The development of radiology guidelines in Canada, Part 2.

In the second part of a two-part article on the development of Canadian clinical practice guidelines in radiology, the author discusses the implementation of guidelines. The aim is to translate guidelines into practice policies, but nation-wide implementation is difficult because of the regional circumstances and constraints in Canadian health care. One approach to making guidelines more effective tools and preventing conflict is to distinguish between effectiveness (benefit of an intervention under average conditions of use) and efficiency (value of an intervention compared with other things that could be done with the same resources). Clinical practice guidelines are based on effectiveness criteria alone, whereas practice policies can be based on efficiency criteria and are made by those responsible for allocating resources. From an ethical point of view, guidelines have an important feature in common with applied ethics: neither can give the right answer in a situation, but both can indicate the right decision-making process, including who should decide, on what basis, using which process and for what purpose. From a legal standpoint, if the medical community views guidelines as constituting reasonable medical care and jurists see them as a medical and legal norm, they can have significant influence in malpractice litigation. At the last annual meeting of the CAR, the executive committee decided that an integrated national approach to guidelines is needed because of the considerable confusion in this field. It supports the National Framework Development Committee's efforts to set national principles and operating rules for development and implementation. This necessitates an organizational structure consisting of a coordinating group representing consumers, service providers, regulators and funding agencies; multidisciplinary guidelines-development groups; and methodology resource groups.     

A Foundational Guide to Understanding Radiology Department Business Operations for Trainees

The financial success of a radiology department is crucial to the well-being of both the hospital and the community it serves. Radiology trainees should therefore be conscious of how the department maintains its value within the health system. The purpose of this review is to provide a concise foundational resource for contemporary radiology residents and fellows to understand the basic financial operations of a hospital-based radiology department and to demonstrate its importance in supporting clinical activities. The radiology report is at the heart of reimbursement. Coders use this tool to assign International Classification of Diseases and Current Procedural Terminology codes to file reimbursement claims. Medicare, commanding the highest market share for third-party payers, sets algorithmic standards for compensation practices. Private insurers contract with hospitals, and providers use these systems or create their own contractual framework. Radiology leaders strategically balance these revenue streams with various departmental costs utilizing tools such as budgets and forecasts to ensure long-term organizational viability. Notably, payment practices in the United States are transforming from fee-for-service to value-based care. The roles of the radiologist and the radiology report are evolving with it. Examples of value-based payment models are accountable care organizations and bundled payments. Radiologists participating in these models are increasingly expected to be stewards of imaging utilization and effectively manage health care resources. Within this context of a globally changing incentive structure, trainees must reconceptualize their educational experience to equip themselves for both current and future types of clinical practice.     

Clinical Imaging Guidelines Part 1: A Proposal for Uniform Methodology

Inappropriate imaging can lead to unnecessary medical radiologic exposures and cost and may not answer the clinical question. Imaging referral guidelines inform the justification of radiologic procedures and facilitate the choice of the best test first, but their acceptance by referrers, use, and value may be limited by shortcomings in the methodology of development. Focusing on common, essential elements of methodology will help guideline developers. In 2012 and 2013, the International Atomic Energy Agency hosted Technical Meetings on Radiation Protection of Patients Through the Development of Appropriateness Criteria in Diagnostic Imaging. Participants identified and agreed on issues concerning development of imaging referral guidelines. Items based on the Appraisal of Guidelines for Research and Evaluation II instrument were amended with additional items including development and consensus group composition. Consensus was sought on 28 items, 18 of which were agreed should be uniform, and 10 should allow for regional differences. Further work is required to encourage, provide, and identify higher quality evidence and to agree on a grading system for recommendations. Many key areas are common to guideline developers globally, opening the way for international collaboration to help demystify, simplify, and justify.     

