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

Study Overview
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Brief Summary
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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.

Detailed Description
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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

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

Conditions
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Emergency Department Admission, Imaging Techniques

Intervention / Treatment
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* Other: Implementation of guidelines
* Other: Baseline observation


Participation Criteria
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Eligibility Criteria
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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
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

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


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Before guideline implementation<br>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<br>* During this period of the study, baseline data will be collected.<br>|
| Other: After guideline implementation<br>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<br>* 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.<br>|

What is the study measuring?
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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 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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referral guidelines, exam delays, exam relevance, guidelines