View of Can consultation between the radiologist and patients contribute to reducing unnecessary radiological examinations?

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Community Health Centre Ljubljana, Ljubljana, Slovenia

Correspondence/

Korespondenca:

Saša Staparski Dobravec, e:

sasa.staparski-dobravec@

zd-lj.si Key words:

low back pain; x-ray scan;

prevention; medical consultation Ključne besede:

bolečina v križu;

rentgensko slikanje;

preventiva; zdravniški posvet

Received: 7. 10. 2018 Accepted: 13. 12. 2019

10.6016/ZdravVestn.2881 doi

7.10.2018 date-received

13.12.2019 date-accepted

Oncology Onkologija discipline

Original scientific article Izvirni znanstveni članek article-type

Can consultation between the radiologist and patients contribute to reducing unnecessary radiological examinations?

Ali konzultacija radiologa z bolnikom lahko zman- jša število nepotrebnih radioloških preiskav?

article-title

Can consultation between the radiologist and patients contribute to reducing unnecessary radiological examinations?

Ali konzultacija radiologa z bolnikom lahko zman- jša število nepotrebnih radioloških preiskav?

alt-title

low back pain, x-ray scan, prevention, medical

consultation bolečina v križu, rentgensko slikanje, preventiva, zdravniški posvet

kwd-group The authors declare that there are no conflicts

of interest present. Avtorji so izjavili, da ne obstajajo nobeni

konkurenčni interesi. conflict

year volume first month last month first page last page

2020 89 1 2 3 11

name surname aff email

Saša Staparski Dobravec 1 sasa.staparski-dobravec@

zd-lj.si

name surname aff

Zala Kumše Gale 1

Irena Makivić 1

eng slo aff-id

Community Health Centre

Ljubljana, Ljubljana, Slovenia Zdravstveni dom Ljubljana,

Ljubljana, Slovenija 1

Can consultation between the radiologist and patients contribute to reducing

unnecessary radiological examinations?

Ali konzultacija radiologa z bolnikom lahko zmanjša število nepotrebnih radioloških preiskav?

Saša Staparski Dobravec, Zala Kumše Gale, Irena Makivić

Abstract

Background: Clinical guidelines for managing non-specific back pain do not recommend X-ray imaging within 4–6 weeks from the onset of pain. The overstrain on radiology departments due to inappropriately indicated imaging prompted the introduction of consultations with radiologists. The new practice was started at the Community Health Centre Ljubljana (CHCL) in January 2013. Thus, the possibility of consultation is offered to all patients between 25 and 45 years of age, referred to spinal X-ray.

Methods: Quantitative analysis included all spinal X-ray imagings performed at CHCL from 2011 to 2018. The data were compared with those of two other Slovenian outpatient radiological departments. Qualitative evaluation of consultation implementation was done in the beginning of 2016 with a survey which was sent to all patients (N:497) who had undergone consultation as well as to their referring physicians (N:134).

Results: The number of referrals in CHCL is declining. The survey response rate was 48% for referral physicians and 30% for patients. The majority of physicians (95%) expressed an opinion that the postponing or resigning of imaging did not cause delay of diagnostic or therapeutic procedure. Most of them (95.9%) evaluated consultation as reasonable. Patients evaluated the acquired information as understandable (N = 136; 97.1%), useful (N = 113; 89.7%) and something new (N = 91; 72.8%).

Conclusion: Introduction of patients’ consultations with a radiologist may reduce the number of non-indicated referrals. It is a simple, legitimate, professionally justified, harmless and cost-effi- cient service in radiology practice which allows for a direct personal transfer of medical experience and specific radiological expertise to the patient.

Izvleček

Izhodišče: Smernice za obravnavo nespecifične bolečine v križu odsvetujejo rentgensko slikanje skeleta v prvih 4–6 tednih trajanja bolečine. Preobremenjenost radioloških oddelkov z neustrez- no indiciranim slikanjem je spodbudila uvedbo konzultacije pri radiologu. V Zdravstvenem domu Ljubljana (ZDL) smo jo uvedli januarja 2013. Ponudili smo jo vsem bolnikom v starosti od 25 do 45 let, napotenim na rentgensko slikanje (rtg) hrbtenice.

