Monday, 17 June 2019

The excesses of image diagnostics

The practice of modern medicine is subject to much pressure from the use of diagnostic imaging technologies, many of which are truly dazzling for the eyes of clinicians and patients and, as a result, health budgets are constantly increasing. This being the case, everyone agrees that more professional debate should be generated to put the matter in its place and avoid the excesses that damage resources, irradiate people and don’t add value to clinical reasoning.

Position of scientific societies on restriction of image tests

If we take a look at "", we see that of the more than 4,000 recommendations of practices of low value, 12.4% (538) correspond to the "diagnostic by image" filter.  My advice is to consult the 235 reports prepared by the expert groups of the American College of Radiology (ACR), which offer files of each radiological test with assessment of the indication (appropriateness rating), technical comments, estimation of the level of relative irradiation (RRL), in addition to documentary review and lists of sources used. For its part, the Spanish Society of Medical Radiology (SERAM), in its document of 38 recommendations "not to do", has concluded that 30% of the imaging tests that are performed don’t provide relevant information for clinical decisions, an estimate that if we put it in context, it would offer an impressive number of wasted resources, as well as a lot of unnecessary irradiation for affected patients who, after all, don’t provide any useful information to them or their doctors.

Among the many recommendations of the scientific societies of radiologists in rationalizing these tests, there is a nucleus of coincidences, of which, in a very synthetic way, I would like to highlight:
  • Chest x-rays for the preoperative and also for post-pneumonia follow-ups
  • Simple radiographs for the clinical evaluation of the following pathologies: headaches, sinusitis, cervical issues, lumbago, asthma and bronchiolitis in children, benign pulmonary nodules, bone metastases, acute abdominal pain, acute pyelonephritis and sprains of knees and ankles
  • Cardiac imaging tests in asymptomatic people
  • Mammograms and preventive breast resonances in women outside of screening programs
  • Intravenous urography in patients who have suffered a nephritic colic
  • Opaque enema for colon pathologies
How can the excess of evidence be reversed?

Routines provide security and therefore, despite the fact that many clinicians know the recommendations, when they act, they act as usual. Many think, not without reason, that in case of litigation, judges tend to believe that failing to comply with a precept can be a sign of neglect or carelessness. Knowing this, a group of Spanish researchers has shown that an intervention based on training for prescribers, as well as an information plan for patients, could reduce excessive requests by 30%, and does so in a convincing way for the parties involved. It could also be helpful to use software that, like ACRSelect (based on the working groups of the American College of Radiology) or its extension to CareSelect Imaging, provides support at the same time of the prescription in relation to the adequacy of each specific request.

If you want to change attitudes and routines,  training programs are required that, with the help of specific software, focus on the most deviant prescribers, in addition to offering information to the people being tested, so that they understand the difficult balance between benefits and risks.

Regarding the persistence of defensive practice, doctors should realize that the "right care" recommendations (538 if we stick to image diagnosis) can be a solid documentary support in the face of hypothetical legal claims.

Jordi Varela

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