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

medRxiv - Radiology and Imaging Pub Date : 2024-08-22 DOI:10.1101/2024.08.16.24312127

Harriet Nalubega Kisembo, Richard Malumba, Ezra Kato Nsereko, Deborah Babirye, Victoria Nakalanzi, Francis Xavier Kasujja, Elsie Kiguli Malwadde, Elizeus Rutebemberwa, Simon Kasasa, Dina Husseiny Salama, Michael Grace Kawooya

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Abstract

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.

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在资源有限的环境中，持续医学教育和临床成像指南对减少儿童和年轻患者不适当使用计算机断层扫描的影响：前后对比研究

背景多载体计算机断层扫描（MDCT）彻底改变了医疗保健服务，大大提高了各种临床环境下的诊断准确性和患者治疗效果。然而，过度使用 CT 检查（CTE），尤其是在资源有限的环境中（RLS），对公共卫生构成了巨大挑战。不适当的 CT 检查，尤其是在儿童和年轻成人中，使这些弱势群体面临不必要的辐射风险，20%-50% 的 CT 检查被认为是不适当的，10%-20% 涉及儿童。本研究旨在确定持续医学教育（CME）和临床成像指南（CIG）的引入对乌干达选定医院中儿童和年轻成人使用 CT 的适当性的影响。材料和方法采用前后对比的研究设计，评估由持续医学教育和临床成像指南组成的干预措施对适当使用 CTE 的影响。在为期 12 个月的时间里，干预对象是六家提供 CT 服务的公立和私立三级医院的医疗保健提供者（HCPs）。基线数据显示，目标人群中不适当使用 CTE 的比例很高。以欧洲放射学会的 iGuide 和干预前的研究结果为基准，对干预前后针对不同身体区域（头部、鼻窦旁、胸部、腹部、脊柱、外伤）进行的 CTE 比例及其适当性进行了回顾性分析。结果干预后，进行的 CTE 检查总数增加了 33%（909 对 1210），其中公立医院增加了 30%（300 对 608，p = 0.001），私立营利性医院增加了 41%（91 对 238，p = 0.037）。在头部 CT（19%，746 对 890，p < 0.0001）和对比研究（252%，113 对 410，p < 0.0001）中观察到了具体的增长。相反，创伤的 CTE 减少了 8%（499 对 458，p < 0.0001）。尽管有这些变化，但不适当的 CTE 的总体比例增加了 15%（38% 对 44%，p < 0.001），其中不适当的对比检查增加了 28%（25% 对 53%，p < 0.001），非创伤病例增加了 13%（66% 对 79%，p < 0.001）。值得注意的是，非对比和创伤相关病例的不适当 CTE 分别减少了 28% (75% vs. 47%, p < 0.001) 和 31% (34% vs. 14%, p = 0.0001)。虽然干预措施显著减少了不适当的创伤相关和非对比 CTE，但也凸显了在所有检查类型中实现一致改进的复杂性。建议进一步开展研究，探索在 RLS 中成功实施 CIG 的决定因素，以优化 CT 利用率并改善患者预后。

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medRxiv - Radiology and Imaging

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