Diagnostic Imaging Pathways

RECRUITMENT AND APPOINTMENT OF PERSONNEL

Editor

The current Editor is the foundation editor. He is a Consultant Radiologist at Royal Perth Hospital and has an adjunct appointment at the School of Surgery, University of Western Australia. Future Editors will be appointed according to the advertising and selection procedures that are determined by WA Public Sector Standards.

Manager

The current Manager is the foundation manager. He is the Business Manager of the Division of Imaging Services at Royal Perth Hospital and has an adjunct appointment at the School of Medicine, University of Notre Dame Australia. Future Managers will be appointed according to the advertising and selection procedures that are determined by WA Public Sector Standards.

Research Fellow

The Research Fellow is appointed for 12 months following advertising and selection procedures that are determined by WA Public Sector Standards. Each Research Fellow is employed by the Division of Imaging Services at Royal Perth Hospital.

Editorial Panel

Membership of the Editorial Panel is honorary. The panel is multidisciplinary and comprises imaging consultants with subspecialty interests, and interested clinicians including general practitioners. The panel ensures membership from each subspecialty by networking with local, national and international colleagues to attract qualified personnel who are willing to participate.

External contributor/reviewer

External contributors and reviewers are honorary. The pool of individuals includes specialist consultants in medicine, surgery and medical imaging, as well general practitioners. Editorial Panel members network with local, national and international colleagues to attract qualified personnel who are willing to participate.

Identification and management of conflicts of interest

The Home Page of the web-site and the Home Page of each pathway provide a link via EDITORIAL INDEPENDENCE to information relating to the Funding Policy, Funding Sources, Disclosure of Conflict of Interest, and Management of Conflict of Interest.

PRINCIPLES AND PROCESS FOR PRODUCING, REVIEWING AND UPDATING CONTENT

The following principles are adhered to by all personnel engaged in producing, reviewing and updating materials for the Diagnostic Imaging Pathways application.

1. State The Overall Objective Of The Guidance

The Diagnostic Imaging Pathways application is an evidence-based and consensus-based education and decision-support tool for clinicians. It guides the choice of the most appropriate diagnostic examinations in the correct sequence in a wide range of clinical scenarios.

The objectives are to:

Reduce the incidence of unnecessary examinations which may expose patients to risk without benefit, including the risk of false-positive results; and
Increase the incidence of appropriate examinations which will result in cost-effective diagnosis.

The Home Page of each pathway includes a link via ABOUT GUIDANCE to a statement about the objective of the guidance.

2. Consider The Issues To Be Covered By The Guidance

Inappropriate imaging is a significant problem in the health service sector. Studies report that up to one-third of radiology and pathology examinations are partially or totally unjustified and surveys of clinicians show that 93% rate 'inappropriate imaging' as a problem in the delivery of health care [1]. The findings of an audit have been published which show that 50% of patients with one of four conditions who attended the Emergency Department of a major teaching hospital had evidence of inappropriate diagnostic practice (e.g. received an examination when they didn't need one, did not receive an examination when they should have had one, received an inappropriate examination) [2]. Expenditure on diagnostic imaging is a major contributor to rising health-care costs [3,4]. Inappropriate examinations stimulate this growth unnecessarily and waste scarce resources.

A significant issue in achieving appropriate diagnostic practice is lack of knowledge. The task of keeping up-to-date with developments in clinical practice and policy is increasingly difficult due to expanding research, clinical specialisation and subspecialisation, and the development of new applications in technology. It is difficult to acquire and maintain the necessary breadth and depth of knowledge for confident and correct decision-making. A 'medical knowledge' crisis is well recognised, as is the need for improved knowledge management [5]. The development and implementation of decision-support systems has been suggested as a specific strategy to improve the appropriateness of diagnostic testing [2,3].

When developing and reviewing pathways and guidance, personnel are mindful to provide as much material as possible to educate referring clinicians in the appropriate use of diagnostic imaging services for specified clinical conditions. Guidance is summarised in flow charts (diagnostic algorithms) and these are supported by appropriate documentation and links to other sources of information and evidence wherever possible.

The Home Page of each pathway includes a link via ABOUT GUIDANCE to a statement about the intent, extent and method of presentation of the educational content.

