was recommended that this

utilization be reviewed for specific tests and reported to the Medical Chiefs and Physicians.

Reports have been run from March 1, 2009 to February 28, 2010.

Physicians in the DHA ordered approximately 24,570 ESR tests. Guidelines for ordering from the Ontario Association

of Medical Laboratories are attached.

ESR ordering by physician is as follows:

No. Physician # % Cumulative %

1. Sydney Specialist 2333 9.5 9.5

2. Sydney Family Medicine 1169 4.8 14.2

3. North Sydney Family Medicine 989 4.0 18.3

4. New Waterford Family Medicine 930 3.8 22.0



7. North Sydney Family Physician 601 2.4 31.1

8. Inverness Family Medicine 555 2.3 33.3




12. Inverness Family Medicine 320 1.3 39.1


14. Cheticamp Family Medicine 299 1.2 41.6

15. New Waterford Family Medicine 294 1.2 42.8


17. Glace Bay Specialist 289 1.2 45.2


19. Glace Bay Family Medicine 286 1.2 47.5

20. Inverness Family Physician 275 1.1 48.6


The next 36 Physicians 74.7%

The next 321 Physicians 100%

Appendix E

March 12, 2010; Page 2 of 2 HTO

Utilization of Diagnostic Services- DHA

Erythrocyte Sedimentation Rate Tests

March 1, 2009 to February 28, 2010

5

3616

321

0

50

100

150

200

250

300

350

25% 25 - 50% 50 - 75% 75 - 100%

Percentage of Total Tests Performed

Nu

mb

er

of

ph

ys

icia

ns

Cost: ESR testing costs approximately $0.40 per test.

This does not include technologist time and specimen disposal costs.

Appendix F

MMEEMMOORRAANNDDUUMM TO: (DR. NAME) FROM: CEO DATE: APRIL 25, 2013 RE: DIAGNOSTIC UTILIZATION REVIEWS- INITIAL ANALYSIS- (INSERT TEST)

At the April MAC Meeting, the ordering pattern of (Test) was reviewed. At that time, your profile for ordering (Test) had been identified as one of the 30 health care professionals who ordered 50.13% of the tests. We recognize that there are many factors that influence utilization, including size and type of practice and patient characteristics; however, research has shown that certain tests may be ordered more frequently than evidence based guidelines recommend.

MAC has identified British Columbia Medical Association- Guidelines and Protocol Advisory Committee, B12 Testing Protocol as a useful guide to ordering these tests. You are being asked to consider this guideline in relation to your patients. This guideline has been mailed to you under separate cover and is also available on the Health Transformation (HTO) Intranet Page. Your results to date for ordering (Test) are as follows:

Date Total Variance % Variance

February 1, 2012 – January 31, 2013 (total) n/a n/a

May – July 2012 TBD n/a n/a

May – July 2013 TBD TBD TBD

This information has been shared with the Chief of Service. If you would like to discuss this information, please contact(Chief of Service). In addition, if you have any ideas to improve utilization or feedback on this process, please contact me at (CEO’s Office) Thank you.

of 2 August 23, 2010

Health Transformation Office

UTILIZATION OF DIAGNOSTIC SERVICES

ESR 3 Month Analysis April –June 2010

INTRODUCTION

In 2009, physicians in the CBDHA ordered approximately 24, 570 ESR tests. Following review by MAC in March, 2010, guidelines for ordering from the Ontario Association of Medical Laboratories were distributed to all physicians in the DHA. The top 50% of ordering physicians (21 physicians) also received information concerning the number of tests they ordered.

ANALYSIS The ordering practices from April- June 2010 were analyzed in comparison with April- June 2009. Physicians in the DHA ordered 2018 fewer tests, a reduction of 32.4% (See Graph 1). The largest reduction was by family physicians (see Graph 2). The reduction in testing by community is also shown (see Graph 3). All communities saw a reduction in testing lead by physicians at the Northside General Hospital at 53.89%. Physicians originally in the top 50% will get a separate report comparing their ordering practices post guideline distribution. This reduction in testing represents a potential cost avoidance of ~$37,000 annually.

(Graphs attached, page 2)

Appendix G

of 2 August 23, 2010

Health Transformation Office

ESR Tests Comparison by Specialists/Family Physicians

0

1000

2000

3000

4000

5000

Nu

mb

er

of T

ests

0%

10%

20%

30%

40%

50%

Perc

en

tag

e C

ha

ng

e

Apr - Jun 2009

# of Tests

1521 4521

Apr - Jun 2010

# of Tests

1385 2679

% Change 8.94% 40.74%

Specialists Family Physicians

Graph 1:

Graph 2:

Graph 3:

