RSNA: How to avoid guideline overload and set the stage for success

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CHICAGO--As hospitals continue to focus on incorporating evidence-based guidelines into radiology, departments must first understand their desired outcomes and their audience, according to a presentation on Nov. 29 at the 97th Scientific Assembly and Annual Meeting of the Radiology Society of North America (RSNA).

The first barrier to incorporating evidence-based techniques is the sheer amount of guidelines, said Marta E. Heilbrun, MD, of the University of Utah in Salt Lake City. Departments face information overload due to the number of recommendations.

To demonstrate this, Heilbrun went to the National Guideline Clearinghouse website, which currently contains approximately 2,600 individual guideline summaries. A search of the term ‘radiology’ brings up 36 different sets of guidelines from 2011 alone.

Heilbrun said that complexity matters, as easier to understand guidelines have been shown to have a greater chance of implementation.

From the hospital’s perspective, different organizations will have different priorities, and these must be discussed before aligning practice to a specific set of guidelines, said Heilbrun. Departments must define their focus on patient satisfaction, costs to their department, costs to their enterprise, or some other goal, as not all guidelines will satisfy all affected parties.

Heilbrun provided the concrete example of deciding when screening mammography should be offered. Hospitals must choose whether they want to lower mortality, improve diagnosis, satisfy patients or manage the utilization of resources. Two high profile sets of guidelines come from the American College of Radiology (ACR)/American Cancer Society (ACS) and from the U.S. Preventative Services Task Force (USPSTF). ACR/ACS guidelines recommend annual screening starting at 40 years of age, continuing as long as the patient is healthy, and promote breast self-exams. The USPSTF guidelines, on the other hand, advise routine screening not start until age 50, ending at age 74, and they don’t emphasize self-exams. They also suggest screening every two years as opposed to annually.

“As you can see, it starts becoming a very complex question,” said Heilbrun, adding that patient satisfaction may be affected if women receive less screening than they expect.

Hospitals must also evaluate their community’s expectations and potential barriers to implementation before settling on a set of guidelines. Heilbrun said an understanding of resources, even something as simple as the size of the parking lot for patients, can inform the decision.

Once a set of guidelines is chosen, Heilbrun recommended the use of decision support technology to aid radiologists. She said an example of the effect of such technology can be seen at Virginia Mason Hospital & Medical Center in Seattle, where the organization studied their utilization rates on target exams after implementing decision support tools. The hospital was able reduce the number of lumbar spine MRIs for back pain, brain MRIs for headaches and sinus CTs for sinusitis, and even though radiology spending dropped, care was shifted to alternate management strategies within the organization.

“We need to shift from looking at a department-centric view to an institution or healthcare system approach,” said Heilbrun.