3. Identify The Population And The Target Audience To Whom The Guidance Applies

The Diagnostic Imaging Pathways application is based on international best practice and evidence. It is produced within Australia and is developed with an understanding of the Australian healthcare system including the availability of imaging modalities at major Australian tertiary referral centres. Although guidance is developed to have universal application as far as possible, users of the guidance must be cautioned about using the guidance outside of Australia. The Home Page of each pathway provides a link via ABOUT GUIDANCE to the following statement:

"Each pathway has been produced within Australia and has been developed with an understanding of the Australian healthcare system. Caution is therefore required when using a pathway outside of Australia, especially in areas with limited availability of imaging modalities. Imaging modalities that are available at most Australian referral centres have been included in each pathway. Experimental procedures that have not been approved by Australia's Therapeutic Goods Administration (TGA, http://www.tga.gov.au/) have not been considered for inclusion.

Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. Consideration is always given to the varying availability of resources, and alternative recommendations are incorporated into each pathway wherever possible. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered."

The population to whom a pathway will apply is identified as clearly as possible prior to commencing work on producing a pathway. The population includes people with the primary presenting condition and any relevant associated condition or co-morbidity as far as possible. The population is stated in the Home Page of each pathway. To illustrate, the pathway for Pulmonary Embolism (Haemodynamically Unstable) has the following statement on the Home Page:

"This pathway provides a diagnostic algorithm and supporting information relevant to patients presenting with suspected pulmonary embolism and who are haemodynamically unstable."

It is not possible to take into account a person's specific medical circumstance or condition when drafting materials (e.g. all co-morbidities). As a general rule, information is prepared only as guidance. The Home Page of each pathway and information for consumers provides a link via ABOUT GUIDANCE to the following statement:

"Information in each pathway does not and cannot cover every possible circumstance, including a patient's specific medical condition (e.g. all co-morbidities). Each pathway provides a recommended course of action. Deviation from a pathway may be appropriate in particular circumstances. Each pathway is designed to support, not replace, the professional relationship between a patient and a medical practitioner.

Users should not act or fail to act solely on the basis of the information provided in any pathway. The information is not a substitute for the use of due care and skill by a medical practitioner or any other person involved in the medical assessment and diagnosis of conditions to which the information applies."

The target audience of each pathway is identified as clearly as possible. The Home Page of each pathway includes a link via ABOUT GUIDANCE to the following statement regarding the target audience of the guidance:

"The target audience of the guidance provided in each pathway is:

Current and future referrers to diagnostic imaging services, including medical and surgical specialists, general practitioners, junior medical officers and medical students; and
Current and future providers of diagnostic imaging services, including imaging specialists and students, imaging technologists and students."

The target audience of the information for consumers is identified as clearly as possible. The Introductory Page of information for consumers includes a link via ABOUT GUIDANCE to the following statement regarding the population covered by the guidance and the target audience of the guidance:

"Guidance provided for consumers is relevant to any person (and/or their care-giver) who has been, or may be referred for a diagnostic imaging examination. The target audience is primarily the person and/or their care-giver. The audience also includes referrers and providers of diagnostic imaging services who need to provide information to their patients about diagnostic imaging examinations."

4. Ensure That Guidance Is Presented As A Clear Sequence Of Recommendations

The process leading to the presentation of a sequence of diagnostic recommendations for a clinical condition commences with drafting a diagnostic flow chart (algorithm). The flow chart is then developed and supporting information is added through an iterative process of searching and evaluating evidence and obtaining expert sub-specialist opinion as detailed under Rigor of Development. Finalised recommendations are then summarised in a diagnostic flow chart. The flow chart includes links to all available evidence and supporting documentation.

Pathways are drafted and finalised on the assumption that all medical imaging modalities are available to the referrer, even though there are circumstances in which modalities are not available. The non-availability of an imaging modality to a referrer should serve as an indication for specialist referral. Where there are adequate substitutions for imaging modalities, these are indicated in a diagnostic pathway.

The Home Page of each pathway includes a link via ABOUT GUIDANCE to a brief statement about the availability and substitution of imaging modalities.

5. Ensure That All Stakeholder Groups, Including Patients, Are Identified For Involvement In Developing Guidance

Stakeholder groups include the following:

Current and future referrers to diagnostic imaging services:
- General practitioners, general surgeons, specialist surgeons (e.g. orthopaedic, cardiothoracic, vascular), general physicians, specialist physicians (e.g emergency, respiratory, urology, neurology, endocrinology, haematology, obstetrics and gynaecology, paediatrics), medical students and others (e.g. podiatry)
Current and future providers of diagnostic imaging services:
- Radiologists including those with subspeciality interests, nuclear medicine physicians, medical imaging technologists and nurses.
Clinical educators and health service administrators.
Patients and their carers.

