Effect of continuous medical education and clinical imaging guidelines on reducing inappropriate computerized tomography utilization among children and young patients in a resource -limited settings: A before-and-after study
Authors: Kisembo Harriet Nalubega , Malumba Richard , Nsereko Ezra Kato , Babirye Deborah , Nakalanzi Victoria , Kasujja Francis Xavier , Malwadde Elsie-Kiguli , Rutebemberwa Elizeus , Kasasa Simon , Salama Dina Husseiny , Kawooya Michael Grace 
Published: August 2024

Background

Multi-Detector Computed Tomography (MDCT) has revolutionized healthcare delivery, significantly improving diagnostic accuracy and patient outcomes in various clinical settings. However, the overuse of CT examinations (CTEs), especially in resource-limited settings (RLS), poses a substantial public health challenge. Inappropriately performed CTEs, particularly among children and young adults, expose these vulnerable populations to unnecessary radiation risks, with 20%-50% of CTEs deemed inappropriate, and 10%-20% involving children. Despite the existence of evidence-based interventions like clinical imaging guidelines (CIGs) to curb this overuse, their availability and effectiveness in RLS are not well established.

Objective

This study aimed to determine the impact of continuous medical education (CME) and the introduction of clinical imaging guidelines (CIGs) on the appropriateness of CT utilization among children and young adults in selected hospitals in Uganda.

Materials and Methods

A before-and-after study design was employed to assess the effect of an intervention comprising CME and CIGs on appropriate CTE utilization. The intervention targeted healthcare providers (HCPs) across six public and private tertiary hospitals with available CT services over a 12-month period. Baseline data indicated a high prevalence of inappropriate CTEs among the target population. The proportion of CTEs performed for various body regions (head, paranasal sinuses, chest, abdomen, spine, trauma) and their appropriateness were retrospectively analyzed before and after the intervention, using the European Society of Radiology’s iGuide and pre-intervention study results as benchmarks.

Results

Post-intervention, the total number of CTEs performed increased by 33% (909 vs. 1210), with a 30% increase in public hospitals (300 vs. 608, p < 0.001) and a 41% increase in private-for-profit hospitals (91 vs. 238, p = 0.037). Specific increases were observed in head CTs (19%, 746 vs. 890, p < 0.0001) and contrasted studies (252%, 113 vs. 410, p < 0.0001). Conversely, CTEs for trauma decreased by 8% (499 vs. 458, p < 0.0001). Despite these changes, the overall proportion of inappropriate CTEs increased by 15% (38% vs. 44%, p < 0.001), with a 28% increase in inappropriate contrasted examinations (25% vs. 53%, p < 0.001) and a 13% increase in non-trauma cases (66% vs. 79%, p < 0.001). Notably, inappropriate CTEs for non-contrasted and trauma-related cases reduced by 28% (75% vs. 47%, p < 0.001) and 31% (34% vs. 14%, p = 0.0001), respectively.

Conclusion

The findings underscore the potential of CME and the adaptation of CIGs from high-resource settings to enhance the appropriateness of CT utilization in RLS. While the intervention notably reduced inappropriate trauma-related and non-contrasted CTEs, it also highlighted the complexity of achieving consistent improvements across all examination types. Further research is recommended to explore the determinants of successfully implementing CIGs in RLS, aiming to optimize CT utilization and improve patient outcomes.