SSM perspective
Background
The use of X-ray diagnostic examinations, especially computed tomography, has increased in recent decades and it is essential that this increase is justified and contribute to a better care of the patients. There are many reasons to refrain from performing inappropriate radiological examinations, including not to expose patients to unnecessary ionising radiation. In the radiation protection system, this is expressed as the justification principle and is of particular importance for medical exposures because dose limits for this type of exposure are exempt.
SSM perspective Background The use of X-ray diagnostic examinations, especially computed tomography, has increased in recent decades and it is essential that this increase is justified and contribute to a better care of the patients. There are many reasons to refrain from performing inappropriate radiological examinations, including not to expose patients to unnecessary ionising radiation. In the radiation protection system, this is expressed as the justification principle and is of particular importance for medical exposures because dose limits for this type of exposure are exempt.
The purpose of the project was to investigate the conditions for developing a method, based on evidence-based criteria, to retroactively evaluate a large number of investigations regarding appropriateness and to test the method on clinical cases.
Results
In the project, a method based on the European guidelines, iGuide, has been developed. The method utilized the fact that iGuide constitutes an electronic clinical decision support system. This means that data can be handled digitally, which facilitates the evaluation of a larger number of examinations. The system provides a ranking and results in a score from 1 to 9 for a medical indication. Scores 1-3 are said to indicate usually not appropriate, scores 4-6 may be appropriate and scores 7-9 are usually appropriate for a given medical indication.
In a previous project, iGuide was adopted for use in Sweden and for this project, some further adjustments were made. Information about the medical indication was digitally extracted from the referrals and matched against the medical indication in iGuide. Clinical cases from 4 healthcare regions were collected, and a total of approximately 25 000 referrals were included. Some challenges was encountered, e.g. handling different codes for the same procedure in the health care regions.
The medical indication in just over half of the referrals could be matched against medical indications in the iGuide. It was concluded that the European iGuide database was useful for conducting a large retrospective study. The result of the evaluation was carried out and 66% of all examinations scored in the group 7-9, 20% scored 4-6 and 14% scored 1-3.
The study shows that referral criteria can be used to evaluate the suitability and there is a potential to do this in an efficient and automated way.
Relevance
It is of great importance to include evaluation of justification and appropriateness in the performance evaluation and audit of an X-ray department and preferably be part of the clinic’s quality management system. To do so, evidence-based referral criteria are paramount. In this study, European guidelines were used as there are no such national referral guidelines. The evaluation method must also be efficient and manageable. Furthermore, it is interesting to be able to streamline the evaluation so that a larger number of investigations can be evaluated with reasonable resources.
Need for further research
The method used in this study has both advantages and disadvantages. The significant number of referrals that could not be evaluated is a limitation. The strength is that established criteria are used without the influence of individual observer’s assessment. It may be beneficial to be able to evaluate a large number and further method development may be justified.
It would be possible to develop other methods, e.g. point prevalence surveys could be an alternative. A smaller number of examinations are then evaluated and more information about the patient could be included. It could also be appropriate to specially review individual patient flows from e.g. the emergency department. The advantages and disadvantages need to the further evaluated.