Referral Guidelines in the UK : Making the best use of clinical radiology services

Denis Remedios Northwick Park Hospital, Harrow UK Chair RCR Guidelines Working Party

Making the best use of clinical radiology services: Referral Guidelines The Royal College of Radiologists has published guidelines since 1989. 7th edition due in 2011. • • • • • •

Development Users Implementation Effectiveness Audit Challenges

Web-base guidelines

The need for guidelines

Guideline methodology: • User survey • Centralisation of literature searches (Medline, Embase, Cochrane, ACR-AC, NICE/SIGN, Google scholar) with inclusion / exclusion filters and electronic hand search of 7 high impact journals • 16 Expert Panels drawn from the RCR Special Interest Groups: – main system based specialties, – oncology and paediatrics – modality based groups

• Review 4 yearly

Delphi process • Evidence sent in first iteration with further supporting evidence in subsequent rounds • e-mail based questionnaires: max 3 rounds • Delphi iterative process to agree recommendations and their grades • Groups of c. 10 experts from UK & Europe • 75% participation; 75% agreement Remedios D, McCoubrie P. Making the best use of clinical radiology services: A new approach to referral guidelines. Clin Radiol. 2007 Oct; 62(10):919-920

Consultation and editing • Draft guidelines sent for consultation to >100 organisations in UK & Europe. • The editorial process strengthened draft guidelines with further evidence gleaned through consultation. • The web editorial group included members with web design skills.

RCR Recommendations • Indicated- likely to contribute • Specialised investigation- often complex, time consuming or costly • Indicated only in specific circumstancesonly done if appropriate for the individual • Not indicated • Grading A-C based on evidence level – In 6e: 67 grade A, 409 B, 171 C. US DoH & Hum Services, Agency for Health Care Policy and Research. The Agency, 1993

Guideline: Chronic back pain

Dose information

Criteria for choice of investigations For a given clinical problem, imaging modalities are listed in the following order: 1. Evidence-based diagnostic impact 2. Effective dose 3. Cost effectiveness

Levels of evidence for primary research question Type of study

Therapeutic studies—investigating the results of treatment

Prognostic studies— investigating the effect of a patient characteristic on the outcome of disease

Level I

High-quality randomised controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Systematic review1 of level-I randomised controlled trials (and study results were homogeneous2)

High-quality prospective study3 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients) Systematic review1 of levelI studies

Testing of previously developed diagnostic criteria in series of consecutive patients (with universally applied reference "gold" standard) Systematic review1 of level-I studies

Sensible costs and alternatives; values obtained from many studies; multiway sensitivity analyses Systematic review1 of level-I studies

Level II

Lesser-quality randomised controlled trial (eg,