International Collaboration on Clinical Imaging Guidelines: Many Hands Make Light Work

Abstract

An International Atomic Energy Agency (IAEA) TechnicalMeeting on Justification of Medical Exposure and the Use ofAppropriatenessCriteriawasheldonMarch12-14,2013with3aims: (1) to explore what clinical imaging guidelines (CIG) arecurrently available, (2) to define the problems associated withclinical imaging guideline creation and use, and (3) to begin toestablishconcreteplansforinternationalcollaborationtoachievewideruseofCIG.TheunderlyingconceptisthattheuseofCIGcan improve patient care by improving the appropriate use ofimaging. This meeting was the second of 3 annual workshops,with further ones planned [1], and was organized and supportedbytheIAEAincooperationwiththeWorldHealthOrganization.Sixty medical professionals and regulators, from more than 30countries, participated. The 4 papers that follow in this issueevolved from the meeting, based on presentations, breakoutsessions,anddiscussions.Theintentofthisintroductoryarticleisto put the 4 papers into perspective, by specifically addressingwhatCIGare,whytheyaredifficulttobothproduceanddeploy,and why and how they are important.Several terms are used to describe the concept of guidelinesforclinicalimaging,including“appropriatenesscriteria,”“referralguidelines,” and “justification criteria” [2-5]. CIG (a term usedthroughout the papers) are developed using well-described,transparent methodology and available peer-reviewed literaturetocreaterecommendationsthatindicatewhichimagingexams,ifany,aremostlikelytobeclinicallyusefulinaspecificsetting.CIGare intended to inform the decision of the health care provider,thepatient,andtheradiologistastowhichimagingtest(again,ifany)torequestandperform.Buttheguidelinesarenotabsolute:The ultimate decision is based on many factors, includingpatient-specific ones (eg, risk factors, preferences), disease prev-alence, and availability of expertise and equipment. That is, ifMRI is the best choice but no MRI unit is available, thenchoosing anotherexamis reasonable. If ultrasound wouldbe thebest choice, but no local expertise is available in this area, thenanother imaging study may be recommended.The ACR Appropriateness Criteria on low-back pain pro-vide a good example of the intent of the guidelines. This topicincludes 6 variant scenarios. They range from “acute low backpain with no red flags” (as described in the text), for which therecommendation is that no imaging be done, to cauda equinasyndromewithmultipleorprogressivedeficits,withMRIratedas“usuallyappropriate”andlumbo-sacralx-rayandCTas“possiblyappropriate.” In this setting, based on clinical judgment, ifneither MRI norCT is available, then x-ray may be appropriate.A widely held belief is that imaging is often inappropriatelyused,withbothoveruse(by20%-50%)andunderuse.Amongtheexplanations for overuse are financial self-interest, medicolegalconcerns,expedience,andpatientdesire.Concernabouttheriskofionizingradiationmayleadtoinappropriateunderuse,asmaylackof availability of equipment or expertise. All stakeholders have ahigh level of interest in improving the quality of care and makingthe practice of medicine increasingly evidence based; the use ofsound guidelines is one important approach to this goal.Basingallmedicaldecisionsonrelevantevidenceisnotalwayspossible,becauseevidenceisessentiallynevercompleteforagivendisease, patient, and setting. Many organizations have produceddocuments that provide guidance or otherwise support evidence-based medicine. For example, the Cochrane Collaboration, amultinational nonprofit organization dedicated to improvinghealthcarethroughevidence-basedmedicine,producessystematicreviewsthatcanbeusedasthebasisofcare[6].Severalsocietiesandorganizations produce methodologically sound guidelines specif-ically for imaging. These include the American College of Cardi-ology[5],thegovernmentofWesternAustralia[7],andradiologysocieties such as the Royal College of Radiologists in the UnitedKingdom [4], the Canadian Association of Radiologists [8],theFrench Radiology Society [9], and the ACR [3].Methods for guideline development for clinical care arefairly well defined, based on an approach developed by the