CHALLENGES AND OPPORTUNITIES FOR AFRICA TO ENHANCED JUSTIFICATION IN THE USE OF REFERRAL GUIDELINES

Michael. G. Kawooya: ECUREI. Uganda.

OBJECTIVES

List the challenges to enhancing justification

List the opportunities to enhancing justification

“Doing the Right thing Right”

CHALLENGES

Challenges Insufficient risk awareness, arising from

insufficient risk assessment Absence of referral guidelines Lack of a radiation safety culture Resorting to imaging as means of diagnosis &

as a substitute to thorough clinical assessment Self-referral Self –presentation Litigation pressure Unnecessary information void between

referrers, and radiologists, radiographers & patients.

Challenges 2

(i) Poor or absent legislative and regulatory framework for radiation protection in many countries

(ii) Challenges to match health work force supply and demand: few physicians & radiology personnel

Challenges 3

iii) some prescriptions for medical imaging are probably written by none-physician staff

(iv)There are no imaging RGs and no national policy on their application

(v) A significant proportion of imaging equipment including CT, privately owned : self-referral

(vi) (vi) Imaging professional societies are in their formative stages and yield little influence on policy.

Insufficient human resource

Global Summit on Radiological Quality and Safety

10-11 October 2015, Barcelona

Approximate number of radiologists per country

COUNTRY

Total number of radiologists

National population

Radiologist to population.

South Korea

3,764 49,115,196 1:13,049

Australia and N. Zealand

Australia 1950, N. Zealand 398

27,222,014 1:11,593

Denmark

800 5,678,348 1:7,097

France 7,500 64,641,279 1:8,618

UK 3,000 64, 679, 700 1:21,559

US 33,659 321,216,397 1:9543

Canada 2,000 35,344,962. 1: 17,672

Latin America (Chile)

******

Global Summit on Radiological Quality and Safety

10-11 October 2015, Barcelona

Approximate numbers of radiologists per country

COUNTRY Total number of radiologists

National population

Radiologist to population

Egypt 1,250 (By year 2012) 83,386,739 1:66,709

Tunisia 450+ (By year 2012)

10,225,100 1:22,722

Kenya 170 46, 445 079 1:27,3206

Uganda 45 40, 386 141 1:897,470

Tanzania 40 52,290,795 1:1,307,269

Nigeria 350 178,516,904 1:510,048

S. Africa 799 54,770 560 1:68,548

Ethiopia 160 98,942,102 1:618,388

D.R. Congo 42 74,834,231 1:1,781767

Malawi 2 17, 602 259 1: 8,801,129

Angola 30 19,088,106 1:636,270

Mozambique 5 24,692,144 1: 4,938,428

Sao Tome 2 190,428 1:95,214

Guinea -Bissau

2 1,693,398 1: 846,699

Cape-Verde 3 538,535 1:179,511

Global Summit on Radiological Quality and Safety

10-11 October 2015, Barcelona

Proportion of Radiologists in Rural areas

COUNTRY PROPORTION WORKING IN RURAL (%)

Korea 47.3

Australia and N. Z. Australia = 13.5, N.Z.= 10

Denmark Hardly any( no rural areas)

France France : unknown

UK 30

US 10

Canada 5-10

Latin America ******

Global Summit on Radiological Quality and Safety

10-11 October 2015, Barcelona

Proportion of Radiologists in Rural areas

COUNTRY PROPORTION WORKING IN RURAL (%)

Egypt ********

Tunisia *********

Kenya 10%

Uganda 10

Tanzania <1

Nigeria 10-15

S. Africa <1

Ethiopia 5-10

D.R. Congo 10

OPPORTUNITIES 1

Global interest in safety and justification Global agencies IAEA, WHO that offer

assistance through workshops, sponsorships of trainees and provision of standards, guidelines and tools for justification.

BSS and Bonn call for action Interest from several national health

authorities in radiation safety Creation of professional societies

OPPORTUNITIES 2

Evidence-based guidelines which can be adopted and adapted are already available Eg ACR appropriate criteria, Royal College of Radiologists (UK), Diagnostic Imaging Pathways (Australia) and the ISR- ICRQS.

Imaging campaigns (AFROSAFE, Eurosafe, Latin-SAFE, Image Gently, Image Wisely etc).

Wider range of Imaging equipment, including none-ionising alternatives like MRI and Ultrasound now available in several countries.

Training institutions and trained personnel becoming more available in several countries.

Increased patient awareness and synergies with Patient for Patient Safety (PFPs) initiatives.

