- Email: [email protected]
A study of open access ultrasound for GPs
ABSTRACTS logist. Fifty-seven (54%) were brain scans, 30 (29%) spinal scans and 18 (17%) were a miscellaneous group including scans of the abdomen. Six (11%) of the brain scans, 10 (33"/,,) of the spinal scans and eight (44%) of the miscellaneous scans were abnormal. In 57 (100%) of the brain scans and 21 (70%) of spinal scans, GPs considered the scan helpful with patient m a n a g e m e n t changed in 44 (81%) and 20 (67%) respectively. In 43 (41%) patients it was considered that referral to hospital for investigation was avoided. An open access C T service for G P s helps avoid patient referral to hospital for investigation. It reduces the waiting time for diagnosis and expedites treatment where necessary. A proportion of the scans m a y have been unnecessary and guidelines would be helpful. CAN P A T I E N T S ' A T T I T U D E S T O M I N O R H E A D I N J U R Y M A N A G E M E N T W I T H O U T S K U L L R A D I O G R A P H Y BE I N F L U E N C E D BY A C A R E F U L L Y W O R D E D H E A D I N J U R Y CARD? D. R E M E D I O S , N. RIDLEY, M. I M A N A , T. W E L C H and G. DE L A C E Y
Department of Diagnostic Radiology and Accident and Emergency. Northwick Park Hospital, Harrow College guidelines clearly state that skull radiography is not indicated for minor head injuries and also outline the importance of a head injury card. Recent studies by McNally et al. (I 992) have highlighted patients' disappointment at not having had skull films taken and showed prolongation of symptoms in dissatisfied subjects. Our aim was to address this adverse response by means of a carefully worded head injury advice card, explaining that continued observations are far more important than skull radiography. Five hundred consecutive patients presenting to the Accident and Emergency Department with minor head injuries were randomly assigned on their discharge to receive either the basic head injury card or an updated and more detailed version. Attitudes, levels of satisfaction and duration of symptoms were assessed using a self-completed postal questionnaire. Early analyses suggest that the modified advice card does improve the level of satisfaction in those patients who came expecting radiography and were initially disappointed at not being radiographed. I M P A C T O F O P E N ACCESS T O G E N E R A L P R A C T I T I O N E R S ' R E Q U E S T S F O R BARIUM E N E M A S S. M A H E S H W A R A N and M. G. W A L L I S
X-Ray Department ( Radiodiagnosis) , Coventry' and Warwickshire Hospital, Coventry In March 1992 open access for GP requests for barium enemas, with guidelines (over 40; change in bowel habit; rectal bleeding), was commenced. A year later the impact was evaluated. In 12 months, 1426 barium enemas were performed. 1386 reports were retrieved and analysed according to GP/out-patient (OP) referral, age, sex, clinical information and findings. There was a 20% increase in examinations, 358 (25%) being G P referrals. Above the age of 40, no difference was found in age distribution or male/female ratio (1:2) between the two groups. There was no difference in the incidence of diverticular disease (GP 40%; OP 42%), or significant pathology (carcinoma, polyp, inflammatory bowel disease, strictures and fistulae) (GP 10%; OP 9%). The yield of carcinomas was greater for G P referrals (GP 4.7%; OP 3.4%). No abnormality was seen in 86~ of the OP referrals of patients younger than 40 years. We conclude that, following open access, G P referrals accounted for 25~ of examinations, without a significant decrease in OP referrals. The yield in the G P requests, with guidelines, were on a par with OP requests. The poor yield in the 40 and under age group warrants stricter guidelines for OP referrals. A C L O S E D L O O P AUDIT O F L U M B A R S P I N E C T S C A N N I N G P. DE V. M E I R I N G , M. G A N D H I and R. A. N A K I E L N Y
337
suspected lumbar disc disease in Sheffield was performed. O f 486 cases, 99 were shown to have disc disease of which 16 had disease at the L3/4 level. O f these 16 cases, 11 were suspected clinically. Analysis of the long-term outcome of the five unsuspected cases showed that in none did the CT findings make any significant contribution. After presentation of these data to our Orthopaedic surgeons, it was agreed to change our protocol and three level scanning is now only performed when clinically indicated or where specified indications are met. After an interval of 9 months, a follow-up study was performed to close the audit loop and assess the impact and efficacy o f the new protocol. All referrals for a 4 m o n t h period were analysed. Of 111 scans for suspected PID, 56 (50%) were done at two levels. The incidence of L3/4 PID was unchanged (2%). As a result of this project, a significant reduction in radiation dose has been achieved in our practice together with some associated reduction in scanning costs. A S T U D Y O F O P E N ACCESS U L T R A S O U N D F O R GPs M. R. GIBSON, A. L. H I N E and P. J. S H O R V O N
