Monday, 12 January 2015

Diagnostic Imaging: adjusting the indication

Saurabh Jha, a radiologist at the Hospital of the University of Pennsylvania, in an article in New England (From imaging gatekeeper to service provider: a Transatlantic journey) explains that when he undertook MRI in the UK, residents feared the radiologists, not in vain, since one of them known as “Dr. No”. Migrated to the United States, quickly realized that there, the radiologists who were operating and issuing invoices as service providers, were rather “Dr. Yes”. The involvement of the radiologist in clinical reasoning was gone.

There is a widespread perception that the large investments of modern screening equipment are increasing their disproportionate use and the position of the radiologists, many of them involved in investments, is far from the function of gatekeepers, so praised by Dr. Jha. To this effect, it is revealing in a letter published in JAMA Internal Medicine (Overuse of Magnetic Resonance Imaging) about a consensus methodology (Rand Corporation University of California Los Angeles UCLA) to determine the degree of indication of MRI for low back pain and headache cases. The results say that 77% of the experts consulted, for example, believe that the MRI indication for back pain of less than 6 weeks duration is inappropriate or not well founded.

An initiative of the Hospital Clinic worth monitoring

Dr. Lluís Donoso, radiologist and Director of the “Centre de Diagnòstic per la Imatge Clínic (CDIC)", adopted ACRselect® (American College of Radiology), and to understand what this instrument is, in brief, you should know at least two characteristics:

1. ACRselect® is computerized management information coming from clinical practice guidelines.
2. ACRselect® uses an adequacy scale from 1 to 9: 1-2-3 low suitability, and at the other end, 7-8-9 high suitability. This scale has been tested for over 30 years in the consensus projects of the Rand Corporation (UCLA).

Source: Sistrom C L et al . Radiology 2009; 251:147-155

As seen in the table, when a doctor orders an MRI to diagnose a patient with back pain, the screen will warn him that this technique is an adaptation from 1 (lowest) and that there are two alternatives to consider: radiography and CT. However, the doctor may continue and order the test, but the appropriateness of the request will be recorded. Dr. Donoso is right now leading a test to see how ACRselect® fits in with the requests of image diagnostics arriving at CDIC from family doctors in their reference area. This project makes an important tool to support clinical decisions available to family physicians and radiologists, and therefore I believe that this innovation led by Dr. Lluís Donoso, when implemented, will represent an advance in the adequacy of medical practice.

Jordi Varela

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