Dr. Priyank Gupta Rashid Hospital Dubai Health Authority Dubai, UAE

Transcription

1 Dr. Priyank Gupta Rashid Hospital Dubai Health Authority Dubai, UAE

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3 Asymptomatic Definition: Having or showing no symptom of disease You are considered asymptomatic if you: Have recovered from an illness or condition and no longer have symptoms Have an illness or condition (such as early stage high blood pressure or glaucoma) but do not have symptoms of it Asymptomatic does not mean absence of disease. Possibility of presence of disease is a premise for investigation

4 Local Scenario UAE is a multinational, multiethnic & multicultural nation with expat population forming more than 80% of total inhabitants. Great variability in patient demographics & disease susceptibility & presentation pattern- difficult to have a uniform approach for all. Different backgrounds of Referring physicians from different schools and training - Different working practice systems. Differing expectations of patients regarding treatment approaches - some patients expect more investigations while some do not. Healthcare system partly social, partly privatized, insurance based system. Investigation decision influenced by patient affordability, access to imaging, approval to insurance. At present no coherent system to integrate guidelines with the insurance providers.

5 DHA situation: DHA RGDI Committee Role RGDI committee formulated with representatives from radiology departments of all DHA establishments 4 hospitals & 20 PHC. CT is available in 3 hospitals. The committee will review the worldwide existing RG & then issue recommendations based on the local need & the best scientific evidence available. DHA RGDI committee is in the process of carrying out surveys and PACS added procedures monitoring systems (Tagging).

6 Local Scenario Are CT examinations on asymptomatic individuals outside screening program being performed? Yes - However only anecdotal information available through shared experiences at common forums. Are these procedures demanded by the patients? Referrals originate from patients, physicians as well as radiologists Do(es) your Authority(ties) actively search for the existence of these practices? An active effort has been initiated this year by RGDI committee to identify such examinations under the common umbrella of Unjustified examinations

7 Local Scenario Does any guideline exist? Is it or would it be allowed from a legal point of view / tolerated in your country? Why? Is this practice controlled/regulated? Does your current regulation mention exposure to asymptomatic individuals? If yes, please provide details. No Legislation/Guidelines existent as of now specifically addressing this issue. Current regulations provide only a generalized framework for all radiological exposures but do not specifically refer to the asymptomatic individuals However, federal regulations do recommend that appropriate justification should be sought before performance of any radiological investigation

8 DHA situation: RPC- RGDI-PACS team Query run in DHA CT database for following keywords in Clinical info: Asymptomatic Check-up Follow-up Screening Apart from the screening program for Breast Cancer using mammography, we do not have any other active screening programs using CT. 25 The query resulted in 66 examinations: patients patients patients 2014( till sep)- 21 patients ( till sep)

9 DHA situation: CT Abdomen 14 CT KUB 17 CT Chest 13 HRCT Chest 10 CT Chest & Abdomen 1 CT Face 4 CT Orbit 2 CT Brain 5 CT Face 6% CT Chest/Abd omen 1% Analysis of Examination types CT Orbit 3% HRCT Chest 15% CT Brain 8% CT Chest 20% CT Abdomen 21% CT KUB 26%

10 Case Scenario 1 Previously diseased now asymptomatic (Follow-up CT) CT KUB for previous h/o renal/ureteric calculus (17) CTPA for previous h/o PE/ DVT CT whole body/ specific part for previous h/o cancer (6) Challenges: Is follow-up CT necessary in asymptomatic patient? When to do the follow-up? How frequently? What is the available evidence?

11 Case Scenario 2 Rule out studies: Without previous imaging: CT head in a patient with GCS 15 & trivial head injury CT chest for Suspicious ingestion of foreign body in asymptomatic child Challenge: Anxious Patient Defensive physician

12 Case Scenario 3 Rule out studies: (Requests for Additional Imaging) With previous imaging: Doing CT chest in patient with incidentally detected abdominal mass CT chest in asymptomatic patient with non-specific CXR finding done for pre-employment/ routine medical checkup (14) CT abdomen for incidentally detected abdominal lesion on USG done for pre-employment/ routine medical checkup (10) Challenge: Defensive medicine Overcautious / overenthusiastic investigation One stop investigation Management of incidentalomas/ indeterminate finding

13 Case Scenario 4 Rule out studies: Risk factor present: CT colonography for family h/o colorectal cancer CT abdomen for family h/o abdominal cancer Coronary / cardiac CTA for ruling out IHD Challenge: Patient reassurance Role of media & industry Create panic about dangers of disease adding to patient anxiety Excessively publicize certain investigations as best techniques to rule out underlying disease