When the Editorial Panel identifies the need to develop or review diagnostic pathways and recommendations, it determines which stakeholder groups are to be consulted and which individuals within a group will be contacted and invited to participate.

In regard to information for consumers, the Editorial Panel contacts and advises The Health Consumers' Council of Western Australia about topics to be developed or reviewed. The Council identifies and nominates representatives of patients and their carers who should be consulted.

The Home Page of the web-site and the Home Page of each pathway provide a link via PERSONNEL to information which identifies the Editor, Research Fellow, members of the Editorial Panel and all contributors.

6. Ensure That Patients Are Engaged In Guidance Development

Initially, information for consumers was developed in two phases. This process is provided from the Home Page of the web-site and the Home Page of relevant pathways via CONSUMER INFORMATION.

Phase 1 was concerned with a 'Needs Analysis' and was initiated by the Division of Imaging Services at Royal Perth Hospital in collaboration with The Health Consumers' Council of Western Australia in 2005. A project officer was employed. Focus Groups were convened and held at the offices of the Health Consumers' Council. A Consumer Information Reference Group was established to determine the needs and expectations of consumers and their carers. The Focus Groups and the Consumer Information Reference Group included health service representatives from public hospitals in Western Australia, private providers of imaging services, and consumer representatives nominated by The Health Consumers' Council. These groups developed recommendations relating to 'format and presentation', 'content', 'subject' and 'structure' of information. The recommendations are provided from the Home Page of the web-site and the Home Page of relevant pathways via CONSUMER INFORMATION .

Phase 2 commenced in 2008 with the objective of developing information for consumers based on recommendations that were drafted in Phase 1. The broad aim was to develop information on health topics and imaging examinations identified as a priority in Phase 1 and in a form that 'most people in the community of Western Australia can understand most of the time'. A project officer was employed and a Consumer Information Review Group was convened which included representatives from the following groups:

Aboriginal people
People with disabilities
Seniors
CALD (Culturally and Linguistically Diverse)
Division of Imaging Services at Royal Perth Hospital
General Practitioners

When the Editorial Panel identifies further topics to be developed or topics to be reviewed, it convenes a 'virtual' Consumer Information Review Group in consultation with the Health Consumers' Council.

7. Ensure That Intended Users Are Engaged In Guidance Development

When deciding on which pathways to develop, the Editorial Panel ensures that the needs of different intended users (stakeholder groups) are taken into account. To illustrate:

For general practitioners and medical students, pathways are developed for the following categories:

Common conditions presenting to general practice (e.g. hypertension, chronic headache)
Conditions which are complex in regard to the imaging modalities available (e.g dyspepsia)
Conditions which are subject to inappropriate imaging (e.g. low back pain); and
Conditions which have new and more effective imaging options available (e.g. Magnetic Resonance Imaging).

For hospital-based clinicians, additional pathways are developed for the following categories:
- Conditions involving acute presentations where immediate access to expert radiological opinion may be lacking (e.g. the acute abdomen, haemoptysis); and
- Conditions for which the Editorial Panel indentifies a need for education based on evidence of inappropriate requesting (e.g. renal colic, pancreatitis).

When drafting and finalising the guidance contained in the pathways, the Editorial Panel determines which groups of intended users are consulted and which individuals within a group are contacted and invited to participate. Successive drafts are submitted to participating individuals for their review and suggestions.

In regard to the initial development of information for consumers, a project officer drafted information on health topics and imaging examinations that had been identified as a priority and in accordance with recommendations, in consultation with the Editor and staff from the Division of Imaging Services at Royal Perth Hospital. The recommendations are provided from the Home Page of the web-site and the Home Page of relevant pathways via CONSUMER INFORMATION. The information was then reviewed by the Consumer Information Review Group and Editorial Panel. Input and suggestions were provided to the project officer at meetings and via email. All suggestions were considered and information was re-drafted to ensure that finalised information met the established criteria.

When the Editorial Panel identifies topics to be reviewed or further topics to be developed, it convenes and engages with a 'virtual' Consumer Information Review Group in consultation with the Health Consumers' Council.

The Home Page of the web-site and the Home Page of each pathway invite broad engagement with intended users in guidance development via a CONTACT US link.

