imaging guidance for gp commissioning - the royal college ... · pdf...
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Imaging guidance for GP commissioning
First published in 1989, The Royal College of Radiologists (RCR) has produced the referral guidelines, Making the best use of clinical radiology services, to help GPs, clinicians, radiologists, radiographers and other healthcare professionals to determine the most appropriate imaging investigation(s) for a wide range of clinical problems. They provide practical guidance based on the best available evidence, together with expert opinion where evidence is lacking or conflicting.
The principal objectives of the RCR’s guidelines are:
To ensure patients have timely and accurate diagnosis by ensuring doctors and referring clinicians have knowledge of the most appropriate imaging investigation or intervention
To reduce unnecessary exposure of patients to radiation To assist in the efficient and equitable utilisation of available
diagnostic resources.
The process for development of the seventh edition of the guidelines (November 2011) has been formally approved under the NHS Evidence Accreditation Scheme.
The full resource consists of 330 guidelines designed to assist the clinician in selecting the most appropriate investigation for a given diagnostic or imaging problem. The guidelines are split into 12 sections:
Breast disease Cancer Chest and cardiovascular system ENT/head and neck Gastrointestinal system Interventional radiology
Musculoskeletal system Neurological system Obstetrics and gynaecology Paediatrics Trauma Urogenital and adrenal.
This summary lists the indicated investigations for guidelines which relate to the most common presentations in primary care. This list is based on investigations rather than the clinical problems to facilitate the commissioning process. It is not intended as a GP’s substitute for RCR referral guidelines but rather for those commissioning diagnostics wishing to know which essential radiological investigations to commission. The relevant RCR referral guideline is shown, with links to other related UK guidelines. Commissioners may choose to include other specialised investigations, such as MRI shoulder, which are often resource-intensive and usually only undertaken after discussion with the radiologist or in the context of locally agreed protocols.
In these referral guidelines, the doses have been grouped into broad bands to help the referrer understand the order of magnitude of radiation dose of the various investigations.
Symbol Typical effective dose (mSv)*
Examples
None 0 US; MRI
0 <1 CXR; XR limb, pelvis, lumbar spine; mammography
0 0 1–5 IVU; NM (eg, bone); CT head and neck
0 0 0 5.1–10 CT chest or abdomen; NM (eg, cardiac)
0 0 0 0 >10 Extensive CT studies, some NM studies (eg, some PET-CT)
*The average annual background dose in most parts of Europe falls within the 1–5 mSv range (0 0). [Key: US=ultrasound; MRI=magnetic resonance imaging; CXR=chest X-ray; XR=X-ray; IVU=intravenous urography; NM=nuclear medicine; CT=computed tomography; PET-CT=positron emission tomography co-registered with CT.
Access to the full seventh edition of the RCR guidelines is available via subscription – please see www.irefer.org.uk for further details.
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
BREAST
Mammography 0 B03 Breast screening: women 50–70 years old (the precise age for invitation will depend on national screening programmes)
NICE CG41. Familial breast cancer
B04 Breast screening: women >70 years old (the precise age will depend on national screening programmes)
B07 Breast screening: women ≥50 years old who have had augmentation mammoplasty
B09 Clinical suspicion of carcinoma in patients with augmentation mammoplasty (implants)
B15 Breast inflammation
Ultrasound None B08 Breast cancer diagnosis NICE. Guidance on Cancer Services. Improving Outcomes in Breast Cancer: Manual Update
B15 Breast inflammation
CHEST/CVS CXR 0 CC05 Suspected pericarditis or pericardial effusion
CC07 Suspected valvular heart disease
CC08 Suspected heart failure and/or myocarditis
CC21 Pneumonia SIGN 59. Community Management of Lower Respiratory Tract Infection in Adults
CC23 Pleural effusion suspected
CC24 Haemoptysis (including massive haemoptysis) NICE. The diagnosis and treatment of lung cancer (update)
CA12
Lung cancer: diagnosis
NICE. The diagnosis and treatment of lung cancer (update) NICE CG27: Referral guidelines for suspected cancer SIGN 80. Management of patients with lung cancer
CC12 Suspected deep vein thrombosis (DVT)
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
Ultrasound None CC23 Pleural effusion suspected
CC05 Suspected pericarditis or pericardial effusion
Echocardiography None CC07 Suspected valvular heart disease
CC08 Suspected heart failure and/or myocarditis
CT
0 0 0
CA12
Lung cancer: diagnosis
NICE. The diagnosis and treatment of lung cancer (update) NICE CG27: Referral guidelines for suspected cancer SIGN 80. Management of patients with lung cancer
ENT Ultrasound None E04 Thyroid nodules
E08 Neck mass of unknown origin
E09 Salivary obstruction
E10 Salivary mass
GASTROINTESTINAL US None G21 Palpable mass
G27 Jaundice
G28 Suspected gall bladder disease or post-cholecystectomy pain
Barium swallow 0 0 G01 Difficulty in swallowing: high dysphagia
Barium enema 0 0
G16 Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia
NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update
CA23 Colon cancer: diagnosis
NICE CG27: Referral guidelines for suspected cancer NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer RCR. Recommendations for Cross-sectional Imaging
