Experts Develop Radiography Guidelines for Low-Yield Anatomic Sites

There’s a need for specific guidelines on the appropriate use of radiography when it comes to potentially low-yield anatomic sites, noted Eddy Zandee van Rilland, MD, lead investigator of a study presented yesterday.

Dr. Zandee van Rilland, a clinical assistant professor at Stanford University School of Medicine in California, and colleagues sought to establish guidelines with a three-round Delphi consensus study focusing on 12 anatomic sites: six orthopedic sites and six ear, nose and throat (ENT) sites. 

According to Dr. Zandee van Rilland, the team found that radiography at certain potentially low-yield anatomic sites is commonly performed for indications that have limited diagnostic value. “We chose to focus on appropriate utilization of radiography given that imaging volumes continue to rise and appropriate resource utilization remains a key challenge in modern health care,” he explained. “Our goal was to develop multidisciplinary and multi-institutional consensus recommendations to promote evidence-based imaging practices for appropriate radiograph utilization at these anatomic sites.”

Robert D. Boutin, MD, a clinical professor of radiology at Stanford University School of Medicine, served as senior author/investigator. According to Dr. Zandee van Rilland, Dr. Boutin was the driving force behind the study, which resulted in 58 expert consensus recommendations.

Rigorous Process Yields Strong Result

A total of 34 subspeciality faculty from 21 major academic centers participated in the study. The experts included 16 radiologists, nine emergency medicine (EM) physicians, four orthopedic surgeons and five ENT surgeons

First, each expert voted anonymously using free-text and structured responses regarding use of radiographs at 12 anatomic sites. Then, the investigators assigned the experts to teams of five or six members, including radiologists, EM physicians and surgeons. Each team focused on two anatomic sites, including ribs and scapula, sacrum and coccyx, sternum and sternoclavicular joint, nasal bone and mandible, facial bone and sinus, and skull and neck soft tissue.
 
The team members performed a literature review then authored four to six consensus statements for each of their assigned anatomic sites. For example, one statement focused on the nasal bone asserts that a CT scan, rather than nasal bone radiographs, is appropriate for the imaging evaluation of trauma when injuries other than nasal bone fracture may be present. 

The full panel voted on each statement and supporting text anonymously via an online voting platform using a 9-point Likert scale. Consensus was reached when at least 80% of experts strongly agreed (scores of 7-9), and their votes were close together. If a statement didn’t meet this standard, it was revised and voted on again. After three rounds, all 58 statements had satisfactory agreement from the experts. 

“I was struck by the rigor and time-intensive nature of the Delphi consensus process,” Dr. Zandee van Rilland said. “Our panel members invested many evenings and weekends engaged in multiple rounds of evidence-based discussions, as well as statement drafting, voting and refinement.”

The process culminated in recommendations that reflected both the panel’s collective clinical expertise and supporting evidence from the literature, he added.

“The consensus recommendations on appropriate radiograph utilization have the potential to improve quality of care by reducing unnecessary radiographic exams, radiation exposure and costs,” Dr. Zandee van Rilland said. “However, additional longitudinal studies are needed to assess the impact of these statements in clinical practice and to facilitate further refinement.”

Access the session, “Optimizing Utilization of Radiographic Exams: Multidisciplinary, Multi-Institutional Expert Consensus Recommendations by Radiologists, Emergency Medicine Physicians and Surgeons from 21 Academic Centers,” (S4-SSMK01-4) on demand at RSNA.org/MeetingCentral