Department of Radiology, Central Middlesex Hospital, London Open access ultrasound is not always available to GPs. Such a service has time and resource implications. The primary aims of this study were to assess the effect on patient management, overall value and quality of referrals and reports. All non-O and G ultrasound referrals from five G P practices were prospectively studied. G P s completed questionnaires on referral, on receipt of report and 6 m o n t h s later. Radiologists completed questionnaires after scanning. One hundred and two referrals (68 female, 34 male, mean age 49) for abdominal and small part ultrasound were analysed. Without ultrasound, 67 patients would have been referred to outpatients. After ultrasound only 27 (40%) needed referral. However, 23 of these 27 had their referral delayed by, on average, 21 days. Eight additional referrals were generated by ultrasound. The ultrasound was considered of high or medium value in 88~ of cases by Radiologists and in 100% of cases by GPs. Radiologists considered 94% of referrals to be relevant; GPs considered 93% of reports to be good. The study demonstrates open access ultrasound to be valued by Radiologists and GPs. It dramatically reduces the number of outpatient referrals but can delay the remaining referrals. A small, but significant, number of new outpatient referrals will be generated by ultrasound. DOES AGE AFFECT B A R I U M M E A L R E Q U E S T S F O R INVESTIGATION O F D Y S P E P S I A O R REFLUX OESOPHAGITIS D. M. A. J A C K S O N and C. C O U S I N S
Department of Diagnostic Radiology, Hammersmith Hospital, London In 1990, the British Society o f Gastroenterologists introduced guidelines for investigating dyspepsia, recommending the consideration of treatment without an initial endoscopy for patients under 45 years of age. The recent second edition of guidelines of the Royal College o f Radiologists includes a similar recommendation regarding referral for barium meal (BM). This study was performed to determine if these suggestions influence BM requests. Fifty BMs were performed for a combination of dyspepsia or reflux oesophagitis. Clinical information provided by the requesting doctor was compared with information obtained from the patient in the form of a questionnaire completed during the attendance for the BM. Thirty per cent of patients were under 45 years old. The initiation of therapy prior to requesting a BM was shown in 10% of doctors' requests although a further 51"/,, of patients indicated that they had received treatment prior to the BM request. Of the patients who had received treatment, symptoms were completely resolved in only 10% while the remainder were unchanged or only slightly improved. The demonstrated abnormalities were reflux oesophagitis, hiatus hernia or peptic ulcer in 45 % of the examinations. No other pathology was found in the patients under 45 years old. These results suggest that doctors are following these guidelines in their referral patterns although treatment information is often omitted.
Department of Radiology, Royal Hallamshire Hospital, Sheffield CT scanning is an accepted first line investigation for suspected lumbar intervertebral disc disease (P1D). However, it does involve ionizing radialion and any reduction in the dose involved is desirable. A majority of centres in the U K routinely scan three levels in all cases, even though 90% of PID occurs at the lower two lumbar segments and clinical presentation of disease at higher levels usually has different features. A 2 year retrospective study of all orthopaedic CT referrals for
FLEXITEACH: A N E W C O N C E P T IN R A D I O L O G I C A L EDUCATION P. G I S H E N and N. H. S T R I C K L A N D
Department of Diagnostic Radiology, Royal Postgraduate Medical School, Hammersmith Hospital, London Introduction: Most current radiological film museums follow the format of the American College of Radiologists (ACR) library where films are
Department of Diagnostic Radiology and Accident and Emergency. Northwick Park Hospital, Harrow College guidelines clearly state that skull radiography is not indicated for minor head injuries and also outline the importance of a head injury card. Recent studies by McNally et al. (I 992) have highlighted patients' disappointment at not having had skull films taken and showed prolongation of symptoms in dissatisfied subjects. Our aim was to address this adverse response by means of a carefully worded head injury advice card, explaining that continued observations are far more important than skull radiography. Five hundred consecutive patients presenting to the Accident and Emergency Department with minor head injuries were randomly assigned on their discharge to receive either the basic head injury card or an updated and more detailed version. Attitudes, levels of satisfaction and duration of symptoms were assessed using a self-completed postal questionnaire. Early analyses suggest that the modified advice card does improve the level of satisfaction in those patients who came expecting radiography and were initially disappointed at not being radiographed. I M P A C T O F O P E N ACCESS T O G E N E R A L P R A C T I T I O N E R S ' R E Q U E S T S F O R BARIUM E N E M A S S. M A H E S H W A R A N and M. G. W A L L I S
X-Ray Department ( Radiodiagnosis) , Coventry' and Warwickshire Hospital, Coventry In March 1992 open access for GP requests for barium enemas, with guidelines (over 40; change in bowel habit; rectal bleeding), was commenced. A year later the impact was evaluated. In 12 months, 1426 barium enemas were performed. 1386 reports were retrieved and analysed according to GP/out-patient (OP) referral, age, sex, clinical information and findings. There was a 20% increase in examinations, 358 (25%) being G P referrals. Above the age of 40, no difference was found in age distribution or male/female ratio (1:2) between the two groups. There was no difference in the incidence of diverticular disease (GP 40%; OP 42%), or significant pathology (carcinoma, polyp, inflammatory bowel disease, strictures and fistulae) (GP 10%; OP 9%). The yield of carcinomas was greater for G P referrals (GP 4.7%; OP 3.4%). No abnormality was seen in 86~ of the OP referrals of patients younger than 40 years. We conclude that, following open access, G P referrals accounted for 25~ of examinations, without a significant decrease in OP referrals. The yield in the G P requests, with guidelines, were on a par with OP requests. The poor yield in the 40 and under age group warrants stricter guidelines for OP referrals. A C L O S E D L O O P AUDIT O F L U M B A R S P I N E C T S C A N N I N G P. DE V. M E I R I N G , M. G A N D H I and R. A. N A K I E L N Y
