Trends in radiology and possible overuse
The usefulness and benefits of radiology increases along with the continuous technological development,
which in turn increases the demand for advanced radiological services,
particularly in countries with economic wealth (4,
5).
In Europe,
the utilization of high technology examination (CT and MRI) is comprehensive and steadily increasing (6).
The increased demands for services combined with a lack of radiologists,
are reasons why the radiology department can become a bottleneck in health care (7).
The expected aging population,
with high needs of health care services,
indicates that the pressure on radiological services will not decrease.
At the same time,
there is an increasing concern about unjustified imaging,
i.e.
examinations that are not medically useful for patient management (8-10).
In 2010,
the American Board of Radiology (ABR) addressed the issue (11),
and indicated that “20%–50% of high-tech imaging procedures fail to provide information that improves patient welfare” (12).
This adds to the health authorities’ economic concerns about increasing use of radiology.
The potential hazards from exposure to ionising radiation is a concern for the Radiation Protection Authorities (13).
The principle of justification applies to three levels (14),
of which the justification of a procedure for an individual patient is of special interest here.
Excessive utilization and unnecessary examinations also represents a practical and moral challenge for professionals (15-17).
Additional negative consequences include false positive and negative results,
unexpected incidental findings and overdiagnosis (18),
which can lead to inappropriate patient management and follow-up procedures that are invasive,
risky and expensive (19).
Measures to ensure appropriate investigations for each patient,
delivered in a timely manner will therefore be beneficial for many reasons.
The approach to achieve this should focus on improving the quality of information in the referrals (20).
The referral is the key source of information that enables radiographers and radiologists to provide good quality services i.e.
to conduct appropriate examinations (using proper modalities and techniques) and provide appropriate radiology reports (21).
Among the many approaches to improve referral quality (22),
the most common is to address the referring physicians’ responsibility by various strategies towards clinical guidelines and clinical decision support (23).
Because the physicians may find the justification of referrals challenging (24),
it is argued that both radiologist and radiographers should more actively contribute in the referral process (25).
The radiographers’ involvement in the referral process
Radiologists “play a critical role in justifying and accepting examination requests as,
by virtue of their medical training,
they are best placed to ensure the clinical question is answered.
A study of Norwegian radiologists show that they act upon inadequate referrals regularly,
mainly by searching for more information (26).
A UK study found that vetting of CT and MRI requests by radiologist (shown in 95-96% of referrals),
and amendment or return of inappropriate requests (9-12%),
gave high level of appropriate imaging (27).
However,
the vetting referrals are increasingly shared with radiographers and delegated to other team members that have undertaken appropriate training” (28).
The radiographers’ engagement in assessing the referrals may vary depending on their experience,
education and the institutional setting (29).
As radiographers are the first and often only health care professional interacting with the patient in the radiology department,
they are in a good position to recognise cases of duplicate examinations,
questionably indicated examination,
and patients undergoing multiple similar examinations (29,
30).
They have potential for improving the quality of referrals for convention examinations (which often are not assessed by radiologists) and relieving the radiologist for workload for assessing more advance procedures like CT and MRI,
e.g.
by adhering to department pre screening protocols for managing work lists.
In cases of suspected unjustified referrals the radiographers are responsible for notifying the radiologist (31),
and their role can be to discuss imaging requests with referring clinicians (32).
The aim of the initiative
The justification of radiological procedures are currently highlighted by international bodies like WHO,
IAEA and HERCA.
The aim of the course is to disseminate knowledge,
skills and understanding,
in order to enable radiographers to contribute systematically and efficiently in the multidisciplinary team to improve justification of imaging referrals.