Quality in Primary Care Open Access

Keywords

guideline, radiology, referral

Introduction

In the summer of 2000, an opportunity arose to develop locality guidelines aimed at making the best use of local radiology services, utilising an evidence-based approach. There were three reasons for doing this project. Firstly we wanted to introduce a framework that would allow closer and more e¡ective working between our local radiology department and GPs. Secondly we wanted to implement the Royal College of Radiologists’ guidelines: Making the Best Use of a Department of Clinical Radiology, Guidelines for Doctors.[1] Finally we wanted to ensure that the requirements of the Ionisation and Radiation (Medi-cal Exposures) Regulations 2000 IR (ME) R were met.^a

Method

In the North East Lincolnshire Primary Care Group (NEL PCG), established in 1999, the Clinical Governance Directorate had established a procedure for the development of care pathways (including clinical practice guidelines) for a wide range of clinical areas including cancer, ophthalmology, cardiology, gastroenterology and the management of osteoporosis. This procedure consisted of a framework for considering evidence and engaging a wide range of stakeholders (see Box 1). This framework was followed for the development of a local guideline that we called Making the Best Use of Our Local Radiology Department (see Appendix 1).

Step 1

A small project team from the Directorate of Clinical Governance and the local radiology department was established. The proposed locality guideline Making Best the Use of Our Local Radiology Department considered the appropriate utilisation of plain radio-graphy within a number of diagnostic areas. The proposed guideline considered specific clinical in-dications where a plain x-ray would no longer be routinely available, as current evidence demonstrated that undertaking such an x-ray routinely did not support the appropriate clinical management of the patient. At that time this aspect of the guideline reflected a small number of referrals instigated by primary care. The second element of the guideline focused on relatively large volume areas, primary care referral for plain radiography including cervical spine, lumbar spine, shoulder, hip and knee x-rays. The rationale of this element of the guideline was to facilitate an evidence-based approach to diagnostic use of plain radiography by local GPs with the anticipated reduction in overall number of requests and practical implementation of IR (ME) R. As with the development of other guidelines, the opportunity for the development of an updated referral proforma, in this case a request form was considered. At this stage it was felt appropriate to continue with the historic form.

Step 2

The proposal was discussed at the PCG Clinical Governance Committee that has wide membership from across primary care, including GP and nurse leads, public health, and audit and prescribing leads. In addition, the draft guideline was shared with rheumatology and orthopaedic consultants.

Step 3

A joint meeting of local primary and secondary care health professionals, administrative and audit sup-port sta¡ was held. This was supported by input from the Community Health Council (CHC). Local secondary care clinicians from radiology, orthopae-dics and rheumatology acted as a specialist resource within the meeting.

The proposed guidelines (see Appendix 1) were circulated to all GPs within North East Lincolnshire PCT to be utilised for future referrals within clinical areas specifically identified. The consultant radiol-ogists implemented a deferment process for x-ray requests which did not clearly fulfil the criteria. In such a case, the GP was invited to contact the designated radiologist to discuss the request further.

In addition, we attempted to raise the profile of what was felt to be a potentially significant but appropriate shift in patient expectation by asking our local evening paper to become involved. Previously they had kindly run an article highlighting the modern management of upper respiratory tract infections and the historic shift from patients’ anticipation that they would receive an antibiotic, to an appropriate assessment and in many cases advice alone. We felt that similar gains may be made with regard to requests for x-rays.

Results

Impact on referral behaviour within the focus areas of the guideline

An audit of GP referral for plain x-rays in the following areas – hip, knee, cervical spine, and lumbar spine – was undertaken for the calendar years 2000 and 2001. Table 1 provides a summary of the number of x-rays requested by GPs and undertaken by Diana, Princess of Wales Hospital Radiology Department.

Deferment process

When considering the reduction in the number of plain radiographs requested by GPs in the areas considered by the locality guidelines, it was felt appropriate to review the number of deferments highlighted by the radiology department.

Table 2 provides information on the absolute number of instances where further clarification of the indication for the x-ray by the GP was requested by the radiology department. Following this clarifica-tion, a number of the deferred requests were undertaken and included in the figures compiled within Table 1. During 2001 this element was not collated by the radiology department. However, following further discussion, this is now part of the reporting framework. The table demonstrates a reduction in the absolute number of deferments across all of the focus areas in 2001 compared with 2000. Although the locality guidelines were not adopted until September 2000 the deferment process had been implemented earlier that year by the radiology department as part of their local approach to the IR (ME) R guidance.

Review of all primary care referrals for plain radiography

Table 3 demonstrates the total number of plain x-ray requests made by GPs to the Diana, Princess of Wales Hospital radiology department. Review of the table demonstrates a significant reduction in requests.

The audit demonstrates a significant reduction in referrals across all diagnostic areas reviewed.