Metoda: Preverili smo število vseh slikanj hrbtenice v ZDL pri bolnikih med 25. in 45. letom sta- rosti v letih 2011–2018. Primerjali smo število preiskav na leto v ZDL z dvema zunajbolnišničnima radiološkima oddelkoma v Sloveniji. Storitev konzultacije smo ocenili z vprašalnikom o nežele-

Slovenian Medical

Journal

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1 Introduction

In Slovenia, as in the rest of Europe, musculoskeletal disorders are a significant cause of sick leave among patients old- er than 20 years (1,2,3). In the 20–44 age group, they cause 12.4% of all sick leaves and are, regarding the frequency, preceded only by injuries (4). Back pain is a complex medical issue with a wide range of differen- tially diagnostic possibilities. Even though it is a non-dangerous condition in most cases, the physician’s task during the first examination is to consider and exclude more serious systemic illnesses, alert- ed to by so-called “red flags”: pain and/

or neurological deficit that lasts continu- ously for more than 1 month, intravenous drug use, pain that is present even during night-time, recent skin or urinary tract infection, history of a malignant disease, fever, unexplained weight loss, significant injury, immunosuppressive therapy, faecal or urinary incontinence, long-term corti- costeroid use, urine retention, decreased muscle strength of extremities and/or se- verely limited spinal movement (5,6,7).

nih dogodkih in smiselnosti storitve, ki smo ga v začetku leta 2016 poslali vsem obravnavanim bolnikom (N = 497) in njihovim napotnim zdravnikom (N = 134).

Rezultati: Po uvedbi konzultacije število napotitev na rtg hrbtenice v ZDL upada. Na vprašalnik je odgovorilo 149 (30 %) bolnikov in 65 (48 %) zdravnikov. Večina (95,8 %) napotnih zdravnikov meni, da odlog ali odstop od slikanja ni povzročil zamude v diagnostičnem ali terapevtskem postopku. Prav tako jih večina (95,9 %) meni, da je taka obravnava smiselna. Bolniki so ocenili informacije kot razumljive (97,1 %), koristne (89,7 %) in nekaj novega (72,8 %).

Zaključek: Konzultacija pri radiologu lahko zmanjša število nepotrebnih napotitev na rtg diag- nosticiranje. Je enostavna, legitimna, strokovno upravičena, neškodljiva ter glede na ceno ugod- na storitev, ki omogoča oseben prenos strokovnih izkušenj in specifičnega radiološkega znan- ja neposredno na bolnika. S tako radiološko prakso lahko prispevamo h krepitvi preventivnih ukrepov na primarni ravni.

Cite as/Citirajte kot: Staparski Dobravec S, Kumše Gale Z, Makivić I. Can consultation between the radiologist and patients contribute to reducing unnecessary radiological examinations? Zdrav Vestn.

2020;89(1–2):3–11.

DOI: https://doi.org/10.6016/ZdravVestn.2881

When we can determine the cause of back pain during the examination or with further diagnostic procedures, we talk about

“specific” pain, which represents 5–15%

of all cases. When we cannot ascribe a determined cause to the pain, we speak of “non-specific” pain, which represents 85–95% of all cases (6,8,9,10).

Current European guidelines for back pain treatment advise against the routine use of diagnostic imaging for pain that lasts less than 4–6 weeks. Imaging is recommended only in the case of warning signs (so-called “red flags”) when clinical- ly significant spinal pathology is suspected (7,11,12,13). In case of non-specific back pain there is often no correlation between the level of degenerative changes seen on the X-ray and the clinical symptoms (14,15,16,17).

Because ionizing radiation has a harmful effect on human health, it should be used only if the information obtained by imaging will affect the course of treatment (18).

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Routine imaging of the spine in patients with non-specific low back pain that lasts less than 6 weeks does not only expose the patient to unnecessary and potentially harmful radiation (19,20,21);

it also does not improve the final clinical outcome. It contributes to the poorer per- ception of one’s health and increases the likelihood of unnecessary surgical procedures (13,22,23,24). According to current guidelines, instead of using X-ray imaging in the population aged 25 to 45, an MRI examination is recommended (11,12,13).

Slovenian legislation is clear: a radiologist is responsible for the justification, optimization and approval of an X-ray examination (25). While the legislation imposes on the radiologist an explanato- ry duty, the latter is not defined; it is not clear where in the organization of the work process the radiologist can fulfill it, nor how it could be evaluated (26). There is no need to emphasize that inappropriately indicated X-ray imagings burden the health care system financially and organi- zationally, prolonging the waiting periods for patients that actually need treatment.

That is why, in 2013, we introduced a new

“radiological consultation” practice at the Ljubljana Community Health Centre (LCHC) departments Center and Vič.