Email links are provided to the following:
- The Editor for feedback, comments or suggestions regarding clinical and academic content
- The Information Technologist for feedback, comments or suggestions regarding the structure and functionality of the web-site; and
- The Manager for any enquiries regarding the dissemination, implementation and evaluation of the Diagnostic Imaging Pathways application.
A survey instrument is provided, which invites feedback on:
- Clinical and academic content, including suggestions for revisions and additions
- Associated information including images, including suggestions for revisions
- Organisation of materials and functionality, including suggestions for changes; and
- Barriers to implementation of the guidance.

8. Use Systematic Methods For Searching For Evidence And Provide Details Of The Search Strategy

The method for developing diagnostic imaging pathways is based on guidance published by the National Health Service, Centre for Reviews and Dissemination at the University of York. When a diagnostic pathway is approved for development and when an existing pathway has been identified for review, the PICOS (Population, Indicator, Comparator, Outcome and Study Design) method is used to define the parts of a clinical question.

Population - defines the relevant patient group to whom the question applies
Indicator - defines the relevant investigation or intervention that was performed on the Population
Comparator - refers to the relevant 'gold standard' investigation or intervention that is desired as a comparison (if any exists)
Outcome - refers to the outcome of the Indicator on the Population
Study Design - different study designs are better suited to answering specific questions (e.g. for questions about intervention, randomized control trials are superior to other study designs)

A literature search is then performed using some of these parts (particularly Population and Indicator) as search terms. The majority of studies will be obtained by searching the electronic database MEDLINE (through Ovid or PubMed). Other studies may be identified by searching reference lists from relevant studies, hand searching key journals, and searching other relevant Internet resources such as the Cochrane Database of Systematic Reviews.

In another process, an automatic literature alert (henceforth referred to as 'autoalerts') based on keyword searches in the MEDLINE electronic database, is forwarded monthly to the relevant Editorial Panel members. The intent is to provide members with the latest high level research in their subspecialty, which they can then assessed to give guidance to the Editor and Research Fellow as to whether existing pathways require updating or whether a new pathway is required.

The search strategy used to generate the autoalerts is similar to that described above, but somewhat simplified. For example, the Population search term covers an entire body section and/or disease processes affecting that body section (e.g. chest and lung pathology). The Indicator search term will be all diagnostic imaging procedures. The results are then combined, and exclusion criteria applied. In this case, the search results are limited to studies published in English, human-based studies, and high level studies only (e.g. meta-analyses, randomised control trials and guidelines). The search is performed on a monthly basis. Only studies published within the past month are listed. The list of studies is provided to the Research Fellow via email. The Research Fellow forwards the list to the relevant Editorial Panel member for review and advice.

9. Inclusion And Exclusion Criteria For Evidence

Inclusion and exclusion criteria are determined by the PICOS method. Initially, a literature search is performed using the inclusion criteria (particularly Population and Indicator) as separate search terms. The MEDLINE database makes extensive use of medical subject headings (MeSH) for categorizing studies. These will usually align with the Population and Indicator search terms. However, a good search strategy will generally include a mix of MeSH terms along with other text terms to generate a broad set of search results. The Population search terms should generate studies relating to a particular clinical condition or undifferentiated symptom. The Indicator search terms should generate studies involving diagnostic radiological investigations. This provides two broad sets of studies which are then combined. From this larger set, study designs and reports that are not useful for providing relevant evidence (e.g. case-reports, letters and editorials) are excluded, forming the initial pool of studies.

Study selection then takes place. Initially, the studies in the pool are screened by inspecting their titles and abstracts, and comparing them against the inclusion criteria. Relevant studies are identified, and their full text is obtained. The full text screening then occurs, and the relevant studies are collated into a penultimate pool of studies for review.

10. Assess And Document The Strengths And Limitations Of Evidence

After thoroughly reading the studies in the final pool, their quality is assessed. Broadly, a number of factors are considered including the appropriateness of the study design for the research objective, the risk of bias, the quality of statistical analysis, the quality of reporting, the quality of the intervention (or investigation), the extent to which the results can be generalized, and whether the reported conclusions are supported by the study results.

Each study is also graded using the Oxford Centre for Evidence-Based Medicine Levels of Evidence (http://www.cebm.net/). For diagnostic studies, evidence is graded from Level I to V as follows:

Level I - Validating cohort study with good reference standards or systematic review of validating cohort studies
Level II - Exploratory cohort study with good reference standards or systematic review of exploratory cohort studies
Level III - Non-consecutive study or without consistently applied reference standards
Level IV - Case control study, poor or non-independent reference standard
Level V - Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

Poor quality studies are excluded from the final pool of studies.