The essence of the Japan Radiological Society/Japanese College of Radiology Imaging Guideline

Diagnostic imaging is undoubtedly important in modern medicine, and final clinical decisions are often made based on it. Fortunately, Japan has the highest numbers of diagnostic imaging instruments, such as CT and MRI devices, and boasts easy access to them as well as a high level of diagnostic accuracy. In consequence, a very large number of imaging examinations are performed, but diagnostic instruments are installed in so many medical facilities that expert management of these examinations tends to be insufficient. Particularly, in order to avoid risks, clinicians have recently become indifferent to indications of imaging modalities and tend to rely on CT or MRI resulting in increasing the number of imaging examinations in Japan. This is a serious problem from the viewpoints of avoidance of unnecessary exposure and medical economy. Under these circumstances, the Japan Radiological Society and Japanese College of Radiology jointly initiated the preparation of new guidelines for diagnostic imaging. However, the field of diagnostic imaging is extremely wide, and it is impossible to cover all diseases. Therefore, in drafting the guidelines, we selected important diseases and focused on “showing evidence and suggestions in the form of clinical questions (CQs)” concerning clinically encountered questions and “describing routine imaging techniques presently considered to be standards to guarantee the quality of imaging examinations”. In so doing, we adhered to the basic principles of assuming the readers to be “radiologists specializing in diagnostic imaging”, “simultaneously respecting the global standards and attending to the situation in Japan”, and “making the guidelines consistent with those of other scientific societies related to imaging”. As a result, the guidelines became the largest ever, consisting of 152 CQs, nine areas of imaging techniques, and seven reviews, but no other guidelines in the world summarize problems concerning diagnostic imaging in the form of CQs. In this sense, the guidelines are considered to reflect the abilities of diagnostic radiologists in Japan. The contents of the guidelines are essential knowledge for radiologists, but we believe that they are also of use to general clinicians and clinical radiological technicians. While the number and contents of CQs are still insufficient, and while chapters such as those on imaging in children and emergency imaging need to be supplemented, the guidelines will be serially improved through future revisions. Lastly, we would like to extend our sincere thanks to the 153 members of the drafting committee who authored the guidelines, 12 committee chairpersons who coordinated their efforts, six members of the secretariat, and affiliates of related scientific societies who performed external evaluation.     

A collaborative enterprise for multi-stakeholder participation in the advancement of quantitative imaging

Medical imaging has seen substantial and rapid technical advances during the past decade, including advances in image acquisition devices, processing and analysis software, and agents to enhance specificity. Traditionally, medical imaging has defined anatomy, but increasingly newer, more advanced, imaging technologies provide biochemical and physiologic information based on both static and dynamic modalities. These advanced technologies are important not only for detecting disease but for characterizing and assessing change of disease with time or therapy. Because of the rapidity of these advances, research to determine the utility of quantitative imaging in either clinical research or clinical practice has not had time to mature. Methods to appropriately develop, assess, regulate, and reimburse must be established for these advanced technologies. Efficient and methodical processes that meet the needs of stakeholders in the biomedical research community, therapeutics developers, and health care delivery enterprises will ultimately benefit individual patients. To help address this, the authors formed a collaborative program-the Quantitative Imaging Biomarker Alliance. This program draws from the very successful precedent set by the Integrating the Healthcare Enterprise effort but is adapted to the needs of imaging science. Strategic guidance supporting the development, qualification, and deployment of quantitative imaging biomarkers will lead to improved standardization of imaging tests, proof of imaging test performance, and greater use of imaging to predict the biologic behavior of tissue and monitor therapy response. These, in turn, confer value to corporate stakeholders, providing incentives to bring new and innovative products to market.     

Evaluating current chest imaging practices of pediatric patients with COVID-19: A retrospective analysis

PurposeThis retrospective analysis aims to examine the effectiveness of the current chest imaging guidelines regarding COVID-19 positive pediatric patients on our study group of patients aged 0 to 18.Materials and methodsWe examined clinical and imaging data of 178 pediatric COVID-19 positive patients confirmed by PCR admitted to the Children's Hospital of Los Angeles between March 6, 2020 and June 23, 2020.ResultsOf 178 patients, only 46 (27%) patients underwent any form of chest imaging. Thirteen (28%) of 46 imaged patients had positive chest X-rays (CXR) or computed tomography (CT) chest findings, with 8 (62%) of the 13 patients suggesting pneumonia or multifocal pneumonia, 3 (23%) patients having acute respiratory distress syndrome, and 2 (15%) patients demonstrating left sided pleural effusions thought to be the result of ruptured appendicitis unrelated to their COVID-19 diagnosis. All but one patient had significant prior medical histories with an associated comorbid medical condition. Of the 46 imaged patients, 17 (37%) patients had a negative chest X-ray, and 15 (33%) patients had suggestive findings of viral etiology. 132 patients were not imaged.ConclusionOur study population corroborated current chest imaging guidelines in pediatric patients. Chest imaging modalities such as CXR and CT should be reserved for patients who are severely symptomatic and/or possess prior comorbidities such as immunosuppression, diabetes, asthma, obesity, or where other differential etiologies must be entertained.     

