Are family physicians' musculo-skeletal imaging requests indicated for diagnostic or clinical management purposes?

Abstract

Research Objectives This research study aimed to address the following objectives: To evaluate the current level of awareness of state health centres general practitioners (G.Ps) about radiation safety and musculo-skeletal imaging referring criteria; To explore the differences between the state health-centres G.Ps’ awareness on these two aforementioned topics in relation to their routes of attainment of the Family Medicine specialization, their years of work experience, their usage of imaging referring guidelines as well as the amount of individually-sought training that has been pursued in relation to radiation safety and the imaging referral criteria; To explore the current beliefs and practices of state health centres G.Ps in imaging referral processes in Malta. Finally, the author also sought to determine whether the patients' exposures to ionizing radiation via plain musculoskeletal radiography are indicated for the diagnostic or clinical management purposes, according to standards defined in the European Commission (Radiation safety 118) Referral Guidelines for Imaging (2001), as well as the Royal College of Radiologists (RCR) i-Refer guidelines (2017). Research Methodology and Data Analysis A non-experimental, exploratory research design was adopted to answer the objectives of this study. Data were collected at two particular points in time; namely through the 694 electronic, musculoskeletal imaging requests that were selected via cluster random sampling, as well as through 39 structured, online questionnaires via non-random, convenience sampling. The data collected were quantitative in nature. The study had a low response rate of 32.8 % from the returned questionnaires, as well as a narrow 3.7 % margin of error (at a confidence level of 95 %) in relation to the analysed imaging request forms. Data were analyzed using descriptive and inferential statistics. A p-value of ≤ 0.05 at a confidence level of 95 % was considered as statistically significant. Results and Discussion On average, the state health centres G.Ps’ awareness on radiation safety measures was lower (mean score of 3.8 out of 9 answers correct / SD 1.9) when compared to their awareness on the musculo-skeletal imaging referral criteria (mean score of 12 out of 16 answers correct / SD 2.1). Moreover, the mean total awareness scores on these two aforementioned topics was noted to be higher in those: G.P. respondents who had obtained their Family Medicine specialization through the completion of the G.P. training programme as opposed to those who have benefited from the grand-father clause; G.P. respondents who have between 3 to 8 years of work experience as opposed to 16 or more years of work exprience, G.P. respondents who have made use of imaging referral guidelines throughout their respective careers; G.P. respondents who have personally taken the initiative to update themselves on the imaging referral criteria. Furthermore, only 20.5 % of plain, musculoskeletal imaging requests that are being referred by state health centres G.Ps are classified as indicated for the diagnostic or clinical management purposes. In addition, 65.3 % of plain, musculoskeletal imaging requests were classified in the not routinely indicated category. The lumbo-sacral spine is the region that has registered the highest number of cases in the not routinely indicated category; being closely followed by the knee and the cervical spine respectively. These findings indicate that there is a greater tendency for state health centres G.Ps to request plain, musculoskeletal imaging investigations which are not routinely warranted according to the European Commission RP118 (2001) or the RCR i-Refer (2017) gold-standard imaging referral guidelines. Moreover, 40.0 % of these imaging requests were also referred with insufficient clinical details. Conclusions and Recommendations Based on the research findings as well as the available literature, the following recommendations are being suggested: Continuing medical education in radiation safety and the imaging referral criteria for state health centres G.Ps and G.P. trainees; Issuing regular departmental memos about any related evidence-based research findings; Ensuring the availability of the imaging referral guidelines on the desktops of all workplace computers, and promoting the use of imaging referral guidelines as well as kindling the safety-net of asking for advice from senior colleagues or radiologists whenever the referrers are in doubt about the management of a particular clinical case; Promoting the development of refinements and updates of locally applicable imaging referral guidelines to address any potential gaps in the older versions; Considering the introduction of a pro-forma clinical checklist for requesting plain imaging investigations on iClinical Manager™, to aid G.Ps in improving the appropriateness of their imaging requests at times of clinical controversy, as well as in providing all the relevant clinical details for reporting; Extending the radiation protection campaign which was founded by the local, state hospital Medical Imaging Department to both the Primary Health Care Department (Malta) as well as to members of the general public and considering the use of radiation protection booklets or posters that may be distributed or show-cased to the patients whilst still in the primary care clinics waiting areas.