1. African Regional Workshop on Imaging Referral Guidelines Setting the scene: Objectives & Overview Denis Remedios Clinical Radiologist, Northwick Park Hospital, UK On behalf of the IAEA

2. African Regional Workshop on Imaging Referral Guidelines: Cairo, 13-16 December 2015 With thanks to: International Atomic Energy Agency World Health Organization Egyptian Atomic Energy Authority Acknowledgement:

3. The need for radiation protection Diagnostic radiology in USA accounts for as much radiation than natural causes (15% in 1980 to 48% in 2006) NCRP 160 http://www.ncrponline.org/ http://www.ncrponline.org/ CT exams have increased at 10% pa in USA from 3-80 million since 1980 44% of CT exams not justified in USA Hadley JL, Agola J, Wong P. AJR 2006; 186: 937-942 http://www.ncbi.nlm.nih.gov/pubmed/16554560 http://www.ncbi.nlm.nih.gov/pubmed/16554560 Low level of knowledge of dose; only 1:3 doctors received formal training in radiation protection Soye & Paterson. BJR 81 (2008),725-729 http://bjr.birjournals.org/cgi/content/abstract/81/969/725 http://bjr.birjournals.org/cgi/content/abstract/81/969/725

4. “Awareness, Appropriateness & Audit” Triple A http://www.ncbi.nlm.nih.gov/pubmed/21343316 http://www.ncbi.nlm.nih.gov/pubmed/21343316

6. Joint Position Statement by the IAEA and WHO

7. Criteria for choice of investigations Investigations are recommended according to the following criteria: 1.Clinical effectiveness (evidence- based diagnostic/therapeutic impact) 2.Effective dose (effective low or no dose investigations preferred) 3.Cost-effectiveness (cheaper equally effective investigation preferred) Essential for uniformity of practice

8. The Basic Safety Standards and “Justification”

9. Appropriate Imaging “The best test first” Investigation should answer the clinical question posed Must be a justified investigation: benefit>>risk Recommendations should give latitude for equipment and expertise Appropriate imaging should take into account over- utilisation of imaging in some member states but under- utilisation of imaging in others Cost savings come from avoidance of unhelpful investigations

10. Justification and clinician involvement: Issues Overloaded knowledge base Medical and technical advances Competition for inclusion in curricula/CPD Time challenged Fastest test with shortest wait best? Mixed messages Different guidance from different sources? Patient expectations Historical or geographical bias Unreliable evidence base from the web

11. Justification and clinician involvement : challenges Dissemination of Referral Guidelines Widely and freely available to end-users “If they haven’t heard it you haven’t said it” McLuhan Implementation of guidance decision support tools? “We shape our tools and thereafter our tools shape us” McLuhan Uptake need buy-in by users and preferably ownership “Computers can do better than ever what needn’t be done at all. Making sense is still a human monopoly” McLuhan Monitoring clinical audit, feedback and education “We drive into the future using only our rearview mirror ” McLuhan

12. Justification and clinician involvement: possible solutions Education Undergraduate and Continuing Professional Development. Requests not orders Referral Guidelines from a trusted source, in line with clinical guidance, +/- clinical decision support Monitor with clinical audit Local internal audit (bottom up) External audit (top down) External control by payers legislation

13. African Regional Workshop on Imaging Referral Guidelines: Overview Day 1 Setting the scene- why do we need referral guidelines, what are they, who should use them, what improvements may we get? Day 2 Current status- what measures are in place in African countries; what good practices can be shared Day 3 Strategies for improvement- existing, wanted and needed. Visit to the National PACS. Day 4 The way forward- recommendations for national and international help

14. Break out Groups, Day 2 and Day 3 To enable all participants to share experiences and good practices 2 streams, one in the French language, one in English Chairman and Rapporteur for each group Chair will lead structured discussion Rapporteur will feedback to all participants and provide a framework for recommendations Group 1: Barriers and solutions to appropriate imaging Group 2: Strategies and tools for adopting/adapting, implementing, using and monitoring Imaging Referring Guidelines

15. African Regional Workshop on Imaging Referral Guidelines: Objectives 1.Understand benefits of imaging referral guidelines 2.Guideline implementation: Adopting and adapting for appropriate imaging 3.Introduction to methods for monitoring / audit of appropriate imaging Secondary objectives are: a.To strengthen justification in diagnostic imaging; b.Reduction in unnecessary radiation dose to patients. c.To promote awareness among referrers, radiologists, radiographer and regulators. Clinical champions. d.To address country-specific problems. Awareness, Appropriateness and Audit Referrers, Radiologists, Radiographer and Regulators