11. Arrive At Recommendations And Acknowledge Any Areas Of Uncertainty

The final pool of studies is summarized and their data are collated. An evidence-based pathway document consisting of a flow chart, notes on imaging procedures, and references is drafted by the Research Fellow. This may require information beyond what has been gleaned from the final pool of studies including, background information on the subject matter (e.g. disease prevalence or aetiology) or information regarding non-imaging interventions. This information may be obtained through a separate, less exhaustive search that may include review articles and editorials.

Internationally recognised, prospectively validated guidelines (e.g. Ottawa Ankle Rules, NEXUS cervical spine injury prediction rule) when available and where appropriate are incorporated into the pathway document. This decision is made in consultation with specialist physicians and surgeons with regard to their preferred clinical practice and the practicality of the recognised guideline.

Pathways are drafted on the assumption that all medical imaging modalities are available to the referrer, even though there are circumstances in which all modalities are not available. For example, the current Australian health care system restricts general practitioners in their requesting of Magnetic Resonance Imaging (MRI). Nonetheless MRI is included in pathways when it is the most appropriate form of investigation because this should be an indication for specialist referral. Where there are adequate substitutes for imaging modalities without referral restrictions, these are included in a diagnostic pathway.

The draft pathway document is reviewed by the Editor. Following any necessary corrections and amendments, the revised document is then sent to relevant Editorial Panel members and/or a range of contributors including referrers and providers of diagnostic imaging services for their review and feedback. It is expected that individuals who are requested to review the materials will consult with and solicit views from their own network of colleagues.

Based on the feedback received, the pathway document is revised by the Editor and the Research Fellow. The revised draft is then re-submitted to the Editorial Panel members and their comments and feedback are incorporated into the published version.

When there is conflicting opinion or controversy, which may be due to lack of adequate published evidence or lack of consensus, discussion of the pathway occurs at a clinical-radiological forum, allowing opinions to be voiced and a consensus reached. In rare cases when differences in opinion remain unresolved, this is stated in the narrative text of a pathway to the effect that the issue remains controversial and there is insufficient evidence to make a firm recommendation. In addition, options are provided for imaging in a specific circumstance and the 'pros and cons' of each option are described. The final decision regarding the pathways rests with the Editor.

12. Assess The Health Benefits Compared To Side Effects And Risks

Risks of ionizing radiation.

No dose of ionizing radiation (IR), however small, is entirely without the risk of inducing cancer. The risk is considerably greater than average in children and young adults and becomes progressively smaller with age. When pathways are drafted and finalized, consideration is given to this risk. The Home Page of the web-site and the Home Page of each pathway provide a link via ABOUT IMAGING to relevant information including the assessment and mitigation of risk.

Imaging providers are responsible for ensuring that IR during imaging is kept to a minimum according to the ALARA principle (As Low As Reasonably Achievable), while maintaining the diagnostic quality of the examination. Imaging examinations that deliver no IR or low doses of IR are recommended whenever appropriate. However, if the available evidence and consensus opinion indicate that an imaging examination with a high dose of IR is the best for diagnosis, then it will be recommended.

The Home Page of each pathway provides a "relative radiation level scale" for quick reference. Within each pathway, the radiation level associated with the recommended examination is displayed as an alert in a pop-up box.

Risks of contrast agents.

The use of contrast agents as an adjunct to imaging has associated risks of allergic-like reactions, nephropathy, and extravasation. When pathways are drafted and finalized, consideration is given to these risks. The Home Page of the web-site and the Home Page of each pathway provide a link via ABOUT IMAGING to an alert that a contrast agent may be administered when an imaging examination is performed and about the assessment and mitigation of risk.

Imaging during pregnancy and lactation

Special consideration is required to the imaging of females of reproductive age, especially when ionizing radiation (IR) and contrast agents are administered. When pathways are drafted and finalized, examinations that don't involve the administration of ionizing radiation or contrast agents are recommended whenever possible. The Home Page of the web-site and the Home Page of each pathway provide a link via ABOUT IMAGING to relevant information including the assessment and mitigation of risk.

Risk of Bleeding

Surgery and invasive procedures can cause excessive bleeding. The Home Page the web-site and the Home Page of each pathway provide a link via ABOUT IMAGING to relevant information including how to assess and mitigate any risk of excessive bleeding.