It is offered to all patients between the ages of 25 and 45 who have been referred for X-ray imaging due to pain in various parts of the spine (X-ray imaging of the entire spine, X-ray imaging of the cervical, thoracic or lumbar spine).

The patient is informed about the possibility of a consultation when scheduling an examination and may voluntarily decide between imaging and a consultation prior to imaging. If he/she decides for consultation, he/she is directed to LCHC department Vič where consultations take place. During the consultation, which takes approximately 10–15 minutes, a radiologist reviews the patient’s current doc- umentation (if available), obtains patient`s anamnesis to exclude the “red flags”, and performs a targeted clinical examination

if necessary (when such an examination is not evident from the referral or other doc- umentation, or when more than 3 weeks have passed since the referral). During the conversation, the radiologist informs the patient about the anticipated effective radiation dose on radiosensitive organs, with an estimation about how the results of the imaging might impact the course of treatment. A safe window of postponing imaging for 6 weeks is proposed. At the conclusion the patient may, on the basis of the information received, voluntarily decide on one of the following steps: a)postponing the imaging (in this case, he/she takes responsibility to start regular and proper exercise twice a day for 20 minutes and, if necessary, seeks professional help, e.g. a physiotherapist); b) optimized imaging as advised by radiologist; c) imaging according to the referral. A common example of optimized imaging: referral for thoracic and lumbar spine X-ray because of tender point paraspinally at the height of the tho- racolumbar junction. The estimated effective dose of radiation to the lungs, breasts, esophagus, stomach, intestines, gonads, urinary tract, bone marrow,… is approximately 1.7 mSv. According to the clinical examination the radiologist suggests optimized, targeted imaging of the thoraco- lumbar junction where effective radiation dose is approximately 0.4 mSv.

If the patient decides to postpone the imaging, he/she is informed that in the case of persisting pain despite regular and correct exercise, or in the case of acute deterioration or change in the type of pain, he/she may immediately undergo X-ray diagnostics at any time.

After the consultation, the radiologist issues a written report, containing information about the estimated effective dose of radiation, how obtained data could affect the course of treatment, the agreement with the patient that he/she will introduce regular exercise (when the patient decides for the postponing of the imaging), or the radiologic report of optimized imaging, when this is performed.

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2 Methodology

We extracted data from the Radiolog- ical Information System (RIS) of all patients between 25 and 45 years of age who had undergone X-ray imaging of spine in the years form 2011 to 2018. We separately analysed the number of performed images of the entire spine and the number of images of the lumbar spine. We compared the number of examinations throughout all the observed years and compared it with the data of two other outpatient radiology departments in Slovenia (hereinafter:

center 1, center 2) since their introduction

of RIS (2015). We observed the number of X-ray imagings in CHCL before and after the introduction of consultations and the reallocation of referrals within the two CHCL radiology departments (Vič and Center).

We evaluated the number of all consultations in the years from 2013 to 2018;

we compared the number of patients that underwent X-ray imaging following the consultation (imaging following referral or optimized imaging) with the number of patients who decided to postpone imaging and introduced regular exercise.

In 2016 we conducted a survey of all patients, who had undergone consultation with a radiologist (N = 497) and their referring physicians (N = 134). The referring physicians were invited to evaluate the patient’s treatment by the radiologist, whether any of the patients experienced delays in further treatment due to the consultation and whether they would like us to continue with the practice. We also included comments and the demographics of the survey participants. Each patient was sent a survey about their opinion of the consultation, the reason for the referral for imaging, whether they had undergone the planned imaging and, if they had, the reasons for doing so. Patients also answered questions about regular exercising.

3 Results

The number of all spinal X-ray imagings in patients between 25 and 45 years of age in the CHCL was increasing in the two years preceding the implementation of consultations and after it gradually declined, while the number of imaging continued to increase in the comparison of departments center 1 and 2 (data was available since 2015, when RIS was introduced there (Table 1).

During the six years (2013–2018), 835 patients entered consultation. The total number of consultations that concluded with no imaging was 544, and the number of consultations with imaging (referred or Table 1: Number of performed imagings, recorded in RIS.

Year Center 1 Center 2 CHCL all CHCL Center CHCL Vič 2011

no data available

1853 1238 615

2012 2016 1323 693

2013 1756 1305 451

2014 1793 1247 546

2015 141 189 1607 1153 454

2016 172 380 1559 1041 518

2017 180 349 1435 919 516

2018 231 359 1283 818 465

optimized) was 291 (Figure 1, Table 2). The number of imagings performed versus the number of referred patients in- dicates that an average of 15.3% of patients annually decided to delay imaging and ini- tiate exercise twice a day, which is directly contributable to consultation.

