Imaging acute knee trauma: Are referral criteria and clinical guidelines used in Belgium?

Transcription

1 Imaging acute knee trauma: Are referral criteria and clinical guidelines used in Belgium? Poster No.: C-2209 Congress: ECR 2010 Type: Scientific Exhibit Topic: Musculoskeletal Authors: M. A. T. Vergauwen, K. L. Verstraete, W. C. J. Huysse; Ghent/BE Keywords: Radiography, Clinical decision rules, Acute knee injury DOI: /ecr2010/C-2209 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Purpose A literature study of clinical practice guidelines for radiology in acute knee trauma was performed, followed by a pilot study in a university emergency department to determine whether physicians use these referral criteria. Methods and Materials A systematic literature search on referral criteria for acute knee trauma was performed. Clinical guidelines were evaluated for quality, validity, potential use and implementation using criteria for both the guidelines and their development. During 4 months an observational pilot study was conducted in all patients referred for acute knee pain to the emergency department of our University Hospital. Interns completed a questionnaire on motivation of the physician-prescriber for requesting radiology, and on adequacy and importance of the requested exam. Results were compared with recommendations from literature. Results 1. Guidelines from literature A search of literature resulted in five clinical practice guidelines for radiology in acute knee pain. I Pittsburgh Knee Rule (PKR) [1] Radiography is recommended if the following criteria are fulfilled: Page 2 of 10

3 - Fall or blunt trauma mechanism - Patient is not able to walk OR < 12y or > 50y II Ottawa Knee Rule (OKR) [2] Radiography is recommended if one or more of the following criteria are fulfilled: - # 55 year old - Tenderness over the fibula head - Isolated tenderness over the patella - Inability to flex the knee > 90 - Inability to bear weight immediately after trauma or in the emergency room III Weber's Rule [3] Radiography is NOT necessary if one or both of the following criteria are fulfilled: - Patient is able to walk without limping - Twist injury without effusion IV Bauer's Rule [4] Radiography is recommended if one or more of the following criteria are fulfilled: - He/she is unable to bear weight on the pathologic knee - There is effusion present - There is ecchymosis present V Rule of Fagan and Davies [5] Radiography is recommended if two or more of the following criteria are fulfilled: - # 55 year old - Effusion - Haemarthrosis Page 3 of 10

4 - Inability to bear weight in the emergency department - History of direct trauma - Point of bony tenderness at any of the following anatomical locations: patella, tibial plateau, femoral condyles or fibular head. Evaluation Fig. 1 shows the five different clinical decision rules and their value. Seven topics were evaluated: -Type of study of development - Sensitivity - Specificity - Potential reduction of number of requests: these percentages show how many radiological requests could have been avoided, if the rule was applied. - Misclassification ratio: these percentages show how many patients got a radiograph when there was no fracture and vice versa. In other words, these are the total percentages of patients who did not end up in the right group (no radiograph vs. radiograph) using the clinical rule. - Deviation of the OKR inclusion/exclusion criteria: this explains to which specific patient characteristics the rule applies. The inclusion and exclusion criteria of the Ottawa Knee Rule are used as the standard. - Last step in development: this gives the last step that was undertaken in development and evaluation of the rule to this date. [1-7] Conclusion The Ottawa Knee Rule is undoubtedly the most qualitative guideline. This decision rule was developed according to the methodology of guideline development as well as with an eye for practical issues. This results in a valid, cost effective guideline which will improve quality of care and decrease costs in the health care if implemented correctly. The Pittsburgh Knee Rule, Bauer's Rule, Weber's Rule and the Rule of Fagan and Davies meet several quality criteria which justify further research to establish validation, cost effectiveness and implementation value. Page 4 of 10