337
suspected lumbar disc disease in Sheffield was performed. O f 486 cases, 99 were shown to have disc disease of which 16 had disease at the L3/4 level. O f these 16 cases, 11 were suspected clinically. Analysis of the long-term outcome of the five unsuspected cases showed that in none did the CT findings make any significant contribution. After presentation of these data to our Orthopaedic surgeons, it was agreed to change our protocol and three level scanning is now only performed when clinically indicated or where specified indications are met. After an interval of 9 months, a follow-up study was performed to close the audit loop and assess the impact and efficacy o f the new protocol. All referrals for a 4 m o n t h period were analysed. Of 111 scans for suspected PID, 56 (50%) were done at two levels. The incidence of L3/4 PID was unchanged (2%). As a result of this project, a significant reduction in radiation dose has been achieved in our practice together with some associated reduction in scanning costs. A S T U D Y O F O P E N ACCESS U L T R A S O U N D F O R GPs M. R. GIBSON, A. L. H I N E and P. J. S H O R V O N
Department of Radiology, Central Middlesex Hospital, London Open access ultrasound is not always available to GPs. Such a service has time and resource implications. The primary aims of this study were to assess the effect on patient management, overall value and quality of referrals and reports. All non-O and G ultrasound referrals from five G P practices were prospectively studied. G P s completed questionnaires on referral, on receipt of report and 6 m o n t h s later. Radiologists completed questionnaires after scanning. One hundred and two referrals (68 female, 34 male, mean age 49) for abdominal and small part ultrasound were analysed. Without ultrasound, 67 patients would have been referred to outpatients. After ultrasound only 27 (40%) needed referral. However, 23 of these 27 had their referral delayed by, on average, 21 days. Eight additional referrals were generated by ultrasound. The ultrasound was considered of high or medium value in 88~ of cases by Radiologists and in 100% of cases by GPs. Radiologists considered 94% of referrals to be relevant; GPs considered 93% of reports to be good. The study demonstrates open access ultrasound to be valued by Radiologists and GPs. It dramatically reduces the number of outpatient referrals but can delay the remaining referrals. A small, but significant, number of new outpatient referrals will be generated by ultrasound. DOES AGE AFFECT B A R I U M M E A L R E Q U E S T S F O R INVESTIGATION O F D Y S P E P S I A O R REFLUX OESOPHAGITIS D. M. A. J A C K S O N and C. C O U S I N S
Department of Diagnostic Radiology, Hammersmith Hospital, London In 1990, the British Society o f Gastroenterologists introduced guidelines for investigating dyspepsia, recommending the consideration of treatment without an initial endoscopy for patients under 45 years of age. The recent second edition of guidelines of the Royal College o f Radiologists includes a similar recommendation regarding referral for barium meal (BM). This study was performed to determine if these suggestions influence BM requests. Fifty BMs were performed for a combination of dyspepsia or reflux oesophagitis. Clinical information provided by the requesting doctor was compared with information obtained from the patient in the form of a questionnaire completed during the attendance for the BM. Thirty per cent of patients were under 45 years old. The initiation of therapy prior to requesting a BM was shown in 10% of doctors' requests although a further 51"/,, of patients indicated that they had received treatment prior to the BM request. Of the patients who had received treatment, symptoms were completely resolved in only 10% while the remainder were unchanged or only slightly improved. The demonstrated abnormalities were reflux oesophagitis, hiatus hernia or peptic ulcer in 45 % of the examinations. No other pathology was found in the patients under 45 years old. These results suggest that doctors are following these guidelines in their referral patterns although treatment information is often omitted.
Department of Radiology, Royal Hallamshire Hospital, Sheffield CT scanning is an accepted first line investigation for suspected lumbar intervertebral disc disease (P1D). However, it does involve ionizing radialion and any reduction in the dose involved is desirable. A majority of centres in the U K routinely scan three levels in all cases, even though 90% of PID occurs at the lower two lumbar segments and clinical presentation of disease at higher levels usually has different features. A 2 year retrospective study of all orthopaedic CT referrals for
FLEXITEACH: A N E W C O N C E P T IN R A D I O L O G I C A L EDUCATION P. G I S H E N and N. H. S T R I C K L A N D
Department of Diagnostic Radiology, Royal Postgraduate Medical School, Hammersmith Hospital, London Introduction: Most current radiological film museums follow the format of the American College of Radiologists (ACR) library where films are