Justification principle & Family Doctors

Ernesto Mola (MD) World Organization of National Colleges,

Academies and Academic Associations

of General Practitioners/Family Physicians

(WONCA)

Wien 10° March 2016

HERCA - Justification and

optimisation in the medical field1

Objectives

Starting from the content of Euratom BSS 2013

• To describe the responsibilities of Family Doctors (FDs)concerning Justification, as implied in the characteristics ofGeneral Practice

• To define the role of FDs in the strategic approach to appropriateness and radiation risks prevention

• To illustrate the commitments of WONCA aimed to increaseradiation protection culture among doctors and patients

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World Organization of Family Doctors

“The Mission of WONCA is to improve the quality of life of the peoples of the world through defining and promoting its values, including respect for universal human rights and including gender equity, and by fostering high standards of care in general practice/family medicine”

118 Member Organizations In 131 countries 500,000 family doctors 90 per cent of the world’s population.

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Euratom BSS: definition of Justification

“Medical exposure shall show a sufficient net benefit, weighingthe total potential diagnostic or therapeutic benefits itproduces, including the direct benefits to health of anindividual and the benefits to society, against the individualdetriment that the exposure might cause, taking into accountthe efficacy, benefits and risks of available alternativetechniques having the same objective but involving no or lessexposure to ionising radiation.”

“Member states shall ensure that:

all individual medical exposures are justified inadvance”

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European BSS

Article 57

Responsibilities

….

(c) the referrer and the practitioner are involved, as specified

by Member States, in the justification process of individual

medical exposures;

(d) wherever practicable and prior to the exposure taking

place, the practitioner or the referrer, as specified by

Member States, ensures that the patient or their

representative is provided with adequate information relating

to the benefits and risks associated with the radiation dose

from the medical exposure. ....5

European BSS

Article 58

Procedures

Member States shall ensure that:

(a) written protocols for every type of standard medical

radiological procedure are established for each

equipment for relevant categories of patients;

(b) information relating to patient exposure forms part of the

report of the medical radiological procedure;

(c) referral guidelines for medical imaging, taking into

account the radiation doses, are available to the

referrers;....6

European BSS: Justification

• Relies on professional evaluation of comprehensive patientinformation, including previous relevant clinical, imaging,laboratory, and treatment data. The final decision usuallyrequires a clinical assessment and a physical examination,taking into account patient expectations and the psycho-socialcontext

• Provides for a cooperation between referrers and practitioner

• Takes into account the benefits to the community

• Should be based on referral guidelines available to the referrerswhich should support the decision for individual patient, byproviding generic evidence-based criteria.

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What the referrer should

answer

Main causes of unnecessary use of radiology

Has it been done already?Repeating investigations that have been already

done

Do I need it?Undertaking investigations when results are

unlikely to affect patient management

Do I need it now?Investigating too early

Is this the best investigation?Doing the wrong investigation

Have I explained the

problem?

Failing to provide appropriate clinical

information and questions that the imaging

investigation should answer

Are they all needed?

From Maria Perez del Rosario – WHO

Over-investigating

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A x-ray examination process

Patient witha Healthproblem Family doctor

SpecialistX-ray

referral

Practitioner

Physicist

Radiographer

X-ray examination

X-rayreferral

J U S T I F I C A T I O N

O

P

T

I

M

I

Z

A

T

I

O

N9

Characteristics of General Practice

General Practice:• is normally the first point of medical contact..• makes efficient use of health care resources

through coordinating care ….• develops a person-centred approach…..• has a specific decision making process determined by the prevalence and incidence of illness in the community• manages comprehensive care….

World Organization of National Colleges, Academies and Academic Associations

of General Practitioners/Family Physicians

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FDs play an advocacy role "protecting patients from the harm which may ensue through unnecessary screening, testing, and treatment"and have a specific responsibility for the health of the community.

Besides, in many countries, FDs are the gate keepers of the National Health Service, and request most clinical tests for outpatients.

Characteristics of General Practice

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Appropriate Use of Radiation in Medical Imaging

Gate keeper

Bo

oki

ng

Reg

istr

atio

n

Pre

par

atio

n

Exam

inat

ion

Rep

ort

Tran

scri

pti

on

Val

idat

ion

Del

iver

y

QA / Error reduction

Justification Optimization

Patient journey

(adapted from Dr. L. Lau IRQN)

Family doctors can contribute

to both … How?12

How GPs can contribute to both?

• Communication between the family doctor and the imaging specialist affords opportunities for more rational use of imaging (justification)

• Communicating in the request, the clinical question that the imaging procedure is expected to answer, allows the imaging specialists to tailor the protocol and reduce doses to the level of acceptable noise for the given clinical condition (optimization)

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FDs and the strategic approach

Risk assessment

Risk communication

Risk management

Assessing risks and potential impacts

Implementing policies, health interventions

Engaging and communicating with stakeholders

Risk sharingInvolving patients in decision-making process

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What GPs can do

Risk management

• sharing international and local guidelines with specialists, radioligists and health authorities

• communicating with the specialists (cardiologist, orthopaedist, etc.) and the imaging professionals (practitioner, nuclear medicine physician) for a more rational use of imaging

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What GPs can do

Risk assessment

• collecting and recording the exposure history of their patients

• assessing the individual benefit / risk balance

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What GPs can do

Risk communication

•informing patient about his/her individual risk / benefit balance

• explaining risks and benefits to the patient in a way that it is informative and understandable for them (including radiation risks as well as the risk of not performing the examination)

•listening, answering questions, and addressing concerns about radiation risks

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What FDs can do

Risk sharing

• explaining to the patient the reasons motivating the examination (i.e. the clinical question expected to be answered and the consequences on the treatment)

• rather than just collecting an informed patient’s consent, involving the patient in the decision-making process

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Communication is a crucial crossing of the modern health systems

PatientRadiol.

Practitioner

Specialist

FD

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WONCA Resolution

Justification and appropriateness

in radiological diagnostics

to stimulate medical colleges and networks of general practice to develop initiatives in their countries to increase Radiological Protection Culture in Medicine

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Doctors’ Education for RPCM

• Promoting radiological protection culture through educationon radiation safety among all healthcare professionals, in thebasic medical education, specialty training and ContinuingMedical Education (CME)

• Education should:

include knowledge on ionizing radiation sources and relatedrisks, and use of clinical imaging guidelines

develop communication skills and competences to informpatients in an understandable way about risks and advantagesof performing an x-ray procedure, and to give suitableinformation to radiology practitioners.

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WONCA commitments

• To cooperate with other stakeholders to encourage nationalhealth authority to establish regulations, which defineresponsibilities and procedures to make the justificationprocess clear and traceable

• To cooperate with radiology associations, and take part ininterdisciplinary panels, to set or adapt Clinical ImagingGuidelines (CIG) at international and local level

• To cooperate with other stakeholders for an effectivestrategy to spread CIG, implement them in Clinical DecisionSupport systems (CDS) and include CDS in the databasesused by family doctors

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WONCA commitments

• To incorporate in regulations the need to include in thereports of procedures that require IR, the administered dose

• To include into the discharge letters from hospital theoverall dose of IR administered

• To include data concerning previous examinations and IRexposure of each patient in the Patient’s File of the HealthServices, where available

• To include into the FDs’ databases the expectedadministered dose of each examination and an automaticcomputation of the exposure of the patient in the last years,to help the doctor in applying the justification principle

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WONCA commitments

WONCA intends to continue the collaboration with international organizations and institutions to increase appropriateness and pursue justification in radiological procedures

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Thanks for your attention