Are Maltese General Practitioners’ Musculoskeletal Imaging Requests Indicated for Diagnostic or Clinical Management Purposes? – A Research Study

Research Objectives: This research study aimed to determine whether the patients' exposures to ionizing radiation via plain musculoskeletal radiography are indicated for the diagnostic or clinical management purposes, according to standards defined in the European Commission (Radiation safety 118) Referral Guidelines for Imaging (2001), as well as the Royal College of Radiologists (RCR) i-Refer guidelines (2017). Research Methods: A non-experimental, exploratory research design was adopted to answer the objectives of this study. Data were collected through 694 electronic, musculoskeletal imaging requests that were selected via cluster random sampling. The data collected were quantitative in nature. The study had a 3.7 % margin of error (at a confidence level of 95 %) in relation to the analysed imaging request forms. Data were analysed using descriptive statistics. A p-value of ≤ 0.05 at a confidence level of 95 % was considered as statistically significant. Results: Only 20.5 % of plain, musculoskeletal imaging requests that are being referred by Maltese, state health centres G.Ps are classified as indicated for diagnostic or clinical management purposes. In addition, 65.3 % of plain, musculoskeletal imaging requests were classified in the not routinely indicated category. The lumbo-sacral spine is the region that has registered the highest number of cases in the not routinely indicated category; being closely followed by the knee and the cervical spine respectively. These findings indicate that there is a greater tendency for Maltese state health centres G.Ps to request plain, musculoskeletal imaging investigations which are not routinely warranted according to the European Commission RP118 (2001) or the RCR i-Refer (2017) gold-standard imaging referral guidelines. Moreover, 40.0 % of these imaging requests were also referred with insufficient clinical details. Recommendations: Based on the research findings as well as the available literature, the following recommendations are being suggested: Continuing medical education in radiation safety and imaging referral criteria for Maltese state health centres G.Ps and G.P. trainees; Issuing regular departmental memos about any related evidence-based research findings; Ensuring the availability of the imaging referral guidelines on the desktops of all workplace computers, and promoting the use of imaging referral guidelines as well as kindling the safety-net of asking for advice from senior colleagues or radiologists whenever the referrers are in doubt about the management of a particular clinical case; Promoting the development of refinements and updates of locally applicable imaging referral guidelines to address any potential gaps in the older versions; Considering the introduction of a pro-forma clinical checklist for requesting online plain imaging investigations to aid G.Ps in improving the appropriateness of their imaging requests at times of clinical controversy, as well as in providing all the relevant clinical details for reporting; Organizing a radiation protection campaign to both the Primary Health Care Department (Malta) as well as to members of the general public and considering the use of radiation protection booklets or posters that may be distributed or show-cased to the patients whilst still in the primary care clinics waiting areas.

Knowledge on Irradiation, Medical Imaging Prescriptions, and Clinical Imaging Referral Guidelines among Physicians in a Sub-Saharan African Country (Cameroon)

Background. Clinical imaging guidelines (CIGs) are suitable tools to enhance justification of imaging procedures. Objective. To assess physicians’ knowledge on irradiation, their self-perception of imaging prescriptions, and the use of CIGs. Materials and Methods. A questionnaire of 21 items was self-administered between July and August 2016 to 155 referring physicians working in seven university-affiliated hospitals in Yaoundé and Douala (Cameroon). This pretested questionnaire based on imaging referral practices, the use and the need of CIGs, knowledge on radiation doses of 11 specific radiologic procedures, and knowledge of injurious effects of radiation was completed in the presence of the investigator. Scores were allocated for each question. Results. 155 questionnaires were completed out of 180 administered (86.1%). Participants were 90 (58%) females, 63 (40.64%) specialists, 53 (34.20%) residents/interns, and 39 (25.16%) general practitioners. The average professional experience was 7.4 years (1–25 years). The mean knowledge score was 11.5/59 with no influence of sex, years of experience, and professional category. CIGs users’ score was better than nonusers (means 14.2 versus 10.6; p<0.01). 80% of physicians (124/155) underrated radiation doses of routine imaging exams. Seventy-eight (50.3%) participants have knowledge on CIGs and half of them made use of them. “Impact on diagnosis” was the highest justification criteria follow by “impact on treatment decision.” Unjustified requests were mainly for “patient expectation or will” or for “research motivations.” 96% of interviewees believed that making available national CIGs will improve justification. Conclusion. Most physicians did not have appropriate awareness about radiation doses for routine imaging procedures. A small number of physicians have knowledge on CIGs but they believe that making available CIGs will improve justification of imaging procedures. Continuous trainings on radiation protection and implementation of national CIGs are therefore recommended.