Using evidence-based imaging referral guidelines to facilitate appropriate imaging: Are they all the same?

Area of Science:

• Radiology and Medical Imaging
• Clinical Guideline Concordance
• Emergency Medicine

Background:

• International adoption of evidence-based imaging referral guidelines from professional radiology bodies is common.
• Assessing the concordance of these guidelines is essential for consistent clinical practice.
• Evaluating appropriateness rates in emergency departments is critical for resource optimization.

Purpose of the Study:

• To establish the concordance among three major imaging referral guidelines: ACR (American College of Radiology), ESR (European Society of Radiology), and RCR (Royal College of Radiologists).
• To examine the appropriateness rates of cervical spine imaging in the emergency department.
• To analyze inter-rater agreement using statistical measures like Fleiss' Kappa and Cohen's Kappa.

Main Methods:

• Retrospective analysis of 452 radiography and 153 CT imaging referrals from electronic medical records (October 1st - December 31st, 2022).
• Integration of initial clinical diagnosis with corresponding clinical notes for each case.
• Dichotomization of appropriateness ratings into 'indicated' or 'not indicated' for analysis.

Main Results:

• Cervical spine X-ray appropriateness rates varied significantly (13.3%–75.2%) depending on the guideline used.
• CT cervical spine appropriateness rate was consistently high (90.8%) across all three guidelines.
• Fleiss' Kappa revealed slight agreement for X-ray (κ=0.135) and almost perfect agreement for CT (κ=1.000) among guidelines.

Conclusions:

• Discrepancies in agreement for cervical spine X-ray guidelines complicate audits and impact output.
• Near-perfect agreement for CT cervical spine guidelines suggests greater consistency in their application.
• Multidisciplinary collaboration enhances CT appropriateness rates, highlighting the need for harmonized guideline development.