Basic training requirements for the use of dental CBCT by dentists: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology

Cone beam CT (CBCT) is a relatively new imaging modality, which is now widely available to dentists for examining hard tissues in the dental and maxillofacial regions. CBCT gives a three-dimensional depiction of anatomy and pathology, which is similar to medical CT and uses doses generally higher than those used in conventional dental imaging. The European Academy of DentoMaxilloFacial Radiology recognizes that dentists receive training in two-dimensional dental imaging as undergraduates, but most of them have received little or no training in the application and interpretation of cross-sectional three-dimensional imaging. This document identifies the roles of dentists involved in the use of CBCT, examines the training requirements for the justification, acquisition and interpretation of CBCT imaging and makes recommendations for further training of dentists in Europe who intend to be involved in any aspect of CBCT imaging. Two levels of training are recognized. Level 1 is intended to train dentists who prescribe CBCT imaging, such that they may request appropriately and understand the resultant reported images. Level 2 is intended to train to a more advanced level and covers the understanding and skills needed to justify, carry out and interpret a CBCT examination. These recommendations are not intended to create specialists in CBCT imaging but to offer guidance on the training of all dentists to enable the safe use of CBCT in the dentoalveolar region.     

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.     

Acceptance testing of medical imaging equipment: CT and MRI.

Acquisition of medical imaging equipment should be followed by verification of its ability to satisfy clinical objectives. This verification normally is fulfilled by initial acceptance testing before clinical use and by an ongoing quality-assurance program thereafter. This article describes our experience with the acceptance testing of computed tomography scanners and magnetic resonance imaging systems.     

PACS workstation design

This paper covers some of the recent concepts in designing a digital imaging workstation in a multimodality Picture Archiving and Communications Systems (PACS) network. A workstation in a multimodality PACS network must access, display, and analyze digital images from different imaging modalities with very different formats. The user interface should allow clinicians with minimal or no computer manipulation skills to use complex analysis tools. General guidelines of a graphics oriented user interface, based on windows and icons, are proposed. Instantaneous (real-time) response in the primary display and processing functions is vital for user acceptance. The hardware architectural concepts to achieve such a performance speed are described. Finally, a workstation environment conducive to comfortable viewing by the radiologists is discussed.     

Toward Evidence-based Decisions in Diagnostic Radiology: A Research and Rating Process for Multiple Decision-makers

The use of diagnostic imaging tests and the development of evidence-based guidelines, reviews, and other materials have both undergone substantial growth in recent years. However, the proliferation of evidence-based information has not translated into the universal deployment of medical and coverage policy for diagnostic imaging that is similarly evidence-based. One possible reason is the failure of those institutions generating evidence-based information to format findings in an accessible manner for all relevant stakeholders. The Institute for Clinical and Economic Review has developed a simple and transparent method for rating evidence that is accessible to clinicians, patients, payers, and other policy makers. The authors describe this process in relation to three imaging-based examples (computed tomographic colonography, coronary computed tomographic angiography, and positron emission tomography for dementia neuropathology). The issues raised, controversies considered, and use of the ratings in setting policy are discussed in relation to each example.     

