XXVIII Congresso CSeRMEG 21-22 Ottobre 2016 LA COMPLESSITA' NELLE CURE PRIMARIE www.csermeg.it

1. Justification principle & Family Doctors
Ernesto Mola (MD)
World Organization of National Colleges,
Academies and Academic Associations
of General Practitioners/Family Physicians
(WONCA)
Wien 10° March 2016
HERCA - Justification and
optimisation in the medical field
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2. Objectives
Starting from the content of Euratom BSS 2013
• To describe the responsibilities of Family Doctors (FDs)
concerning Justification, as implied in the characteristics of
General Practice
• To define the role of FDs in the strategic approach to
appropriateness and radiation risks prevention
• To illustrate the commitments of WONCA aimed to increase
radiation protection culture among doctors and patients
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3. World Organization of Family Doctors
“The Mission of WONCA is
to improve the quality of life
of the peoples of the world
through defining and
promoting its values,
including respect for
universal human rights and
including gender equity, and
by fostering high standards
of care in general
practice/family medicine”
118 Member Organizations
In 131 countries
500,000 family doctors
90 per cent of the world’s
population.
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4. Euratom BSS: definition of Justification
“Medical exposure shall show a sufficient net benefit, weighing
the total potential diagnostic or therapeutic benefits it
produces, including the direct benefits to health of an
individual and the benefits to society, against the individual
detriment that the exposure might cause, taking into account
the efficacy, benefits and risks of available alternative
techniques having the same objective but involving no or less
exposure to ionising radiation.”
“Member states shall ensure that:
all individual medical exposures are justified in
advance”
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5. European BSS
Article 57
Responsibilities
….
(c) the referrer and the practitioner are involved, as specified
by Member States, in the justification process of individual
medical exposures;
(d) wherever practicable and prior to the exposure taking
place, the practitioner or the referrer, as specified by
Member States, ensures that the patient or their
representative is provided with adequate information relating
to the benefits and risks associated with the radiation dose
from the medical exposure. .... 5

6. European BSS
Article 58
Procedures
Member States shall ensure that:
(a) written protocols for every type of standard medical
radiological procedure are established for each
equipment for relevant categories of patients;
(b) information relating to patient exposure forms part of the
report of the medical radiological procedure;
(c) referral guidelines for medical imaging, taking into
account the radiation doses, are available to the
referrers;....
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7. European BSS: Justification
• Relies on professional evaluation of comprehensive patient
information, including previous relevant clinical, imaging,
laboratory, and treatment data. The final decision usually
requires a clinical assessment and a physical examination,
taking into account patient expectations and the psycho-social
context
• Provides for a cooperation between referrers and practitioner
• Takes into account the benefits to the community
• Should be based on referral guidelines available to the referrers
which should support the decision for individual patient, by
providing generic evidence-based criteria.
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8. What the referrer should
answer
Main causes of unnecessary use of radiology
Has it been done already?Repeating investigations that have been already
done
Do I need it?Undertaking investigations when results are
unlikely to affect patient management
Do I need it now?Investigating too early
Is this the best investigation?Doing the wrong investigation
Have I explained the
problem?
Failing to provide appropriate clinical
information and questions that the imaging
investigation should answer
Are they all needed?
From Maria Perez del Rosario – WHO
Over-investigating
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9. A x-ray examination process
Patient with
a Health
problem Family doctor
Specialist
X-ray
referral
Practitioner
Physicist
Radiographer
X-ray examination
X-ray
referral
J U S T I F I C A T I O N
O
P
T
I
M
I
Z
A
T
I
O
N
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10. Characteristics of General Practice
General Practice:
• is normally the first point of medical contact..
• makes efficient use of health care resources
through coordinating care ….
• develops a person-centred approach…..
• has a specific decision making process determined
by the prevalence and incidence of illness in the
community
• manages comprehensive care….
World Organization of National Colleges, Academies and Academic Associations
of General Practitioners/Family Physicians
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11. FDs play an advocacy role "protecting
patients from the harm which may ensue
through unnecessary screening, testing, and
treatment"
and have a specific responsibility for the
health of the community.
Besides, in many countries, FDs are the gate
keepers of the National Health Service, and
request most clinical tests for outpatients.
Characteristics of General Practice
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12. Appropriate Use of Radiation in Medical Imaging
Gate keeper
Booking
Registration
Preparation
Examination
Report
Transcription
Validation
Delivery
QA / Error reduction
Justification Optimization
Patient journey
(adapted from Dr. L. Lau IRQN)
Family doctors can contribute
to both … How? 12