In the CHCL, the number of all performed spinal X-ray imagings has been declining since 2013. This trend is also observed in the number of performed imagings of individual parts of the spine (the Figure 1: Number of performed consulations in years 2013 to 2018.

Table 2: Percentage of performed imagings according to the number of refferals within CHCL (reduction of imaging due to implementation of consultation).

Year CHCL Vič CHCL Center

2013 73.7 100.0

2014 84.8 100.0

2015 84.4 100.0

2016 90.4 100.0

2017 89.6 100.0

2018 85.2 100.0

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optimized) was 291 (Figure 1, Table 2).

The number of imagings performed versus the number of referred patients in- dicates that an average of 15.3% of patients annually decided to delay imaging and ini- tiate exercise twice a day, which is directly contributable to consultation.

In the CHCL, the number of all performed spinal X-ray imagings has been declining since 2013. This trend is also observed in the number of performed imagings of individual parts of the spine (the Figure 1: Number of performed consulations in years 2013 to 2018.

Table 2: Percentage of performed imagings according to the number of refferals within CHCL (reduction of imaging due to implementation of consultation).

Year CHCL Vič CHCL Center

2013 73.7 100.0

2014 84.8 100.0

2015 84.4 100.0

2016 90.4 100.0

2017 89.6 100.0

2018 85.2 100.0

whole spine and lumbar spine), as shown in Figure 2.

Physicians answered the questionnaire in 38% (N = 50) and patients in 30% (N

= 149). Results of the questionnaire for physicians: most of them were family doctors (N = 40; 80%), two (4%) were ortho- pedic surgeons, and other specializations accounted for 16%. After receiving the results of the radiological consultation, nearly all of the surveyed physicians found that the consultation made sense (N = 47;

96%), that the consultation favorably af- fected the patient’s health condition (N

= 22; 45%), and that it was of benefit to the patient (N = 21; 43%). Some thought it had had no effect (N = 6; 12%) or that it had been unnecessary (N = 2; 4%). No physicians thought the consultation had been senseless (N = 0; 0%).

The majority of the surveyed physicians (N = 46; 96%) observed no delay in the diagnostic or therapeutic procedures due to the postponement or withdrawal from the imaging. In two cases, the physicians noticed a delay; one of the patients was referred to a surgeon without imaging. The vast majority of doctors showed a Figure 2: Number of all spinal X-ray imagings, number of lumbar spine X-ray imagings (the most common refferal), number of the whole spine X-ray imagings (refferal with the highest dosage of ionasing radiation) in CHCL.

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positive attitude towards the consultation and wanted it to continue (N = 38; 95%), including the doctor who sent the patient to the surgeon without imaging.

Among surveyed patients, most were women (N = 86; 63%). Nearly half of the responders (N = 68, 49%) have higher or university level education. In most cases, the responders were employed in the service industry or held an office job (N = 91, 67%).

In most cases they were referred to X-ray imaging due to back pain (N = 84;

57%) or pain in several spinal regions (N

= 32; 22%). Patients evaluated the consultation on average with a score of four (4.39 ± 0.880). They mainly evaluated the information provided by radiologists as understandable (N = 136; 97%), useful (N

= 113; 90%), and as new information (N = 91; 73%).

After having consultation, more than half of the patients decided not to undergo imaging (N = 75; 52%). The patients who decided to undergo imaging following the consultation stated the following reasons: they wanted to clear up the issues they were having (N = 37), the issues per- sisted (N = 25), fear of a serious medical condition (N = 16), or they wished to take advantage of the possibility offered by the referral for imaging (N = 4).

Most patients who decided for imaging after postponement had it performed in CHCL (N = 62, 92%). A majority of patients performed exercises during the postponement of imaging (N = 98; 68%), with only a small decrease in the perfor- mance of exercise after the survey was completed (N = 58; 62%).

On average 140 patients between 25 and 45 years of age who were referred for spinal imaging entered consulation per year since 2013.

4 Discussion

Unnecessary investigations are defined as investigations that have negligible impact on the course of treatment. The de-

mands of patients in the information era call for greater availability of expert and relevant information and interpretation of it. Unfortunately, with the development of radiological technology, the clinical role of a radiologist has been lost. With the current quantitative (normative) and qualitative (post-imaging writing reports) working standards, the clinical work of a radiologist is reduced to an optional and unvalued personal initiative, in the outpatient care to an optional consultation with the referring physician.

