WHO consultancy on “Referral Guidelines for Appropriate Use of Radiation Imaging” Report by Robert George, ISRRT President
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
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 22 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) 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.