Heart-rate disorders: a challenge for the radiologist

Arrhythmia or altered heart rhythms can present with or without underlying heart disease. Most cardiopathies give rise to arrhythmias; however, arrhythmias can also be caused in previously healthy hearts by other conditions such as metabolic disorders, electrolyte imbalances, and drug use or abuse. The clinical presentation can range from asymptomatic cases discovered incidentally on routine examination to sudden death as the only clinical sign. In cases with clinical suspicion of arrhythmia, Holter and electrophysiological studies should be performed. If the condition is confirmed, associated cardiopathy must be ruled out. Echocardiography should be the first imaging test to be performed. Multidetector computed tomography (CT) and magnetic resonance imaging (MRI) have been applied to the field of cardiology more recently and are gradually acquiring specific roles with precise indications. In the study of arrhythmias, MRI is indicated in two particular areas: auricular fibrillation and arrhythmogenic right ventricular dysplasia.     

Monitoring of Clinical Imaging Guidelines Part 3: Norms,Standards, and Regulations

It is known that the use of imaging in clinical situations is not always optimal, leading to suboptimal health care and potential radiation risk. There may be overuse of imaging, underuse, or use of the wrong modality. The use of clinical imaging guidelines is likely to improve the use of imaging, but roadblocks exist. Some of these relate to regulatory oversight and mandates. There is wide variation by country and region in the regulatory setting, ranging from actual absence of regulatory authorities to mandated availability of clinical imaging guidelines in the European Community. Collaborative efforts to ensure that clinical imaging guidelines are at least available is a good starting point. Regulatory oversight and support are necessary to ensure the use of clinical imaging guidelines. Regulations should address 3 areas: availability, clinical utilization, and adherence to and revision of guidelines. The use of both internal and external audits, with the aim of both use of and adherence to guidelines and quality improvement, is the best tool for enhancing use. The major challenges that need to be addressed, collaboratively, to ensure the dissemination and use of clinical imaging guidelines are the development of regulations, of regulatory structures that can be effectively deployed, and of benchmarks for adherence and for utility.     

Guidelines and algorithms: strategies for standardization of referral criteria in diagnostic radiology

Guidelines can be regarded as special forms of algorithms and have been shown to be useful tools for supporting medical decision making. With the Council Directive 97/43/Euratom recommendations concerning referral criteria for medical exposure have to be implemented into national law of all EU member states. The time- and cost-consuming efforts of developing, implementing, and updating such guidelines are balanced by the acceptance in clinical practice and eventual better health outcomes. Clearly defined objectives with special attention drawn on national and regional differences among potential users, support from organisations with expertise in evidence-based medicine, separated development of the evidence component and the recommendations component, and large-scale strategies for distribution and implementation are necessary. Editors as well as users of guidelines for referral criteria have to be aware which expectations can be met and which cannot be fulfilled with this instrument; thus, dealing with guidelines requires a new form of "diagnostic reasoning" based on medical ethics.     

Guidelines and legal requirements which inform role expansion in radiography

Purpose: Role expansion in radiography is linked to ethico-legal responsibilities and accountability. This paper clarifies the legal requirements, outlines professional guidelines, and suggests that role developments require new rules and standards.Methods: A thorough review of the literature was used to collect information on role expansion and related topics, such as Continuous Professional Development (CPD) and skills mix. Emphasis was placed on case law and professional guidelines.Results: Radiographers who develop their roles must continue to provide a high quality service and demonstrate high level competencies, skills and knowledge. When deciding who should provide the service, the ultimate decision should be based on client benefit. Radiographers who expand their role will be gauged against specialists in that field, e.g. medical professionals, so radiographers must be confident in their own abilities and competent to perform such tasks. If a radiographer claims to be a specialist, the standard of care is that of the reasonable specialist and not that of the general radiographer. In legal terms, a patient is entitled to a greater standard of care from a specialist than from an ordinary practitioner and radiographers must meet that standard.Conclusions: Role expansion in radiography has associated legal responsibilities and radiographers are accountable for acts or omissions arising out of practice. Guidelines should be established which ensure that radiographers have skills and knowledge on a par with specialists in their area of practice so as to maintain the maximum benefit to the client.     

