International Radiology Quality Network
IRQN
Stakeholders to collaborate on referral guidelines
Diagnostic imaging and interventional radiology are indispensible
in health care and save lives. There is an increasing use of
these procedures in recent years, some of which are associated with
an increase in radiation exposure. The stakeholders support
professionalism, are committed to best patient care and are working
towards better quality, safer and more appropriate use of these
procedures. For example, in radiation safety and radiation
protection, there is an increase in interest and actions in recent
years from international agencies, professional organizations and
competent authorities to promote appropriate use and to reduce
unnecessary exposure.
Under its Global Initiative on Radiation Safety in Health Care
Settings (Global Initiative), the WHO hosted a consultancy on
“Referral Guidelines for Appropriate Use of Radiation Imaging” in
Geneva during March 2010. The objectives were to consult the
stakeholders and conceptualize the ways forward to: 1) develop an
international set of evidence-based referral guidelines; 2)
facilitate their implementation; and 3) monitor their use and
evaluate the impact in different clinical settings.
WHO launched the Global Initiative in December 2008. Reduction
of unnecessary medical exposure by justification of radiological
procedures is one of the initial priorities. “An area of
concern is the unnecessary use of radiation when clinical evaluation
or other procedures could provide an accurate diagnosis.
Justification and optimization are the key pillars of radiation
protection of patients. During the coming year, the team’s
work will focus on justification and related aspects, including
referral guidelines.” explained Dr. Maria Neira, Director Department
of Public Health and Environment, WHO.
Dr. Carlos Dora on behalf of Dr. Neira, together with Dr. Steffen
Groth, Director Department of Essential Health Technologies of the
WHO jointly opened the consultancy and welcomed the 35 participants
from 19 countries. The invited participants were experts from
23 international, regional and national agencies and professional
organizations representing the: American College of Radiology (ACR),
Argentine Society of Radiology (SAR), African Society of Radiology
(ASR), Association of General Practitioners (Geneva), Canadian
Association of Radiologists (CAR), Chinese Society of Radiology
(CSR), European Commission (EC), European Society of Radiology
(ESR), Federal Office for Radiation Protection, Germany (BfS), Hong
Kong College of Radiologists (HKCR), Inter-American College of
Radiology (CIR), Image Gently Campaign, International Atomic Energy
Agency (IAEA), International Paediatric Association (IPA),
International Radiology Quality Network (IRQN), International
Society of Radiology (ISR), International Society of Radiographers
and Radiological Technologists (ISRRT), National Centre for Child
Health and Development, Japan (NCCHD), Nuclear Safety Authority,
France (ASN), Pan American Health Organization (PAHO), Royal and
Australian New Zealand College of Radiologists (RANZCR), Royal
College of Radiologists (RCR) and World Health Organization (WHO).
The International Commission on Radiological Protection (ICRP),
World Federation of Nuclear Medicine and Biology (WFNMB) and the
World Federation of Ultrasound in Medicine and Biology (WFUMB) were
invited and supportive but were unable to attend.
During the three days of the consultancy, the delegates shared their
experience and views in a comprehensive program covering: why
referral guidelines are needed; how to developing referral
guidelines; the existing referral guidelines including their
strengths and weaknesses; the ways forward to develop and present
the material; the project framework and work plan; the
implementation barriers and solutions; and the next steps.
There were active contributions from the participants during the
discussions. Following the exchange of views and opinion,
there was consensus and an overwhelming support to the project from
this group of experts. However, it was recognized that there
were areas which would benefit from further attention during project
development. For examples, there is a need to: better define
the targeted audience; emphasize the educational value; note the
different terminologies used in different countries; address the
conflict of interest; attend to the costs if developing de novo;
note the need for regular updates and medico-legal implications.
These important observations were noted and strategies will be
developed to tackle these challenges.
At the end of the consultancy, the delegates agreed to collaborate
and work towards the common objective and develop a common set of
referral guidelines on an appropriate use of diagnostic imaging and
interventional procedures. The delegates agreed that it was
feasible to conduct an international project to achieve this goal.
Based on the tabled framework some fine-tuning is needed in the
roles of the stakeholders, the collaboration framework and the work
plan towards the development, publication, distribution,
implementation and evaluation of referral guidelines.
The participants have agreed to: 1) ensure on-going communication,
consultation and collaboration; 2) include the development, pilot,
implementation and evaluation of referral guidelines in the project
scope; 3) define the roles of stakeholders; 4) apply an
inclusive multi-stakeholder engagement framework and accountable
work plan; 5) establish a core group to spearhead the project; 6)
finalize and publicize the consultancy report; 7) promote awareness
and develop key messages; 8) strengthen advocacy, member states
policies and implementation strategies for justification and use of
referral guidelines; and 9) develop specific implementation
strategies for different settings.
The development and implementation of referral guidelines and
appropriateness criteria is one of International Radiology Quality
Network’s terms of reference. The network formed a referral
guidelines working group in June 2009 which is co-convened by Dr.
Martin Reed from the Canadian Association of Radiology and Dr.
Michael Kawooya from the African Society of Radiology. “The
IRQN looks forward to collaborating with other stakeholders to
develop and implement evidence-based guidelines under an inclusive
and collaborative framework” said Dr. Lawrence Lau, Chairman of
IRQN.
There is a need to strengthen stakeholder engagement to promote
awareness, to encourage participation towards the preparation and
use of these guidelines; to develop implementation strategies; to
build national capacity; and to apply effective implementation
policies. Referrers, imaging specialists, interventionists and
radiographers are the key end-users of these guidelines, could
actively participate by promoting awareness and applying these
evidence-based tools to improve practice or by contributing to the
development and implementation efforts as collaborators.