4.1 Comment on the results of the consultation

In the years from 2011 to 2018 the or- ganizational or staffing conditions in the CHCL did not change, neither did the proffessional criteria, with the exception of introduction of the consultation. Centers 1 and 2 were selected for comparison as similar outpatient radiology departments, which also use the RIS program. Despite the difference in the number of investigations carried out over a four-year period, we can see that the trend of the number of investigations in the comparison centers is not reducing, as observed in the CHCL after the consultation was implemented.

In Slovenia we do not yet have a unified database which would enable us to make a more relevant comparison.

Consultation with a radiologist is co- ordinated by an internal regulation at the level of the entire CHCL, so the redistri- bution of the number of spine imaging from other radiology departments to Vič is expected and shows a good response of referring physicians to the new service.

The ratio between consultations with no imaging and those with optimized imaging is changing in favor of the latter, which might imply that reffering physicians are becoming more compliant with current guidelines.

The introduction of consultation (which at this time is not yet a recognized and evaluated service) required a high

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level of motivation and awareness of the entire radiology team. Thus, it is proba- bly the gradual decline in motivation to which the decline in the total number of consultations can be partly attributed. In- forming patients when they schedule for an appointment requires additional time, professional commitment and education of the health care staff. An additional drop in the number of consultations in the years from 2016 to 2018 was caused by the absence of the radiologist who performs the consultations. By 2018, the number of concluded consultations had stabilized at an average of 120 per year.

The response rate to the questionnaire is comparable to that of online surveys, and represents the responding part of the population of patients; generalization would not be appropriate.

Two delays that were reported by surveyed physicians show potential compli- cation when there deterioration of one’s health after postponing the imaging, despite the exclusion of warning signs.

In CHCL we monitor reported adverse events and patient complaints and since the introduction of consultations in 2016 we have not recorded any such events or complaints regarding consultations. With properly used professional expertise and the exclusion of “red flags” we can state that consultation in radiology is a safe practice. Due to personal consultations, a smaller number of X-rays is performed and this reduces exposure of the population to ionizing radiation. Even though radiation doses for observed indications are relatively low compared to computed tomography (CT) (27), our intervention raises awareness among patients and referring physicians and this may in long term relieve the burden on radiology departments due to unnecessary examinations.

Good medical practice that is demand- ed generally in radiology applies also to the clinical consultation. Considering that consultation was evaluated as meaning- ful and necessary by the referring physicians and the patients, we can again try

to achieve a balance between the clinical and technical specialist work in radiology. Patients’ answers to the questionnaire show encouraging response to the idea of taking responsibility for their own health, well-being and self-care (the introduction of exercise). The explanation given by a radiologist may reinforce the patients’ belief and decision that he or she can safely take responsibility to deal with the condition (back pain) and can be actively involved in promoting his or her own health. It is however concerning that more than half of the patients who underwent X-ray imaging after the consultation stated that the reason for imaging was “because they wanted to clarify what the reason for their problem was…”. Referring to X- ray imaging opens a “Pandora’s box” to patients who believe that imaging will answer their question (28).

In addition to consultation with a radiologist, an e-program “Clinical decision support” (29) could be introduced to help referring physicians be better at referring to radiological examinations. Both measures could ensure good practice to both, the referring physician and the radiologist.

According to Health insurance insti- tute of Slovenia (HIIS) radiological examinations are worth more than a specialist consultation (30), which puts the interest of radiologists to perform consultations to test. In December 2016, the Extended Pro- fessional College of Radiology at the Min- istry of Health supported the acquisition of a valid code at HIIS and thus the formal validation of consultation with a radiologist. Not evaluating this service would be an unacceptable inconsistency to patient’s rights.

We need broader professional and po- litical encouragement and focus on appropriate preventative measures before entering specialist treatment. However, the financial impact of such action will only be measurable in the long term. By introducing a consultation, the radiology profession can contribute its share to prevention.

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5 Conslusion

Based on experience of CHCL, we believe that consultation with a radiologist can help reduce the number of unnecessary spinal imagings which is especial- ly important in a sensitive population of

patients aged 25 to 45. It is a simple, legitimate, professionally justified, harmless and affordable service that enables direct personal transfer of professional experience and specific radiological knowledge to the patient.

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