Number of ESR Tests Comparison

6224

4206

0

2000

4000

6000

8000

Apr - Jun 2009 Apr - Jun 2010

Apr - Jun 2009

Apr - Jun 2010

ESR Tests Comparison by Community

0

1000

2000

3000

4000

Nu

mb

er

of

Tests

0%

10%

20%

30%

40%

50%

60%

Perc

en

tag

e C

han

ge

Apr - Jun 2009 2940 545 1299 616 448 188 61 127

Apr - Jun 2010 2145 459 599 427 285 142 47 102

% Change 27.04% 15.78% 53.89% 30.68% 36.38%24.47% 22.95% 19.69%

Region

al

Glace

Bay

Northsi

de

New

Waterf

Invern

ess

Victori

a

Neil's

Harbo

Chetic

amp

Appendix H

MMEEMMOORRAANNDDUUMM TO: (DR. NAME) FROM: CEO DATE: JULY 25, 2013 RE: DIAGNOSTIC UTILIZATION REVIEWS- 3 MONTH ANALYSIS/FOLLOW UP MEMO- (INSERT TEST)

At the April MAC Meeting, the ordering pattern of (Test) was reviewed. At that time, your profile for ordering (Test) had been identified as one of the 30 health care professionals who ordered 50.13% of the tests. We recognize that there are many factors that influence utilization, including size and type of practice and patient characteristics; however, research has shown that certain tests may be ordered more frequently than evidence based guidelines recommend.

MAC has identified British Columbia Medical Association- Guidelines and Protocol Advisory Committee, B12 Testing Protocol as a useful guide to ordering these tests. You are being asked to consider this guideline in relation to your patients. This guideline has been mailed to you under separate cover and is also available on the Health Transformation (HTO) Intranet Page. Your results to date for ordering (Test) are as follows:

Date Total Variance % Variance

February 1, 2012 – January 31, 2013 (total) n/a n/a

May – July 2012 (total) n/a n/a

May – July 2013 (total) (variance) (variance %)

This information has been shared with the Chief of Service. If you would like to discuss this information, please contact(Chief of Service). In addition, if you have any ideas to improve utilization or feedback on this process, please contact me at (CEO’s Office) Thank you.

Laboratory Dashboard Example Appendix I

Did You Know? As many as 30% of CT scans and other imaging

procedures are inappropriate or contribute no useful

information.

Whole-body CT scanning is promoted as a “preventative

health measure” by some private clinics. The radiation

exposure is signifi cant – 500 to 1000 times higher than a

routine chest X-ray. This increases the risk of developing

radiation-induced cancer.

SolutionsThe Canadian Association of Radiologists is working

with doctors, patients and manufacturers to improve

CT scan safety and decrease patient risk. We are devel-

oping strict protocols and best practices for scanning.

As a result, scanner manufacturers have developed

machines with lower dosage settings. Radiation tech-

nologists are being trained to ask patients about past

scans. Healthcare authorities are developing shared

record-keeping systems.

Do you need that scan?

Know the Risks and Benefi ts■ Talk to your physician. Ask if a non-radiation

imaging test might be as good. Ask if he or she

has consulted a radiologist.

■ If the scan is medically necessary, don’t hesitate

to accept it. Any risks are outweighed by poten-

tial benefi ts.

Tips for Patients

■ Be your own advocate. Learn about the risks and

benefi ts of diagnostic imaging.

■ Don’t opt for an X-ray or scan “just in case.”

You are taking the place in line of someone

who really does need that test and you may be

exposing yourself to radiation unnecessarily.

Tips for Parents

■ Stay on the safe side. Children are 10 times

more sensitive to radiation received from medi-

cal imaging scans than are adults.

■ Avoid multiple scans and ask for alternative

diagnostic studies (such as ultrasound or MRI).

■ Limit your child’s exposure. Ask that the lowest

radiation dose necessary for imaging be used,

based on the size of the child, and that exposure

be limited to the indicated area.

■ Ask questions. Be sure that the imaging facility

is using reduced radiation techniques. You may

not know unless you ask, and it is reasonable

and within your rights to do so.

Canadian Association of Radiologists

377 Dalhousie Street, Suite 310Ottawa, Ontario K1N 9N8

Tel.: (613) 860-3111 Fax: (613) 860-3112Email: [email protected]

www.car.ca


Copyright 2009 Canadian Association of Radiologists

Handle with CareIncreased use of CT scans for children and pregnant women

is a special concern. Children are more sensitive to radiation

because they are still growing. Even minor damage to their

cells could eventually cause cancer. CT settings must be

reduced to protect children and small adults from over-exposure.

In the last 10 years, radiation imaging of pregnant women has increased by more than 100%. Imaging exposes the devel-

oping baby to gene-altering X-rays. Even though the amount of radiation absorbed is small, this is cause for concern.

What is a CT Scan?CT scans, also known as CAT scans for computerized

axial tomography, are used for diagnosis. The scan

quickly produces detailed X-ray images of the body and

displays them on a screen. CT is a vital tool of modern

medicine; however scans themselves can increase your

risk of developing cancer.

Too Much?Medical tests are the biggest source of radiation expo-

sure outside natural exposure. The use of CT in adults

and children has increased about eight-fold since 1980

and is growing at 10% per year.

The radiation dose from a CT scan is 100 to 500 times

more than from a conventional X-ray. If the scan is

medically necessary, the benefi t outweighs any future

risk. However, this is not always the case.

