Evidenced Based Practice in Medical Imaging

1. Evidenced Based Practice in Medical Imaging Kevin D. Evans, PhD, RT, RDMS, RVS

2. Objectives of this presentation • Discuss what is Evidence Based Practice. • Review an example of how EBP might be used. • Describe the levels of EBP and how it might effect patient care decisions. • Discuss the future of EBP in the Radiologic Sciences.

3. What is EBP? • Evidence Based Practice is the use of research information to help in recommending to patients the best next step in their health care. • EBP is based on the idea that scientific evidence exists to assist in making decisions for patients. • In Medical Imaging this is a relatively new concept and it is highly dependent on the Internet.

4. How is EBP used clinically? • EBP is dependent on the practitioner using the internet to tap into research that has been conducted in medical imaging to assist in the process of making a decision on the next step in the treatment or diagnosis of a patient. • Primarily the Radiologist would use this as a means to recommend the best next step for a patient or referring physician. • Often Advanced Practice technologists are put in the situation of suggesting studies that are suitable for referring physicians or Radiologists.

5. How does EBP work? • The best example of the use EBP is when a patient’s imaging examination presents with a result that is much like a list of other presentations. • With a difficult to confirm diagnosis and plus a treatment that is not routinely recommended without confirmation, the physician is forced to consider other tests to confirm the diagnosis.

6. An ERB example to consider • A patient enters the ER with a complaint of lower abdominal pain. • The patient is young and has had similar complaints of lower abdomen pain. • The ER physician would like to confirm that the patient has appendicitis. • Lab values have come back from the blood test and indicate a border line white count. • What is the best imaging test for the appendix???

7. An ERB example to consider • The ER physician orders a KUB or abdomen x-ray of the young patient. • The hope was that an obstructed large colon could be seen by an enlarged appendix. • Although gas appears in the right hepatic flexure of the colon…..the RLQ looks good!!???

8. An ERB example to consider • The ER physician is frustrated with the x-ray and now thinks that perhaps an ultrasound of the appendix might reveal the swollen appendix. • Having heard about this at a conference…he orders the exam for this young patient.

9. An ERB example to consider • Although the appendix showed up in one view of the ultrasound, the ER physician doesn’t want to wake up the surgeon on call without being absolutely sure that this is appendicitis. • To make sure he is right, the ER physician orders a CT of the abdomen.

10. ERB can save money and time for the patient • In the example provided, the ER physician used a number of imaging examinations to try to find out the correct diagnosis. • The best way to have approached the diagnosis would have been to used the internet to pull up some literature about the best imaging examination for appendicitis. • Often the technologist can suggest studies to assist the physician.

11. Using research to inform practice • Using the computer to uncover published studies on the efficiency or effectiveness of certain imaging techniques is an example of single search evidence that is being conducted to advise a patient or physician to optimize the diagnosis of the patient and eliminate waste.

12. Types of EBP studies • The lowest order of evidence based studies are those that are considered case studies. • A single case study of using an imaging technique might not work on every patient that comes for this exam. • The next higher order of evidence based studies are those that involve expert reviews of a number of cases that have been encountered in practice. • The author is biased and remarks on cases from their own practice that might involve highly trained individuals and be hard to reproduce. • The best evidence based studies are those that are a systematic review of the existing literature in the field. • The author provides a review of all the published studies involving the use of an imaging technique and suggests that statistically it is not any more reliable than the exam being currently used.

13. Utilization of EBP • The best scenario is to use the existing literature that provides a systematic review of a technique and use that information to inform practice. • Praxis is the term used for research that informs practice and helps to provide patients with the best quality health care without increasing costs. • The KUB demonstrates the appendix obstructing gas in the colon. Low cost and high yield for diagnosis.

14. Utilization of EBP • Review of the literature reveals that Stavros and Rapp in Denver, Colorado are able to demonstrate the appendix on 65% of their patients • What kind of EBP does this represent and should we use this to recommend implementing this study in our ultrasound lab??

15. Utilization of EBP • Dr. Merritt at Thomas Jefferson University published a review of CT cases that have been published and makes recommendations based on the frequency that appendicitis has been diagnosed with this modality and recommends that certain types of patients are not well suited for this kind of exposure and expense. • What type of EBP is this an example of for technologists and physicians?

16. The Future of EBP • EBP in the imaging profession is relatively new and under developed. • The best way to build evidence about imaging techniques is to foster research in our profession and publish the important studies and cases that we encounter. • Case studies will push others to review all the literature published and provide analysis of the technique.

17. Where do studies fit?