Collaboration is strength and provides synergy. Those
individuals who are interested to contribute to the referral
guidelines working group can contact the IRQN secretariat at
secretariat@irqn.org.
These collective efforts from the stakeholders will result in better
quality, safer and more appropriate use of diagnostic imaging and
interventional radiology.
IRQN Referral Guidelines Working Group
The International Radiology Quality Network (IRQN) is pleased to announce the formation of a Referral Guidelines Working Group to develop a set of referral guidelines applicable to the health care settings in developing nations. At the present time, nine of its member organizations have nominated representatives to this initiative.
New techniques and new technologies have revolutionized diagnostic imaging in the last thirty years. It could be challenging for most referrers to keep abreast of these new developments and select an appropriate diagnostic imaging examination for a given clinical problem. In good medical practice, requesting a diagnostic imaging examination does not replace a careful and detailed clinical history and examination. In fact, in many situations, patient management does not require further investigation be it diagnostic imaging or pathology. Diagnostic imaging is only indicated when the management depends on the imaging findings. In that scenario, further consideration should be given to the benefits versus the risks and side-effects of the examination.
Well-developed and evidence-based referral guidelines are useful tools to assist referrers to decide if imaging is indicated. The most appropriate examination to be selected is based on the information required, i.e. changes in structure or function; local resources; expertise; cost-effectiveness; and side effects including radiation exposure. The diagnostic imaging needs of special patient groups, e.g. the use of radiation in imaging for children must be carefully evaluated.
Justification and optimization are key measures to encourage an appropriate use of diagnostic imaging and to reduce unnecessary and unintended radiation exposure in health care settings. The objective of this IRQN initiative is to provide guidance to the referrers by the publication of referral guidelines, i.e. justification of examination. The working group intends to modify and harmonize the available referral guidelines and to adapt these to the health care setting of developing nations. “The challenge for all stakeholders is to select and perform the right examination, in a timely manner, with the right exposure which is appropriate for the local setting” said Lawrence Lau, Chairman of the IRQN.
The IRQN Referral Guidelines Working Group will be led by the Co-Covenors Michael Kawooya and Martin Reed. The Working Group members are: Ibtissem Bellagha, Azza Hammou and Michael Kawooya from the African Society of Radiology (ASR); Michael Bettman and Pamela A. Wilcox from the American College of Radiology (ACR); Byung Ihn Choi from the Asian Oceanian Society of Radiology (AOSR); Martin Reed and David B. Vickar from the Canadian Association of Radiologists (CAR); Lilian L. Y. Leong from the Hong Kong College of Radiologists (HKCR); Alfredo Buzzi and Rodrigo Restrepo González from the Inter-American College of Radiology (CIR); Cynthia Cowling, Paivi Wood and Sandy Yule from the International Society of Radiographers and Radiological Technologists (ISRRT); Richard Baron, Ramin Khorasani and Mark Watson from the Radiological Society of North America (RSNA), and Richard Mendelson and Don Swinbourne from the Royal Australian and New Zealand College of Radiologists (RANZCR); and Lawrence Lau from the International Radiology Quality Network (IRQN). The European Society of Radiology (ESR) has nominated Jane Adam and the Royal College of Radiologists (RCR) has nominated Rob Manns as observers.
Michael Kawooya is the General Secretary of the African Society of Radiology. “This IRQN referral guidelines initiative is a timely proposal. In Africa, radiologists, radiographers and other users of radiation for diagnostic purposes eagerly await these international guidelines for radiological referrals. This is especially important and urgently needed in Africa where resources are limited. Indeed, my country has just finalized the national standards and guidelines for radiology and imaging which will be binding for all radiology and imaging users in Uganda, and I was part of the team. This national policy would be greatly enhanced by global efforts to harmonize and regularize radiology and imaging referrals” said Dr. Kawooya.
Martin Reed is a pediatric radiologist with special interests in ultrasound and MSK imaging. He is very interested in health services research, which has led him into referral guidelines. Martin has been very interested in radiology guidelines for several years. He is the Chair of the Guidelines Working Group for the CAR and is leading the revision of their set of guidelines. As a member of Guidelines International Network (G.I.N.), he has had the opportunity to attend several international meetings on guidelines. “There are already several versions of guidelines for developed countries and representatives from some of the groups are on this Working Group. The CAR believes it would be appropriate to have a different set of guidelines for at least some of the developing nations because of their limited resources and their different disease burdens” said Dr. Reed.
Given the scope of this initiative, it is expected that some lead
time is required for the Working Group to develop the work plan,
allocate tasks and draft guidelines. “Collaboration is strength” is
the network’s motto. Despite these challenging tasks ahead, the
network is confident that the Working Group will be well supported
by the member organizations and the initiative will advance steadily
in the coming years, leading to the publication of a first set of
internationally developed referral guidelines which is appropriate
for the developing nations.
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News
A team of IRQN Referral Guidelines Working Group members were
invited to a WHO consultancy on “Referral Guidelines for Appropriate
Use of Radiation Imaging” in its Geneva HQ during March 2010. The
35 invited experts from 19 countries representing 23 international,
regional and national agencies and professional organizations have
agreed to collaborate and work towards the common objective and
develop a common set of referral guidelines on an appropriate use of
diagnostic imaging and interventional procedures. The experts also
agreed that it was feasible to conduct an international project to
achieve this goal… More here