Referral Guidelines for Imaging Exams: Impact on Exam Relevance and Associated Delays (RIU)

Implementing Referral Guidelines for Imaging Exams Requested Via the Emergency Department: Impact on Exam Relevance and Associated Delays

The main objective of this study is to evaluate the impact of the implementation of referral guidelines for imaging exams requested by the emergency department on exam relevance. The latter is assessed via the rate of suspected diagnoses that are confirmed by the requested exam.

Study Overview

• Status: Completed
• Conditions: Emergency Department Admission; Imaging Techniques
• Intervention / Treatment: Other: Baseline observation; Other: Implementation of guidelines

Detailed Description

The secondary objectives of this study are to assess the impact of the implementation of referral guidelines for imaging exams requested by the emergency department on the following:

A. How exam results are classified in relation to the initial, suspected diagnosis.

B. Further aspects of exam relevance.

C. Delays associated with exams

D. Changes in practice in terms of type of examination, clinical situations, the number of tests ordered per patient, and emergency situations

E. Radiation and contrast agent exposures

• Study Type: Interventional
• Enrollment (Actual): 8549
• Phase: Not Applicable

Contacts and Locations

Study Locations

• France
  • Nîmes Cedex 09, France, 30029
    • CHU de Nimes - Hopital Universitaire Caremeau

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• The patient (or his/her guardian/parent/person-of-trust) was correctly informed about the study
• A participating ER doctor has requested an imaging exam for the patient during one of the trial observation periods (ie the "before" period or the "after" period).

Exclusion Criteria:

• The patient is under judicial protection
• The patient (or his/her guardian/parent/person-of-trust) refuses to participate in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Before guideline implementation; This study population consists of all patients for whom a participating ER doctor requests an imaging exam during the observation period BEFORE the implementation of the referral guidelines. [This study is composed of (1) a period of observation for 1 month BEFORE the implementation of the referral guidelines, followed by (2) the implementation of the referral guidelines, then (3) a 5-6 month washout period, and finally (4) a 1 month observational period AFTER the implementation of the referral guidelines.] Intervention: Baseline observation	Other: Baseline observation; During this period of the study, baseline data will be collected.
Other: After guideline implementation; This study population consists of all patients for whom a participating ER doctor requests an imaging exam during the observation period AFTER the implementation of the referral guideline. [This study is composed of (1) a period of observation for 1 month BEFORE the implementation of the referral guidelines, followed by (2) the implementation of the referral guidelines, then (3) a 5-6 month washout period, and finally (4) a 1 month observational period AFTER the implementation of the referral guidelines.] Intervention: Implementation of guidelines	Other: Implementation of guidelines; The participating ER doctors are required to request imaging exams for their patients according to a guide mutually constructed by the emergency and imaging departments of the Nîmes university hospital.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in the % of initial, suspected diagnoses that are confirmed positive by the requested exam	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in the classification of exam results in relation to initial, suspected diagnosis	Qualitative variable: (i) the suspected diagnosis is confirmed; (ii) the suspected diagnosis was not confirmed, the exam was normal; (iii) the suspected diagnosis was confirmed, and another unsuspected pathology was also found; (iv) the suspected diagnosis was not confirmed, and another unsuspected pathology was found. Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the % of requested exams that do not conform with the exam recommended by the implemented guidelines	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the positivity rate for each suspected diagnosis	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the % of exams performed identical to the exam requested	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the average delay between the time marked on the request and the exam.	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the average delay between the time marked on the request and the distribution of written exam results.	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the number of admissions in the emergency department	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the number of requests for imaging exams made by the emergency department	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the % of patients admitted to the emergency department and needing an imaging exam.	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the frequency of each type of exam carried out.	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the frequency of each type of clinical situation associated with imaging exams.	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the average number of imaging exams requested per patient	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the frequency of imaging exams requested per type of emergency situation	vital; imaging needed in 4 - 6 hours; imaging needed in 6 to 24h, scheduled for hospitalisation, external demand, social requirements Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the % agreement between the clinical situation coded by the emergency doctor and the radiologist	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the total radiation exposure per patient	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the frequency of injection of contrast agents	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines
Change in the frequency of patients requiring contrast agents AND whose exam results are classified as "the suspected diagnosis was not confirmed, exam normal"	Measured over an observation period of 1 month.	baseline (days 0 to 30) versus the 6th month after implementation of guidelines

Collaborators and Investigators

• Sponsor: Centre Hospitalier Universitaire de Nīmes
• Investigators: Principal Investigator: Patrick Richard, MD, Centre Hospitalier Universitaire de Nīmes

Study record dates

Study Major Dates

• Study Start: October 1, 2013
• Primary Completion (Actual): June 1, 2014
• Study Completion (Actual): June 1, 2014

Study Registration Dates

• First Submitted: February 5, 2013
• First Submitted That Met QC Criteria: February 5, 2013
• First Posted (Estimate): February 7, 2013

Study Record Updates

• Last Update Posted (Estimate): March 26, 2015
• Last Update Submitted That Met QC Criteria: March 25, 2015
• Last Verified: March 1, 2015

More Information

Terms related to this study

• Keywords: guidelines; referral guidelines; exam delays; exam relevance
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Emergencies
• Other Study ID Numbers: LOCAL/2012/PR-01