THE ROLE OF GLOBAL AGENCIES

WORKSHOPS FACILITATED BY IAEA & WHO TARGETTED TO AFRICA

ADDRESSING JUSTIFICATION AND REFERRAL GUIDELINES

9TH TO 13TH NOV 2015

The Bonn Call for Action (Dec 2012)

1. Enhancing implementation of justification of procedures

2. Enhancing implementation of optimization of protection and safety

3. Strengthening manufacturers’ contribution to radiation safety

4. Strengthening RP education and training of health professionals

5. Shaping & promoting a strategic research agenda for RP in medicine

6. Improving data collection on radiation exposures of patients and workers

7. Improving primary prevention of incidents and adverse events

8. Strengthening radiation safety culture in health care

9. Fostering an improved radiation benefit-risk-dialogue

10.Strengthening the implementation of safety requirements (BSS) globally

http://www.who.int/ionizing_radiation/about/med_exposure/en/index3.htm https://rpop.iaea.org/RPOP/RPoP/Content/News/bonn-call-for-action-joint-position-statement.htm

The New BBS and the Justification Principal

Justification principle: 3 levels Overarching justification of medical

exposures: use of radiation in medicine does more good than harm.

Generic justification : ( carried out by the health authority in conjunction with appropriate professional bodies), for a given radiological procedure, a new technologies or techniques.

Final level of justification: application of the radiological procedure to a given individual has to be considered.

IAEA Safety Standards For Protecting People And The Environment International

Atomic Energy Agency, Vienna 2014.

Requirement 37: New BSS: Justification of Medical procedures

(Level 1 &2)

Justification for an individual patient (level 3)

TOOLS FOR FACILITATING DIALOGUE AND JUSTIFICATION

WHA GENEVA MAY 2015Adapted from Maria Perez. WHO

WHO in consultation with experts including ISR members is finalizing a tool on radiation benefit and risk communication in pediatrics. Health authorities to support its use.

RADIAITON SAFETY AWARENESS: TOOL FOR RADIATION BENEFIT & RISK COMMUNICATION IN PEDIATRIC IMAING

INTEREST BY AFRICAN NATIONAL HEALTH

AUTHORITIES IN RADIATION SAFETY

WHA 68-SIDE EVENT

SPONSORED BY GOVTS OF KENYA, UGANDA, MALAYSIA AND SPAIN

KENYA DIRECTOR GENERAL OF HEALTH LAUNCHES AFROSAFE; 17TH FEBRUARY 2015

UGANDA COMMISIONEMINISTRY OF HEALTHLAUNCHESUGANDA CHAPTER AFROSAFE 7TH NOV 2015

INTEREST BY AFRICAN NATIONAL HEALTH AUTHORITIES IN RADIATION SAFETY

FORMATION OF AFRICAN RADIOLOGY SOCIETIES

FORMATION OF AFRICAN RADIOLOGY SOCIETIES

CONTINENTAL IMAGING CAMPAIGNS

CONTINENTAL IMAGING CAMPAIGNS

LATIN-SAFE!!!! 2015?

2006

2010

2015

2014

AFROSAFE

WHA GENEVA MAY 2015

AFROSAFE LAUNCH FEB 8TH 2015; PACORI NAIROBI KENYA

Health authorities to support these campaigns 11-13 .

AFROSAFE IMPEMENTATION TOOL AND LAUNCH OF UGANDA CHAPTER

PATIENT ENGAGEMENT: PATIENT SAFETY

Patient engagement through Patient for Patient Safety

Justification should be contextual and patient centered: patients’ values, opinions & perspectives have to be considered.

Imaging Referral Guidelines: A Key Tool for Justification

• Few available regularly updated evidence-based (EB) referral guidelines

• IRQN (ICRQS), in liaison with WHO developed referral guidelines (RG): published in 2014 thru adopting & adapting available E-B guidelines .

• RG guide referring medical practitioners in justification of imaging for children & adults

• Available for use on ISR website 10.

http://isradiology.org/isr/docs/quality/IRQN_RGDI2014PilotVersion.pdf

REFERRAL GUIDELINES

HEADACHE

Imaging in a child with headache but without associated neurological symptoms, signs or ‘red flags’; is rarely beneficial and is not indicated.

In a child with neurological symptoms, signs or ‘red flags’, the imaging modalityof choice is either MRI or CT (Lewis et al 2002, Millichap 2011).

In general, MRI is preferred since it avoids the use of ionizing radiation.

Some African countries offering training for radiologists

COUNTRY TYPE OF TRAINING DURATION OF TRAINING IN YRS

Egypt Masters degree and Fellowship

Masters 3, Fellowship 4

Kenya Masters degree 4

Uganda Masters degree 3

Tanzania Masters degree 3

Ethiopia Masters degree 3

D.R. Congo Masters degree 5

Nigeria Fellowship 5

S. Africa Fellowship 5

Tunisia Fellowship 5

SUMMARY

Major challenges which include awareness and insufficient human resource

Opportunities including collaboration with global agencies, global campaigns, AFROSAFE, available guidelines for adopting and adapting.