Orthopaedic referrals

A parallel initiative undertaken within primary care to the implementation of the locality radiology guidelines has been the surgical referral guidelines.^b Two elements of the referral workups included within the guideline are those for patients who are to be considered for hip and knee replacements. In both cases the workup undertaken by primary care includes plain x-rays of the appropriate hip and knee. There is therefore the potential that this initiative may increase the demand on the radiology department by primary care investigations that historically may have been instigated once the patient had been seen in the orthopaedic outpatient clinic.

The initiative was developed within the year 2000 and widely adopted and undertaken by practices within 2001. Table 4 documents the number of surgical referral guidelines for patients being con-sidered for hip and knee replacements where plain x-rays of the appropriate joint would be undertaken.

Sustainability

A key challenge is whether this reduction can be sustained. Table 5 provides comparative information for the first six months of 2001 and 2002. It would appear from this information that our local GPs are maintaining the improvement.

Anecdotally, with the implementation of the locality radiology guidelines, there was a perception that this may drive up referrals to rheumatology and orthopaedics. However, review of referral behaviour has shown no significant impact.

These findings have been discussed further with the Executive Committee within the primary care organisation (PCO) and represent the beginning of the feedback process. A detailed report of the referral behaviour will be circulated to all local practices in two formats. Information pertaining to behaviour at practice level will be provided across the PCT in the currently agreed format whereby the majority of practices are identified. At primary healthcare team (PHCT) level, the intention is to circulate detailed information pertaining to each GP within their relevant PHCT for further consideration.

Conclusions

This interface audit programme demonstrates signi-ficant reduction in the number of plain radiological x-ray requests initiated by primary care for the priority areas considered within the guideline. This is despite the potential increased demand by primary care, instigated by other initiatives, including the surgical referral guidelines. The reduction in primary care referrals for plain radiography for the priority areas within the guideline is mirrored by an overall reduction in primary care plain radiography requests. The audit demonstrates a very positive response by local GPs and re• ects an e¡ective and shared implementation of the guideline.

Discussion

The interface audit programme has demonstrated that the objectives of the adopted guideline have been significantly implemented and these changes appear sustainable. The success of this guideline clearly re• ects the willingness of our local practitioners to adopt it. This is hopefully because it was developed in a form that was intended to be useful and a prompt to good clinical practice. In addition, our local frame-work for the development of guidelines has, we hoped, achieved true ownership of the initiative and its e¡ective communication and implementation, following its adoption.

An important element for the successful imple-mentation of any guideline is its incorporation into the commissioning model to create the appropriate service in primary and secondary care, to support a guideline. With regard to resources, the guideline may highlight a further call on current resources or, in certain circumstances, facilitate the availability of resources that can then be utilised within other elements of the care pathway. Our local experience has been that it is essential, where resource may be created through the implementation of the guideline, that those health professionals involved have appro-priate input into the utilisation of the resource that is released. A clear and tangible benefit to local GPs has been the opportunity to halve the waiting time for primary care access to plain radiography.

The establishment of PCOs has created the opportunity for a co-ordinated approach to e¡ective implementation of guidelines that were perhaps less practical previously. The creation of PCOs has also made a reality the harmonisation of clinical and managerial skills, supported by appropriate resources to develop and implement such guidelines.

Reflecting on the positive impact of the initiative from the individual GP’s perspective, the develop-ment of this guideline appears to have provided the additional support for them in appropriate circum-stances, to manage patients in a sensible and evid-ence-based fashion, which was re• ected in the change in utilisation of plain x-rays. By doing so and securing the agreement of the patient that the x-ray is not clinically beneficial, achieves the double benefit of both utilising local resources most e¡ectively and also preventing the patient from unnecessary expo-sure to radiation.

From the outset it has been our intention to progress from a radiology guideline focused onprimary care, to one adopted and shared across the local health community. Following recent discussions with the radiology department they have identified this as a priority area. They have indicated that they wish to implement similar guidelines within second-ary care in the near future. This will facilitate the standardisation of approach, which will further consolidate the primary care elements.

To date, our focus has been to review best use of plain radiography. Given the success of the current initiative, we will now consider whether it may be appropriate to broaden the remit and consider other elements of diagnostic investigations such as ultra-sound, including Doppler. However, we will await further feedback from our constituent practices.

Acknowledgements

The success of the implementation of the radiology guidelines re• ects a significant input of a number of individuals including: Lynn Poucher, Associate Director of Governance; Elaine Cullum, Facilitator, Directorate of Governance; Linda Manley, Data Analyst, Directorate of Governance; Mrs Clair Brookes, PA/Administrator, Directorate of Govern-ance; and Sarah Johnstone, previously Assistant Director of Clinical Governance, NEL PCT; Dr R Harries, Lead Consultant Radiologist; Mr Jeremy Baskett, Divisional Manager, Clinical Sciences; Mrs Claire Jenkinson, Divisional Support Manager; and Paul Gould, Radiology Manager, Diana, Princess of Wales Hospital.

The success of the guideline perhaps most importantly re• ects the active support and involve-ment of all local GPs.