13. How GPs can contribute to both?
• Communication between the family doctor and the
imaging specialist affords opportunities for more
rational use of imaging (justification)
• Communicating in the request, the clinical question
that the imaging procedure is expected to answer,
allows the imaging specialists to tailor the protocol
and reduce doses to the level of acceptable noise
for the given clinical condition (optimization)
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14. FDs and the strategic approach
Risk assessment
Risk communication
Risk management
Assessing risks and
potential impacts
Implementing
policies, health
interventions
Engaging and communicating with stakeholders
Risk sharing
Involving patients in decision-making process
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15. What GPs can do
Risk management
• sharing international and local guidelines with
specialists, radioligists and health authorities
• communicating with the specialists
(cardiologist, orthopaedist, etc.) and the imaging
professionals (practitioner, nuclear medicine
physician) for a more rational use of imaging
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16. What GPs can do
Risk assessment
• collecting and recording the exposure
history of their patients
• assessing the individual benefit / risk
balance
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17. What GPs can do
Risk communication
•informing patient about his/her individual risk / benefit
balance
• explaining risks and benefits to the patient in a way that
it is informative and understandable for them (including
radiation risks as well as the risk of not performing the
examination)
•listening, answering questions, and addressing concerns
about radiation risks
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18. What FDs can do
Risk sharing
• explaining to the patient the reasons motivating the
examination (i.e. the clinical question expected to be
answered and the consequences on the treatment)
• rather than just collecting an informed patient’s
consent, involving the patient in the decision-making
process
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19. Communication is a crucial crossing of the
modern health systems
Patient
Radiol.
Practitioner
Specialist
FD
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20. WONCA Resolution
Justification and appropriateness
in radiological diagnostics
to stimulate medical colleges and
networks of general practice to develop
initiatives in their countries to increase
Radiological Protection Culture in
Medicine
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21. Doctors’ Education for RPCM
• Promoting radiological protection culture through education
on radiation safety among all healthcare professionals, in the
basic medical education, specialty training and Continuing
Medical Education (CME)
• Education should:
include knowledge on ionizing radiation sources and related
risks, and use of clinical imaging guidelines
develop communication skills and competences to inform
patients in an understandable way about risks and advantages
of performing an x-ray procedure, and to give suitable
information to radiology practitioners.
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22. WONCA commitments
• To cooperate with other stakeholders to encourage national
health authority to establish regulations, which define
responsibilities and procedures to make the justification
process clear and traceable
• To cooperate with radiology associations, and take part in
interdisciplinary panels, to set or adapt Clinical Imaging
Guidelines (CIG) at international and local level
• To cooperate with other stakeholders for an effective
strategy to spread CIG, implement them in Clinical Decision
Support systems (CDS) and include CDS in the databases
used by family doctors
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23. WONCA commitments
• To incorporate in regulations the need to include in the
reports of procedures that require IR, the administered dose
• To include into the discharge letters from hospital the
overall dose of IR administered
• To include data concerning previous examinations and IR
exposure of each patient in the Patient’s File of the Health
Services, where available
• To include into the FDs’ databases the expected
administered dose of each examination and an automatic
computation of the exposure of the patient in the last years,
to help the doctor in applying the justification principle
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24. WONCA commitments
WONCA intends to continue the
collaboration with international
organizations and institutions to
increase appropriateness and
pursue justification in radiological
procedures
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Thanks for your attention