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
CT (incl colonography)
0 0 0 G16
Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia
NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update
G21 Palpable mass
CA23 Colon cancer: diagnosis
NICE CG27: Referral guidelines for suspected cancer NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer RCR. Recommendations for Cross-sectional Imaging
MSK XR 0 M07 Osteomyelitis
M10 Soft tissue mass
M11 Bone pain
M13 Metabolic bone disease
M14 Suspected osteomalacia with pain
M15 Suspected osteoporotic collapse
M16 Arthropathy: presentation SIGN 123. Management of early rheumatoid arthritis
M19 Shoulder instability
M20 Sacroiliac pain
M21 Non-traumatic hip pain including suspected avascular necrosis
M23 Knee pain with locking
M24 Painful prosthesis
Ultrasound None M10 Soft tissue mass
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
MRI None M05 Acute back pain with potentially serious (red flag) features
NICE CG88. Low back pain
M07 Osteomyelitis
M10 Soft tissue mass
M11 Bone pain
M21 Non-traumatic hip pain including suspected avascular necrosis
M23 Knee pain with locking
DEXA 0 M13 Metabolic bone disease
NEUROLOGICAL
MRI None N02 TIA National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)
N03 Demyelinating and other white matter disease NICE CG08. Multiple sclerosis
N04 Space-occupying lesion NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual
N14 Epilepsy (adult) NICE CG20. The epilepsies
CA01
Brain and spinal cord tumours: diagnosis
RCR. Recommendations for Cross-sectional Imaging NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual
CT 0 0 N01 Acute stroke SIGN 108. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention NICE CG68. Stroke DH. National Stroke Strategy easy access version DH. National Stroke Strategy National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
N02 TIA National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)
N04 Space-occupying lesion NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual
N05 Headache: sudden onset, severe; subarachnoid haemorrhage
RCP. National clinical guideline for stroke, Third edition
CA01 Brain and spinal cord tumours: diagnosis RCR. Recommendations for Cross-sectional Imaging NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual
O&G Ultrasound None OG01 Screening in pregnancy NICE. Antenatal care
OG04 Possible early intrauterine pregnancy failure
OG05 Postmenopausal bleeding: to exclude significant endometrial pathology
SIGN 61. Investigation of Post-Menopausal Bleeding
OG06 Suspected pelvic mass
OG07 Pelvic pain, including suspected pelvic inflammatory disease and suspected endometriosis
RCOG. Guideline 32. Management of Acute Pelvic Inflammatory Disease
OG08 Lost intrauterine contraceptive device (IUCD)
OG09 Recurrent miscarriages (3 or more) RCOG. Guideline 17. The Investigation and Treatment of Couples with Recurrent Miscarriage
OG10 Infertility NICE. CG24. Fertility assessment and treatment for people with fertility problems
OG12 Suspected polycystic ovary syndrome NICE. CG24. Fertility assessment and treatment for people with fertility problemsf
CA42 Ovarian cancer: diagnosis RCR. Imaging for Oncology RCR. Recommendations for Cross-sectional Imaging
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
CA48 Cancer of the uterine body: diagnosis RCR. Recommendations for Cross-sectional Imaging NICE CG27: Referral guidelines for suspected cancer
PAEDIATRICS XR 0 P03 Inhaled foreign body (suspected) in children
P22 Ingested foreign body in children
P36 Focal bone pain in children
Ultrasound None P24 Projectile vomiting in infants
P28 Acute abdominal pain in children
P30 Palpable abdominal/pelvic mass in children
P34 Hip pain in children: suspected irritable hip
P35 Limp (no trauma) in children
P37 Clicking hip: suspected developmental dysplasia of the hip (DDH) in infants
P40 Impalpable testis in children
MRI None P17 Back pain in children
TRAUMA XR 0 T10 Neck injury with pain NICE. Head Injury. Triage, assessment, investigation and early
management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury
T14 Thoracic and lumbar spine trauma with pain but no neurological deficit, or patient not able to be evaluated
T15 Thoracic and lumbar spine trauma with neurological deficit with or without pain
T16 Pelvic injury with inability to weight-bear NICE. The management of hip fracture in adults
T19 Shoulder injury
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
T20 Elbow trauma
T21 Wrist injury: suspected scaphoid fracture
T22 Knee trauma: fall/blunt trauma
T23 Acute ankle injury
T24 Foot injury
T25 Stress fracture
T26 Soft tissue injury: foreign body – eg, metal, glass, painted wood, thorns
T32 Sternal injury
Ultrasound None T26 Soft tissue injury: foreign body – eg, metal, glass, painted wood, thorns
MRI None T15 Thoracic and lumbar spine trauma with neurological deficit with or without pain
T25 Stress fracture
CT 0 0 T01 Head injury NICE. Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury
UROGENITAL/ADRENAL Ultrasound None U02 Renal failure
U10 Lower urinary tract symptoms
U11 Scrotal mass or pain
U12 Suspected testicular torsion
U20 Microscopic haematuria
U21 Macroscopic haematuria
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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines
CA32
Kidney cancer: diagnosis
NICE. Guidance on Cancer Services. Improving Outcomes in Urological Cancers. The Manual NICE CG27: Referral guidelines for suspected cancer
CT 0 0 0 U04 Suspected ureteric colic
U21 Macroscopic haematuria
XR 0 U20 Microscopic haematuria
U21 Macroscopic haematuria