Meeting considers exposure to radiation through medical imaging

Report from the Technical Meeting IAEA-WHO

WONCA is concerned about the impact of exposure to radiation through medical imaging, and the risks of unnecessary exposure due to inappropriate or excessive investigations. WONCA has been working with the World Health Organization (WHO) and the International Atomic Energy Agency (IAEA) to look at ways to improve the appropriateness of imaging, and to measure each person's cumulative exposure to radiation from imaging.

In recent years WHO and International Atomic Energy Agency (IAEA) have been making a significant effort to promote the correct use of radiological examinations. In particular, the principles of justification and optimisation have been stated, to increase the appropriateness of imaging and to reduce the level of delivered radiation dose.

A technical meeting on the justification of medical exposure and the use of appropriateness criteria was held at the IAEA's Headquarters in Vienna, Austria, from 9 to 11 March, 2015.

The organisers invited WONCA to take part in the meeting to put forward the point of view of family doctors (FDs), in order to seize the opportunity to examine the problem.

The process of justification uses an evidence-based approach to choose the best test for a given clinical scenario, taking into account the diagnostic efficacy of the radiological procedure, as well as alternative procedures that do not use ionizing radiation. The meeting had as key point of the discussion the development and deployment of Clinical Imaging Guidelines and their implementation in Clinical Decision Support systems. Developing good guidelines is not enough; it is important to reach the users, by placing the guidelines at the ready disposal of the referrer with a simple click in the Clinical Decision Support system.

From 20 to 50% of imaging examinations are considered inappropriate. The justification principle is too often not fulfilled. Awareness of the referrers (family doctors among them) of radiation risks is very low worldwide.

The Clinical Imaging Guidelines are considered a key tool to overcome these problems and an important support to doctors in daily practice.

The Clinical Imaging Guidelines sit well with family doctors’ work, because they are not “vertical” guidelines, which are based on a complete management of a disease, but “horizontal”, and oriented to a diagnosis, based mainly on symptoms and syndromes.

Not every country is able to develop Clinical Imaging Guidelines, because developing guidelines is time and resource intensive. A possible approach for some countries is to adapt and adopt international Clinical Imaging Guidelines, or Clinical Imaging Guidelines tested in other countries. There was a large discussion concerning many issues, particularly:
- how develop and deploy Clinical Imaging Guidelines in the countries with lack of technologic infrastructure;
- the role of the IAEA and the WHO in supporting the process of developing Clinical Imaging Guidelines;
- how to enable countries with similar infrastructure and concerns to work collaboratively;
- the necessity of adapting Clinical Imaging Guidelines at a national level particularly in countries with lack of expertise and equipment.

There was also a discussion about the education of doctors and patients. Education on diagnostic radiation is considered crucial at every level of instruction of doctors : undergraduate, post-graduate, and in continuing medical education. It should be oriented to increase awareness of the biologic harm of ionizing radiation, delivered doses, use of the Clinical Imaging Guidelines, and skills in communication of benefits and risks of radiologic investigations to the patients.

Individual patient education is also very important. Education by the referrers is important, especially by family doctors, who maintain a continuous relationship with patients based on trust. Individual education is part of a unique process of: information, education, involvement in decision-making. The Clinical Imaging Guidelines could give significant support to doctors for patient education. Also for this reason there was unanimous agreement about the need of involving family doctors in the core group of stakeholders to develop and deploy Clinical Imaging Guidelines, at international and national levels.

Experiences on the utilisation of Clinical Imaging Guidelines in Clinical Decision Support systems were illustrated by representatives of several countries during the meeting.

For the future programs of IAEA-WHO, involvement of regulatory stakeholders and national health authorities has been planned to promote a larger utilization of Clinical Imaging Guidelines.

WONCA intends to pursue the collaboration with WHO and IAEA to improve appropriateness of radiologic examinations and involve colleges and academies of general practice to cooperate at national level in developing and deploying Clinical Imaging Guidelines.

Ernesto Mola