5 2. Belgian guidelines # Belgian guidelines [8] are derived from the European recommendations [9] and distributed by the Belgian provider of social security (RIZIV). Fig. 2 shows the Belgian referral guidelines. Differences from the European referral guidelines are marked in bold. # The development and quality of the European, and therefore the Belgian guidelines are not as good as the guidelines from literature. The criteria in the Belgian referral guidelines are less well defined in comparison to the guidelines from literature. However, Belgian guidelines win in potential and implementation because social, economic and healthcare factors are considered. 3. Results of the Belgian pilot study Fig. 3 shows the results of the Belgian pilot study in percentages (actual numbers between brackets). Highlighted numbers will be discussed. # During 4 months study period, 39 patients were reported to have acute knee pain (male/ female 20/17; mean age 37 [6-91y]). The main complaints were pain and swelling. Radiology was requested in 85% of the patients, while in only 23% a fracture was clinically suspected. The mostly quoted reason to request radiology was 'exclusion of injury', a rather non-specific motivation. # The interns were asked to estimate the change in which the requested examination would show the expected diagnosis. In 54% they expected the imaging study to be negative, based on their own clinical examination. In other words: 54% of the requested radiographs did not provide any additional information. # When the Belgian guidelines were retrospectively applied to all cases, taking into account the pre-imaging clinical diagnosis, 24 of the 33 patients who underwent imaging would not have been sent to the radiology department for imaging. # An important result of this pilot study is that in many cases (39%) a radiological examination is requested based on clinical history and the suspected diagnosis before a physical examination is performed. Page 5 of 10

6 # For each patient, the interns had to estimate their level of confidence in the hypothetical case that no radiological exam would have been performed. In 13 of the 33 cases the interns felt 'very comfortable' if no radiological exam would have been requested. This means that in there opinion these exams were not necessary for diagnosis and treatment of the patients. Images for this section: Page 6 of 10

7 Fig. 1 Fig. 2 Page 7 of 10

8 Fig. 3 Page 8 of 10

9 Conclusion Five well developed guidelines for acute knee trauma are extensively described in literature. (Inter-) national guidelines are equally qualitative. The criteria in the Belgian referral guidelines are less well defined in comparison to the guidelines from literature. However, Belgian guidelines win in potential and implementation because social, economic and healthcare factors are considered. Our pilot study indicates lack of implementation, despite the obvious potential of improving clinical practice and reducing imaging costs. References 1. SEABERG D.C., JACKSON R.: Clinical decision rule for knee radiographs. Am. J. Emerg. Med., 1994, 12, STIELL I.G., GREENBERG G.H., WELLS G.A., MCKNIGHT R.D., CWINN A.A., CACCIOTTI T., MCDOWELL I., SMITH N.A.: Derivation of a decision rule for the use of radiography in acute knee injuries. Ann. Emerg. Med., 1995a, 26, WEBER J.E., JACKSON R.E., PEACOCK W.F., SWOR R.A., CARLEY R., LARKIN G.L.: Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma. Ann. Emerg. Med., 1995, 26, BAUER S.J., HOLLANDER J.E., FUCHS S.H., THODE H.C., JR.: A clinical decision rule in the evaluation of acute knee injuries. J. Emerg. Med., 1995, 13, FAGAN D.J., DAVIES S.: The clinical indications for plain radiography in acute knee trauma. Injury, 2000, 31, NICHOL G., STIELL I.G., WELLS G.A., JUERGENSEN L.S., LAUPACIS A.: An economic analysis of the Ottawa knee rule. Ann. Emerg. Med., 1999, 34, Page 9 of 10

10 7. STIELL I.G., GREENBERG G.H., WELLS G.A., MCDOWELL I., CWINN A.A., SMITH N.A., CACCIOTTI T.F., SIVILOTTI M.L.: Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA, 1996, 275, CONCILIUM RADIOLOGICUM: Richtlijnen voor verwijzing naar beeldvormend onderzoek. Verbond der Belgische Beroepsverenigingen van Geneesheren- Specialisten, EUROPEAN COMMISSION DIRECTORATE-GENERAL FOR THE ENVIRONMENT: Referral guidelines for imaging Personal Information Page 10 of 10