13. Document External Peer Review

The process by which draft evidence-based pathways are subjected to external peer review is described in Section 11

14. Update Guidance And Maintain And Improve Guidance Quality

Once the pathway has been finalised (see Section 11), a Home Page for the pathway is compiled which includes statements and links to information as detailed in Sections 1 to 4 and the dates of last and next review. The "date of last review including any literature search" is given as the current date. The "date of next review" is given as the current date plus 12 months. This Home Page also includes hidden metadata used for analysis by search engines.

All of the material is collated and prepared for uploading to the Diagnostic Imaging Pathways web-site. This involves conversion of the pathway documentation into HTML and other appropriate formats. Care is required to ensure the resulting code complies with HTML standards. The pathway is uploaded to the web-site as soon as practical.

The process for subsequently updating and improving a particular pathway is triggered by one of three events:

The Editor, Research Fellow or a member of the Editorial Panel discovers literature via the autoalerts process (see Section 8) or other activities, which suggests that new imaging modalities or updates to exiting technology improves the capability of current imaging techniques to detect disease.
Editor, Research Fellow or a member of the Editorial Panel receives feedback or suggestions from stakeholders including contributors to the pathways and users of the pathways which suggest that current recommendations should be reviewed.
The Editor is alerted automatically when the period of time since a pathway was last reviewed exceeds 12 months.

The Editorial Panel has a fixed agenda item against which any of the above events in relation to each pathway are discussed. The Research Fellow collates the available information for the Editorial Panel to review. The panel decides if it is appropriate and timely to investigate whether a particular pathway requires revision.

If the panel decides that it is not appropriate to investigate whether a particular pathway requires revision, the "date of last review including any literature search" is updated with the current date. The "date of next review" is given as the current date plus 12 months.

If the panel decides that it is appropriate to investigate whether a particular pathway requires revision, the process of searching, assessing and grading the evidence, and finalising any revisions, is similar to that described for the initial development of a pathway as detailed in Sections 8 to 13. If and when the pathway is revised, finalised and uploaded to the web-site, the "date of last review including any literature search" is updated with the current date. The "date of next review" is given as the current date plus 12 months. The final version of the revised pathway is uploaded to the web-site as soon as practical.

The web-site is updated with a frequency of not less than four occasions a year. The Home Page of the web-site and the Home Page of each pathway provide a link via WHAT'S NEW to information which alerts users to all material changes to the content.

15. Ensure That Recommendations Are Specific, Unambiguous And Clearly Identifiable

As described in Section 4, the process leading to the publication of a sequence of diagnostic recommendations for a clinical condition commences with drafting a diagnostic flow chart (algorithm). The flow chart is then developed and supporting information is added through an iterative process of searching and evaluating evidence, and obtaining expert sub-specialist opinion.

The process of searching, accepting and grading evidence relating to a particular pathway is described in Sections 8 to 10.

As described in Section 11, a draft evidence-based pathway consisting of a flow chart, notes on imaging procedures and references is formulated by the Research Fellow, reviewed the Editor, and is then sent to a range of contributors including referrers and providers of diagnostic imaging services for their review and feedback. Based on the feedback received, the pathway documentation is revised by the Editor and the Research Fellow. The revised draft is then submitted to the Editorial Panel members and their comments and feedback are incorporated into a final published version.

The recommendations in each pathway are summarised and published at a discrete web-page.

The Home Page of each pathway contains a brief statement which identifies the population to whom the guidance applies and contains a link via ABOUT GUIDANCE to the following information:

objective of the guidance
issues covered by the guidance
jurisdiction of the guidance
status of the guidance
in the consultation process
target audience
the availability and substitution of imaging modalities

The algorithm for each pathway includes links to information supporting particular recommendations and links to relevant evidence. In rare cases when unequivocal recommendations cannot be made, this is stated.

The Home Page of each pathway also contains information and links to information via ABOUT IMAGING regarding the assessment and mitigation of risks associated with:

Ionizing radiation
Administration of contrast
Imaging during pregnancy and lactation; and
Bleeding.

16. Ensure That Different Options For The Management Of A Condition Are Clearly Presented

Section 4 and Sections 8 to 11 describes the process by which a sequence of diagnostic recommendations is developed for a particular clinical condition and eventually published at a discrete web-page. The dominant feature of each pathway's web-page is a diagnostic flow chart. Each flow chart will clearly present different options for achieving a diagnosis in a particular clinical scenario that are based on the best available evidence and consensus opinion.