Subjective perception of radiation risk

Physicians, medical staff, and patients, much like the general population, are becoming increasingly sensitized to the issue of radiation exposure from diagnostic or therapeutic procedures. The attitudes of patients undergoing diagnostic imaging procedures that use ionizing radiation vary widely. Patient perception of radiation dose strongly influences their acceptance of diagnostic examinations or therapies involving radioactivity. Here, we review perceptions and concerns about radiation and radioactivity by laypersons and medical experts. Several studies show that physicians are frequently poorly informed about radiation levels associated with nuclear medicine and radiologic examinations. In addition, patients' decisions against undergoing an imaging procedure are frequently based on partial and sometimes incorrect information. Thus, physicians must take the concerns of their patients seriously. From the literature and our own experience, we conclude that it is extremely important to thoroughly and carefully educate all involved in patient work-up about radiation exposure levels and perceived or actual health risks. Although the choice and timing of imaging examinations should always outweigh the risk that secondary illness will develop, the patients' concerns still must be alleviated.     

The future of catheter-based angiography: implications for the vascular interventionalist

Based on the assumptions mentioned previously, the author makes the following predictions regarding catheter-based angiography and related procedures: 1. Most diagnostic angiography will be performed with noninvasive methods. In the peripheral circulation. MRA will be the predominant method, with CTA having an important role in aortic imaging and coronary imaging. MRA will have increased use for elective diagnosis and in clinical emergencies. 2. Catheter-based angiography will have an important role as an adjunct or preliminary procedure related to interventions. This is significant for planning catheter development and functionality of future angiographic equipment. 3. The need for angiographic equipment will continue to grow despite this decrease in diagnostic application, as a result of increase in interventional therapy. This increase in therapy will be a result of a variety of factors, including aging population, early diagnosis, and increasing acceptance of less invasive therapy. 4. Interventionists should be considering and planning for vascular imaging devices--MRA, CTA, and US--to be included as part of the interventional sections and the workload. 5. Cardiovascular imaging should be a clinical imaging specialty, with patient interaction at the time of imaging. 6. These changes should be embraced by vascular interventionalists, who should incorporate these tools into their clinical practice. 7. The changes, if they occur as predicted, will create significant problems in training skilled interventionists who will not have the foundation of diagnostic angiography on which to build complex endovascular skills.     

How to evaluate the quality of health related websites

To establish reliable quality criteria for medical websites is of foremost importance in relation to the increasing number of Internet users, both health professionals and lay people, searching for medical information in the mass of these sites. Quality in general refers to a set of features that distinguish one person or thing from others of the same type. The quality of a website is usually related to its content and usability. The first criteria we considered are contents and readability, which must be targeted to the intended type of user. Other important criteria include: transparency, consistency, honesty, references to sources, accountability, respect of privacy, currency of content material, responsibility, and accessibility. Technical criteria are the use of consolidated and standard technologies, soft colours, short page download time. Good medical websites should also follow the suggestions of organizations such as the World Health Organization, the Food and Drug Administration, the European Communities. Another organization, Health On Net Foundation, has issued some guidelines for medical websites, summarized in eight points, fundamental to assign real scientific value to a site. We believe, in agreement with the literature, that it is unnecessary to apply strict rules to medical website developers. We want to stress the importance of guidelines and recommendations to be modified with the development of web technology and the cultural evolution of patient and physicians. In the near future the presence on the Internet of websites certified by national or international medical web authorities will lead users to trust and give their preference to such sites, leading to the self-regulation of website developers and users.     

ACR Appropriateness Criteria Head Trauma

Neuroimaging plays an important role in the management of head trauma. Several guidelines have been published for identifying which patients can avoid neuroimaging. Noncontrast head CT is the most appropriate initial examination in patients with minor or mild acute closed head injury who require neuroimaging as well as patients with moderate to severe acute closed head injury. In short-term follow-up neuroimaging of acute traumatic brain injury, CT and MRI may have complementary roles. In subacute to chronic traumatic brain injury, MRI is the most appropriate initial examination, though CT may have a complementary role in select circumstances. Advanced neuroimaging techniques are areas of active research but are not considered routine clinical practice at this time. In suspected intracranial vascular injury, CT angiography or venography or MR angiography or venography is the most appropriate imaging study. In suspected posttraumatic cerebrospinal fluid leak, high-resolution noncontrast skull base CT is the most appropriate initial imaging study to identify the source, with cisternography reserved for problem solving.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.