 ^aIonisation and Radiation (Medical Exposures) Regulations 2000 – IR (ME) R place a legal responsibility on all clinicians to ensure that any exposure to radiation is clinically justified.

^bSurgical referral guidelines – an element of the local quality development programme which is the co-ordinating development programme focused on individual health professionals but utilising practice and primary healthcare team structure within North East Lincolnshire PCT to facilitate its e¡ective and sustainable implementation.

References

1. The Royal College of Radiologists (1998) Making the Best Use of a Department of Clinical Radiology, Guidelines for Doctors (4e). The Royal College of Radiologists: London.

Appendix 1

Making the Best Use of Our Local Radiology Department

 These guidelines were developed in collaboration between the local radiology department, primary care and appropriate secondary care clinicians given the initial focus of the guidelines.

The outline guidelines were supported by the Radiology Service Review Meeting of 28 September 2000.

‘A guideline is not a rigid constraint upon clinical practice but a concept of good practice against which the manage-ment of the individual patient can be considered.’ Royal College of Radiologists (1990)

Clinical indications where plain x-rays will no longer be routinely available

This group of conditions consists of areas where the current evidence shows that the undertaking of an x-ray routinely does not support the appropriate clinical management of the patient. Prior to an x-ray being undertaken for any of the clinical areas outlined below, it is appropriate that a discussion with either a radiologist or senior radiographer be undertaken to consider the appropriate options.

 X-rays will no longer be routinely available for the following:

•plantar fasciitis

•sinusitis

•headaches

•Tietz syndrome

•potential rib fractures (unless complicated by underlying lung pathology)

•coccydynia

•cervical spine x-ray for patients presenting with vertebro-basilar symptoms.

Evidence-based indications for plain x-rays

When considering indications for plain x-rays it is appropriate to consider indications in three age groups for adults:

 •young

•middle aged

•elderly.

Within these specific age groups certain conditions can be common.

It is also appropriate to consider the indications for x-ray requests in association with significant medical conditions, for example, rheumatoid arthri-tis.

Spine

Cervical spine

Potential atlanto-axial subluxation

 A single lateral cervical spine x-ray with the patient in supervised comfortable • exion should review any significant subluxation in patients, e.g. with rheuma-toid arthritis.

Neck pain, brachialgia, degenerative change (cervical spondylosis) ± in the absence of neurological signs

 Routine plain x-rays are not indicated, as degen-erative changes begin in early middle age and are often unrelated to symptoms. Where brachialgia is present, further clinical assessment, including MRI, may be appropriate (dependent upon the clinical circumstances).

Lumbar spine

Chronic back pain with no pointers to infection or neoplasm

 Plain lumbar spine x-ray is not routinely indicated as degenerative changes are common and non-specific. An x-ray may be helpful in younger patients where there is a clinical suspicion of spondylolisthesis or ankylosing spondylitis.

Acute back pain

 Where clinically a patient may have an acute disc, a plain x-ray of the lumbar spine is routinely not helpful. Appropriate assessment and treatment includes physiotherapy, advice re posture, analgesics and other assessments, including MRI scan/specialist opinion as felt appropriate.

In patients where there is a suspicion of osteo-porotic collapse of a vertebra a plain x-ray of the lumbar spine is helpful.

For back pain with possible serious features, which include sphincter, or gait disturbance, saddle anaes-thesia, severe progressive motor loss, urgent specialist opinion is appropriate. In such cases plain x-rays may be falsely reassuring.

Suspected skeletal metastasis

 In patients with known primary tumour, where there is a clinical suspicion of skeletal metastasis, a skeletal survey is not routinely indicated. Localised plain x-rays may be helpful in association with a bone scan. It is important in such scenarios not to rely purely on radiological investigations but, where appropriate, to develop the clinical picture, e.g. for patients with suspected prostatic cancer and bony secondaries, undertaking a PSA and alkaline phosphatase can further clarify the situation.

Joints

Painful shoulder

 Routine plain x-ray not indicated.

Degenerative changes in the acromio-clavicular joints and rotator cu¡ are common and not always related to symptoms. An indication for a plain x-ray is where soft tissue calcification is suspected.

Knee pain/hip pain

 Principal indication for plain x-ray is within assess-ment of the patient for consideration of surgery.

 Other indications:

• plain x-ray of the hip is appropriate here if there is a clinical suspicion of avascular necrosis, although in early disease an x-ray may be normal

•if the patient is presenting with knee pain associated with locking, plain x-ray can be helpful to identify radio-opaque loose bodies

•in a child, a plain x-ray of the hip is appropriate if Perthe’s is clinically suspected.

Sacroiliac joints

 Plain x-ray of the sacroiliac joints can be helpful in the assessment of a patient with suspected seronega-tive arthropathy such as ankylosing spondylitis.

 For patients with both seronegative and seroposi-tive rheumatoid arthritis who have active disease, yearly x-rays of the hands and feet are appropriate to assess disease progression.