14 Case Scenario 5 Medicolegal indication CT KUB/ CT abdomen for suspected drug carriers / body packers Case Scenario 6 Employment benefit Medical imaging examinations, for instance full body CT, offered by employers to their managerial staff members, as part of their periodical medical checkup

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16 Common challenges a) Patient wishes. Anxious patient due to past or peer experiences Lack of authentic information Imaging provides objective evidence & reassurance b) Role of industry/ Financial/ Self-referral Referrer/ Service Providers take advantage of knowledge deficiency, patient anxiety & lack of awareness on the risk-benefit ratio and promote unwarranted investigations c) Defensive medicine. Imaging safeguards the referrer as well as provider against litigation. d) Role of media. Exaggerated publicity in reporting a medical mistake increased public sensitivity about the subject practitioners practicing defensive medicine Exaggerated publicity about risk & effects of Cancer & the ability of investigations being able to detect early disease increased demand both by patients as well as referrers

17 Gaps to Bridge a) Information Gap Lack of available evidence with radiologists regarding role of imaging in IHA b) Awareness Gap Lack of knowledge in the referring physicians regarding risks of CT Inadequate assessment of benefit vs risks of doing CT c) Dissemination Gap Lack of reliable source available to patients to inform risks vs benefit of use of CT

18 Local Scenario Plan of Action 5. How do (did) you react on these practices? (What would you do?) At Institutional/ Organizational level: Identify the source or originator patient or referrer Establishing a patient-referrer- provider dialogue Understand the concern- reassurance or any other reason Educate patients & referrers about relative risks vs benefits Establish shared responsibility Perform the study if both the referrer as well as patient provide consent no legislation available to authorize the provider the right to deny the investigation

19 Local Scenario Plan of Action How do (did) you react on these practices? (What would you do?) At Regional/ National Authority level (Plan Of Action) Map the occurrence of these practices by establishing a registry /notification system Collaborate with all stakeholders to develop consensus regarding conditions in which use of CT for IHA may be justified Develop common actions with health authorities, social security providers and private insurances to ensure compliance by not reimbursing unjustified CT examinations. Ensure compliance to guidelines by conducting on-site inspections & audits of the referrals

20 Local Scenario Are CT examinations on asymptomatic individuals outside screening program reimbursed by the national health and pensions organization or by private insurance companies? At present public or private insurance providers follow their own justification criteria for reimbursement procedure. Depends on case to case basis - patients family history, past medical / surgical history, risk factors etc. Are these practices/services advertised? Are these services provided by public and/or private entities? Are you aware of some kind of advertisement on this service in your country? If yes, does it seem to you that it is a small or large scale phenomenon? No system available to monitor such activities. No data available to comment.

21 Local Scenario How would you suggest creating awareness to this focus-group? General Measures: Develop national awareness campaign: Organize workshops on justification in imaging for the health-care providers like physicians, referrers, nurses (e.g. WHO- IAEA workshops) Introducing radiation safety education in medical school & residency curriculum. Making radiation safety a part of mandatory education for practicing physicians Making radiation risk & safety communication & informed consent an integral part of radiology referral request Provide information to public on benefits and risks regarding CT examinations through print or electronic media Organizing radiation awareness weeks/days to create awareness in general population about role of imaging

22 Local Scenario How would you suggest creating awareness to this focus-group? Specific Measures: Establish need: Introducing pre-approval for such requests & Adopting a policy on providing radiologist consultation to the referrer as well as asymptomatic patient presenting for such CT investigations To understand patient s concern To provide available evidence & explain risk vs benefit to patient To take informed consent Establish Evidence: To maintain a registry & conduct periodic audits on such requests and share the results with referring clinicians to assess the clinical utility & long-term significance of doing CT for IHA in different categories of asymptomatic patients Establish Guideline: Establish a dedicated group/committee consisting of radiologists as well as specialists to make recommendations on the indications in which CT in asymptomatic patients is justified

23 Summary CT examinations on asymptomatic individuals is not considered a common practice. However, there is an increased concern on the rising utilization trends due to increased availability & access to CT Specific guidelines are needed for conditions in which the use of CT in IHA may be justified. A regulatory framework to address the issue specifically is necessary to ensure compliance to guidelines There is a need to increase awareness regarding justification in imaging among the public as well as the health care providers to help both take an informed decision Regular audit should be an integral part of imaging practice to highlight unjustified imaging & identify knowledge or practice gaps. Concerted effort by all stakeholders will ensure appropriate use of imaging

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