As described in Section 3, it is not always possible to take into account a person's specific medical circumstance or condition (e.g. all co-morbidities). As a general rule, information is prepared only as guidance. The Home Page of each pathway provides a link via ABOUT GUIDANCE to the following statement:

Users should not act or fail to act solely on the basis of the information provided in a pathway. The information is not a substitute for the use of due care and skill by a medical practitioner or any other person involved in the medical assessment and diagnosis of conditions to which the information applies."

17. Ensure That The Date Of Search, Date Of Last Update And Proposed Date For Review Are Clearly Stated

As described in Section 14, when a new pathway is developed and finalised, the "date of last review including any literature search" is given as the current date. The "date of next review" is given as the current date plus 12 months. This information is provided on the Home Page of each pathway.

As described in Section 14, if following an alert that a pathway may require updating and improving, the panel decides that it is not appropriate to investigate whether the pathway requires revision, the "date of last review including any literature search" is updated with the current date. The "date of next review" is given as the current date plus 12 months. This information is provided on the Home Page of each pathway.

As described in Section 14, if following an alert that a pathway may require updating and improving, the panel decides that it is appropriate to investigate whether a particular pathway requires revision, the process of searching, assessing and grading the evidence, and finalising any revisions, is similar to that described for the initial development of a pathway as detailed in Sections 8 to 13. When the pathway is finalised the "date of last review including any literature search" is updated with the current date. The "date of next review" is given as the current date plus 12 months. This information is provided on the Home Page of each pathway.

The final version of a new or revised pathway is uploaded to the web-site as soon a practical. The web-site is updated with a frequency of not less than four occasions a year.

18. Ensure That The Language And Format Of Each Piece Of Guidance Is Suitable For The Target Audience

Sections 5 and 7 describe the process by which stakeholder groups are identified and engaged in guidance development. In drafting and finalising materials including text and images, all participants including the Editor, Research Fellow, members of the Editorial Panel and any other contributors are mindful of the following:

Text will be published in the English language, except when a foreign term or phrase is appropriate and is in common use among English speaking people
The terminology and the prose will be understandable to intended users
Acronyms will be avoided as far as possible, but be explained whenever used; and
Materials will be in a format that can be viewed and comprehended on a colour computer monitor and on printed paper in black/white/grey scale.

In addition and in relation to information for consumers, Section 6 describes the method by which patients are engaged in guidance development. In Phase 1, recommendations were developed relating to 'format and presentation', 'content', 'subject' and structure'. The recommendations are provided from the Home Page of the web-site and the Home Page of relevant pathways via CONSUMER INFORMATION. In Phase 2, information for consumers on health topics and imaging examinations identified as a priority in Phase 1 was developed in a form that 'most people in the community of Western Australia can understand most of the time'. In drafting and finalising materials, there was minimum use of medical terminology, and sentences and words were as short and simple as possible. The same publishing standards are used when the Editorial Panel identifies further topics to be developed or topics to be reviewed

19. Ensure That Appropriate Support Tools Are Provided To Aid In The Implementation Of Guidance

Tools to aid the implementation of guidance are supplied and maintained. The Home Page of the web-site and the Home Page of each pathway provide the following links:

USER GUIDE

A PDF User Guide and a video tutorial provide an overview of the major features of the Diagnostic Imaging Pathways application and a navigation guide.

WHAT'S NEW

Each time the web-site is updated, users are alerted to all material changes to the content.

ABOUT GUIDANCE

Advice is provided about the intent of the guidance, the target audience and the status of guidance in the consultation process.

ABOUT IMAGING

An overview of the major imaging modalities and general principles for requesting and providing imaging examinations is provided. Information is provided about the assessment and mitigation of risks associated with ionizing radiation, contrast agents, imaging during pregnancy and lactation, and bleeding.

Email links are provided to the following:
The Editor for feedback, comments, suggestions or assistance regarding clinical and academic content
The Information Technologist for feedback, comments, suggestions or assistance regarding the structure and functionality of the web-site; and
The Manager for any enquiries regarding the dissemination, implementation and evaluation of the Diagnostic Imaging Pathways application including any assistance.

The Home Page of the web-site and the home page of each pathway provide a link via LEGAL MATTERS to information about general terms and conditions associated with the use of Diagnostic Imaging Pathways and associated links.

Within each pathway, options and substitutes for recommended examinations are provided whenever possible.

20. Ensure That Potential Organisational And Financial Barriers Are Considered

Information about potential organisational and financial barriers is supplied and maintained. The Home Page of the web-site and Home Page of each pathway has a link via ABOUT GUIDANCE to information about the following:

Jurisdiction of the guidance
Status of the guidance within the context of the consultation process; and
Substitution of modalities.