Sometimes people come to an emergency room and

are given a CT scan without a diagnosis by a physi-

cian or a conference with a radiologist. Sometimes

the scan is done because patients insist on it. Often

medical records are missing details of previous scans

and X-rays.

There is a one in three chance that you don’t.

How Much Radiation?Comparison of exposure for common diagnostic imaging procedures

Procedure Dosage (millisieverts) Equivalent chest X-rays Days of background radiation

Magnetic resonance imaging (MRI) 0 0 0

Ultrasound 0 0 0

X-ray – limbs less than 0.01 mSv less than half 1.6 days

X-ray – chest (single fi lm) 0.02 1 3.3 days

X-ray – lumbar spine 1 50 166 days

X-ray – barium swallow 1.5 75 249 days

CT scan – head 2 100 331 days

One year natural background 2.2 mSv 110 1 year

X-ray – barium enema 7.2 360 3.2 years

CT scan – chest 8 400 3.6 years

CT scan – abdomen or pelvis 10 500 4.5 years

Guidelines Used to Date Appendix K

1

No. Area Test Guideline Reference

LAB TESTS

1 Lab Antinuclear Antibody (ANA) Antinuclear Antibody (ANA) Testing for Connective Tissue Disease

British Columbia Medical Association, Guidelines and Protocols Advisory Committee

2 Lab Blood Urea Nitrogen (BUN) Guidelines for the Use of Serum Tests to Detect Renal Dysfunction

Ontario Association of Medical Laboratories

3 Lab Carcinoembryonic Antigen (CEA)

ASCO 2006 Update of Recommendations for the Use of Tumor Markers in Gastrointestinal Cancer

American Society of Clinical Oncology

4 Lab Erythrocyte Sedimentation Rate (ESR)

Guideline for the Ordering of Erythrocyte Sedimentation Rate (ESR)


5 Lab Folate (Serum) Guideline for Folate Testing Ontario Association of Medical Laboratories

6 Lab Folate (RBC) Guideline for Folate Testing Ontario Association of Medical Laboratories

7 Lab Lipid Profile Guideline for Lipid Testing in Adults Ontario Association of Medical Laboratories

8 Lab Liver Enzymes (ALT) Abnormal Liver Chemistry - Evaluation and Interpretation


9 Lab Prostate Specific Antigen (PSA)

Using the PSA test for early detection of prostate cancer in asymptomatic men

Ontario Ministry of Health and Long Term Care

10 Lab Testosterone Testosterone Testing Protocol British Columbia Medical Association, Guidelines and Protocols Advisory Committee

11 Lab Throat Culture

Acute Pharyngitis in Adults Centre for Disease Control and Prevention

12 Lab Rapid Throat Screen

Acute Pharyngitis in Adults Centre for Disease Control and Prevention

13 Lab Thyroid (Free T4) Thyroid Function Tests: Diagnoses and Monitoring of Thyroid Function Disorders in Adults


14 Lab Urine Culture Indications for Urine Culture Ontario Association of Medical Laboratories

15 Lab Vitamin D 25-hydroxy Guideline for the Appropriate Ordering of Serum Tests for 25-hydroxy Vitamin D and 1,25-dihydroxy Vitamin D


16 Lab Vitamin D 1,25 dihydroxy Guideline for the Appropriate Ordering of Serum Tests for 25-hydroxy Vitamin D and 1,25-dihydroxy Vitamin D


17 Lab Cobalamin (Vitamin B12) Cobalamin (vitamin B12) Deficiency - British Columbia Medical Association, Guidelines and


2

Investigation & Management Protocols Advisory Committee

DI TESTS

1 DI Ultrasound -Abdominal

Practice Guideline for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum

American Institute of Ultrasound in Medicine

2 DI Barium Enema CDHA Guidelines for Ordering Gastrointestinal Fluoroscopy Studies (GI)

Capital District Health Authority

3 DI Barium Swallow CDHA GUIDELINES FOR ORDERING GASTROINTESTINAL (GI) FLUOROSCOPY STUDIES

Capital District Health Authority

4 DI X-Ray- Chest Chest X-Ray as an Imaging Tool American Imaging Management

5 DI CT- Chest Diagnostic Imaging Referral Guidelines A guide for physicians (2005)


6 DI CT- Head Diagnostic Imaging Referral Guidelines A guide for physicians (2005)


7 DI CT-Lumbar spine Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice

American College of Physicians and the American Pain Society

8 DI X-Ray -Lumbar Spine Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice

American College of Physicians and the American Pain Society

9 DI Ultrasound -OBS (Early, 4-12 Weeks)

The Use of First Trimester Ultrasound Society of Obstetricians and Gynaecologists of Canada

10 DI Ultrasound- Pelvis Practice Guideline for the Performance of Pelvic Ultrasound Examinations


11 DI Rib Fracture ACR Appropriateness Criteria- Rib Fractures American College of Radiology

12 DI Ultrasound- Shoulder Diagnostic Imaging Referral Guidelines A guide for physicians (2005)


13 DI Ultrasound- Thyroid

Practice Guideline for the Performance of a Thyroid and Parathyroid Ultrasound Examination



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