rischio radiologico (ernesto mola e giorgio visentin)
TRANSCRIPT
Justification principle & Family Doctors
Ernesto Mola (MD) World Organization of National Colleges,
Academies and Academic Associations
of General Practitioners/Family Physicians
(WONCA)
Wien 10° March 2016
HERCA - Justification and
optimisation in the medical field1
Objectives
Starting from the content of Euratom BSS 2013
• To describe the responsibilities of Family Doctors (FDs)concerning Justification, as implied in the characteristics ofGeneral Practice
• To define the role of FDs in the strategic approach to appropriateness and radiation risks prevention
• To illustrate the commitments of WONCA aimed to increaseradiation protection culture among doctors and patients
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World Organization of Family Doctors
“The Mission of WONCA is to improve the quality of life of the peoples of the world through defining and promoting its values, including respect for universal human rights and including gender equity, and by fostering high standards of care in general practice/family medicine”
118 Member Organizations In 131 countries 500,000 family doctors 90 per cent of the world’s population.
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Euratom BSS: definition of Justification
“Medical exposure shall show a sufficient net benefit, weighingthe total potential diagnostic or therapeutic benefits itproduces, including the direct benefits to health of anindividual and the benefits to society, against the individualdetriment that the exposure might cause, taking into accountthe efficacy, benefits and risks of available alternativetechniques having the same objective but involving no or lessexposure to ionising radiation.”
“Member states shall ensure that:
all individual medical exposures are justified inadvance”
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European BSS
Article 57
Responsibilities
….
(c) the referrer and the practitioner are involved, as specified
by Member States, in the justification process of individual
medical exposures;
(d) wherever practicable and prior to the exposure taking
place, the practitioner or the referrer, as specified by
Member States, ensures that the patient or their
representative is provided with adequate information relating
to the benefits and risks associated with the radiation dose
from the medical exposure. ....5
European BSS
Article 58
Procedures
Member States shall ensure that:
(a) written protocols for every type of standard medical
radiological procedure are established for each
equipment for relevant categories of patients;
(b) information relating to patient exposure forms part of the
report of the medical radiological procedure;
(c) referral guidelines for medical imaging, taking into
account the radiation doses, are available to the
referrers;....6
European BSS: Justification
• Relies on professional evaluation of comprehensive patientinformation, including previous relevant clinical, imaging,laboratory, and treatment data. The final decision usuallyrequires a clinical assessment and a physical examination,taking into account patient expectations and the psycho-socialcontext
• Provides for a cooperation between referrers and practitioner
• Takes into account the benefits to the community
• Should be based on referral guidelines available to the referrerswhich should support the decision for individual patient, byproviding generic evidence-based criteria.
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What the referrer should
answer
Main causes of unnecessary use of radiology
Has it been done already?Repeating investigations that have been already
done
Do I need it?Undertaking investigations when results are
unlikely to affect patient management
Do I need it now?Investigating too early
Is this the best investigation?Doing the wrong investigation
Have I explained the
problem?
Failing to provide appropriate clinical
information and questions that the imaging
investigation should answer
Are they all needed?
From Maria Perez del Rosario – WHO
Over-investigating
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A x-ray examination process
Patient witha Healthproblem Family doctor
SpecialistX-ray
referral
Practitioner
Physicist
Radiographer
X-ray examination
X-rayreferral
J U S T I F I C A T I O N
O
P
T
I
M
I
Z
A
T
I
O
N9
Characteristics of General Practice
General Practice:• is normally the first point of medical contact..• makes efficient use of health care resources
through coordinating care ….• develops a person-centred approach…..• has a specific decision making process determined by the prevalence and incidence of illness in the community• manages comprehensive care….
World Organization of National Colleges, Academies and Academic Associations
of General Practitioners/Family Physicians
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FDs play an advocacy role "protecting patients from the harm which may ensue through unnecessary screening, testing, and treatment"and have a specific responsibility for the health of the community.
Besides, in many countries, FDs are the gate keepers of the National Health Service, and request most clinical tests for outpatients.
Characteristics of General Practice
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Appropriate Use of Radiation in Medical Imaging
Gate keeper
Bo
oki
ng
Reg
istr
atio
n
Pre
par
atio
n
Exam
inat
ion
Rep
ort
Tran
scri
pti
on
Val
idat
ion
Del
iver
y
QA / Error reduction
Justification Optimization
Patient journey
(adapted from Dr. L. Lau IRQN)
Family doctors can contribute
to both … How?12
How GPs can contribute to both?
• Communication between the family doctor and the imaging specialist affords opportunities for more rational use of imaging (justification)
• Communicating in the request, the clinical question that the imaging procedure is expected to answer, allows the imaging specialists to tailor the protocol and reduce doses to the level of acceptable noise for the given clinical condition (optimization)
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FDs and the strategic approach
Risk assessment
Risk communication
Risk management
Assessing risks and potential impacts
Implementing policies, health interventions
Engaging and communicating with stakeholders
Risk sharingInvolving patients in decision-making process
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What GPs can do
Risk management
• sharing international and local guidelines with specialists, radioligists and health authorities
• communicating with the specialists (cardiologist, orthopaedist, etc.) and the imaging professionals (practitioner, nuclear medicine physician) for a more rational use of imaging
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What GPs can do
Risk assessment
• collecting and recording the exposure history of their patients
• assessing the individual benefit / risk balance
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What GPs can do
Risk communication
•informing patient about his/her individual risk / benefit balance
• explaining risks and benefits to the patient in a way that it is informative and understandable for them (including radiation risks as well as the risk of not performing the examination)
•listening, answering questions, and addressing concerns about radiation risks
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What FDs can do
Risk sharing
• explaining to the patient the reasons motivating the examination (i.e. the clinical question expected to be answered and the consequences on the treatment)
• rather than just collecting an informed patient’s consent, involving the patient in the decision-making process
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Communication is a crucial crossing of the modern health systems
PatientRadiol.
Practitioner
Specialist
FD
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WONCA Resolution
Justification and appropriateness
in radiological diagnostics
to stimulate medical colleges and networks of general practice to develop initiatives in their countries to increase Radiological Protection Culture in Medicine
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Doctors’ Education for RPCM
• Promoting radiological protection culture through educationon radiation safety among all healthcare professionals, in thebasic medical education, specialty training and ContinuingMedical Education (CME)
• Education should:
include knowledge on ionizing radiation sources and relatedrisks, and use of clinical imaging guidelines
develop communication skills and competences to informpatients in an understandable way about risks and advantagesof performing an x-ray procedure, and to give suitableinformation to radiology practitioners.
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WONCA commitments
• To cooperate with other stakeholders to encourage nationalhealth authority to establish regulations, which defineresponsibilities and procedures to make the justificationprocess clear and traceable
• To cooperate with radiology associations, and take part ininterdisciplinary panels, to set or adapt Clinical ImagingGuidelines (CIG) at international and local level
• To cooperate with other stakeholders for an effectivestrategy to spread CIG, implement them in Clinical DecisionSupport systems (CDS) and include CDS in the databasesused by family doctors
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WONCA commitments
• To incorporate in regulations the need to include in thereports of procedures that require IR, the administered dose
• To include into the discharge letters from hospital theoverall dose of IR administered
• To include data concerning previous examinations and IRexposure of each patient in the Patient’s File of the HealthServices, where available
• To include into the FDs’ databases the expectedadministered dose of each examination and an automaticcomputation of the exposure of the patient in the last years,to help the doctor in applying the justification principle
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WONCA commitments
WONCA intends to continue the collaboration with international organizations and institutions to increase appropriateness and pursue justification in radiological procedures
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Thanks for your attention