21. Include Review Criteria For Monitoring And Audit Purposes

The Home Page of the web-site and the Home Page of each pathway include a link via PRODUCTION to the "Principles And Process For Producing, Reviewing And Updating Content". The process is reviewed annually by the Editorial Panel and is assessed against the criteria of 'completeness' and 'currency'. The process is revised if appropriate and revisions are uploaded to the web-site. The "date of last review" is updated with the current date. The "date of next review" is given as the current date plus 12 months.

The review of the "Principles And Process For Producing, Reviewing And Updating Content" includes the conduct of vertical audits:

The steps used to produce a new pathway are audited for compliance with the prescribed process; and
The steps used to review, update and improve a particular pathway are also audited for compliance with the prescribed process.

The outcome of the audits are reported to the Editorial Panel and action is taken to revise the "Principles And Process For Producing, Reviewing And Updating Content" if necessary, and to ensure compliance with the process.

22. Ensure Editorial Independence From The Funding Body

It is the policy of the Manager not to accept funds from any source that would make funding conditional on any control over the process for producing and updating the content of Diagnostic Imaging Pathways. All agreements with funding bodies are thoroughly reviewed by the Editor, Editorial Panel and Manager for any evidence of editorial control and will only be accepted and signed if total editorial independence from funding sources is maintained. The Home Page of the web-site and the Home Page of each pathway provide a link via EDITORIAL INDEPENDENCE to this policy.

23. Ensure Full Disclosure Of Funding Sources And Mechanisms

The Home Page of the web-site and the Home Page of each pathway include a link via EDITORIAL INDEPENDENCE to information about past and current funding sources. The web-site is updated whenever new grants are received for the production and update of the content of Diagnostic Imaging Pathways.

It is the policy of the Manager not to host or display commercial information, and not to receive any support, financial or otherwise, from commercial entities. The Home Page of the web-site and the Home Page of each pathway provide a link via EDITORIAL INDEPENDENCE to this policy.

24. Ensure That Potential Conflicts of Interest Are Identified And Recorded

The Editor, Research Fellow, members of the Editorial Panel and contributors are required to complete and sign a 'Conflict Of Interest Disclosure Form'. The Home Page of the web-site and the Home Page of each pathway provide a link via EDITORIAL INDEPENDENCE to this document.

Each individual is required to identify all 'relevant' relationships within the previous 2 years that may result in a conflict of interest. A relationship is deemed to be 'relevant' if there is reasonable potential for financial, professional, or other personal gain or loss for the individual, members of the individual's household and/or employer, biasing the development, review and finalisation of materials including recommendations.

A register of Conflict of Interest Disclosure Forms is maintained by the Manager. The register alerts the Manager to the requirement to update disclosures every two years.

25. Ensure That Any Potential For Bias In Recommendations Is Managed

A register of Conflict of Interest Disclosure Forms is maintained by the Manager. The Editor and Research Fellow access the register prior to sending materials out for review and development, and avoid involving individuals who have declared a conflict of interest.

Sections 8 to 14 provide information on how pathways and recommendations are developed, reviewed, revised and approved. The pathways and recommendations are reviewed iteratively by several contributors from medical imaging and clinical specialities, and are approved by an Editorial Panel comprising subspecialty imaging specialists. The pathways and recommendations are the product of the consensus opinion of up to a dozen individuals based on published evidence and recognised best-practice. This process mitigates the risk of any conflict of interest, disclosed or undisclosed, from biasing the development and final approval of recommendations.

26. References

1. Bairstow PJ, Mendelson R, Dhillon R, Valton F. Diagnostic imaging pathways: development, dissemination, implementation and evaluation. Int J Qual Health Care 2006; 18: 51-7

2. Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Reducing inappropriate diagnostic practice through education and decision support. Int J Qual Health Care 2010; 22: 194-200

3. Hammett RJ, Harris RD. Halting the growth in diagnostic testing. Med J Aust 2002; 177: 124-5

4. Hollingworth W. Radiology cost and outcome studies: standard practice and emerging methods. AJR 2005; 185: 833-9

5. OpenClinical Home: Knowledge management technologies and applications for healthcare [Internet]. London: OpenClinical White Paper: The medical knowledge crisis and its solution through knowledge management; 2001 [updated 2003; cited 2005 April 8]: [about 2 screens]. Available from: http://www.openclinical.org/whitepaper.html

Diagnostic Imaging Pathways - Production