Diagnostic Imaging Pathways - Principles for Creating and Managing 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 Home Page of each pathway has access to a sidebar that links via ABOUT GUIDANCE to a statement about the overall 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 has access to a sidebar that links 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 are cautioned about using the guidance outside of Australia. The Home Page of each pathway has access to a sidebar that links via ABOUT GUIDANCE to a statement concerning the jurisdiction of the guidance.


Each pathway is designed to assist clinicians in situations when faced with an 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 recommendations in a particular pathway depending on the 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 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. The HOME PAGE of the pathway for Pulmonary Embolism (Haemodynamically Unstable) provides an example.


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


The target audience of each pathway is identified. The Home Page of each pathway has access to a sidebar that links via ABOUT GUIDANCE to a statement regarding the target audience of the guidance. The target audience of the information for consumers is also identified in ABOUT GUIDANCE


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 from an Expert Panel. Finalised recommendations are then summarised in a diagnostic flow chart. The flow chart includes links to all available evidence and supporting documentation. The Home Page of each pathway has access to a sidebar that links via Production to CREATION OF A NEW PATHWAY.


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 may serve as an indication for specialist referral. However, when there are adequate substitutions for imaging modalities, these are indicated in a diagnostic pathway. The Home Page of each pathway has access to a sidebar that links via ABOUT GUIDANCE to a statement about the substitution of 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.

Current members of the Editorial Panel are listed on the PERSONNEL PAGE of the application; members include clinical subspecialists and nominees of The Health Consumers' Council of Western Australia and the Carers Association of WA


When the Chief Editor identifies the need to develop or review diagnostic pathways and recommendations, the Editorial Panel assists with determining which stakeholder groups are to be consulted and which individuals within a group will be contacted and invited to participate as members of an Expert Panel. The Expert Panel is convened by the Chief Editor. The Home Page of each pathway has access to a sidebar that links via Production to CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY which summarise processes including convening an Expert Panel to advise on the development of guidance.


The Home Page of the website has access to a sidebar that links via PERSONNEL to information which identifies the Chief Editor, Registrar, members of the Editorial Panel and all contributors. Names of contributors and reviewers for each pathway is available on request.


When the Chief Editor identifies the need to develop or review information for consumers, the Quality Coordinator is informed and work is carried out in collaboration with a Consumer Information Review Group which includes nominees of The Health Consumers’ Council of Western Australia and the Carers Association of WA. Information for consumers has access to a sidebar that links via Production to CREATION OF NEW INFORMATION FOR CONSUMERS and REVIEW AND REVISION OF INFORMATION FOR CONSUMERS which summarise processes including collaboration with a Consumer Information Review Group.


6. Ensure That Patients Are Engaged In Guidance Development

Nominees of The Health Consumers' Council of Western Australia and the Carers Association of WA are members of the Editorial Panel. The Chief Editor with assistance from the Editorial Panel recommends membership of each Expert Panel which is convened for the creation and review of each pathway. The Editorial Panel also reviews and agrees on the final version of each pathway prior to publication. The Home Page of each pathway has access to a sidebar that links via Production to CREATION OF A NEW PATHWAY and CREATION OF NEW INFORMATION FOR CONSUMERS which summarise steps in the creation and management of guidance including the role of the Editorial Panel.


Information specifically for consumers was initially developed in two phases, details of which can be accessed from a sidebar via Production in INITIAL ENGAGEMENT WITH CONSUMERS. In summary, 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 and 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.


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 Chief Editor identifies further topics to be developed or topics to be reviewed the Quality Coordinator collaborates with a Consumer Information Review Group. Summaries of processes for creating and managing information for consumers can be accessed from a sidebar via Production in CREATION OF NEW INFORMATION FOR CONSUMERS and REVIEW AND REVISION OF INFORMATION FOR CONSUMERS.


7. Ensure That Intended Users Are Engaged In Guidance Development

When deciding on which pathways to develop, the Chief Editor with assistance from the Editorial Panel ensures that the needs of different intended users 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 identifies a need for education based on evidence of inappropriate requesting (e.g. renal colic, pancreatitis).

Expert Panels which include representatives of intended users who are recommended by the Editorial Panel, are engaged in drafting guidance contained in the pathways. Summaries of the iterative process by which intended users are engaged in guidance development and management can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY.


The process by which intended users including consumers were engaged in the initial development of information for consumers is summarised in SECTION 6. When the Chief Editor identifies further topics to be developed or topics to be reviewed the Quality Coordinator collaborates with the Consumer Information Review Group. Summaries of processes can be accessed from a sidebar via Production in CREATION OF NEW INFORMATION FOR CONSUMERS and REVIEW AND REVISION OF INFORMATION FOR CONSUMERS.


The Home Page of the website and the Home Page of each pathway invite broad engagement with intended users in guidance development from a sidebar via CONTACT US

  • Email links are provided to the following:
    • The Chief 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 website
    • The Manager for any enquiries regarding the dissemination, implementation and evaluation of the Diagnostic Imaging Pathways application.

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

Summaries of methods used for searching and documenting evidence to support guidance can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY. The methods are 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 assess and give guidance to the Chief Editor and Registrar 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 Registrar via email. The Registrar forwards the list to the relevant Editorial Panel member for review and advice.


The following information is recorded for each pathway and recommendation, and is available on request:

  • Search date
  • Search period
  • Search terms

9. Criteria And Reasons For Inclusion And Exclusion Of Evidence

Summaries of methods used for searching and documenting evidence to support guidance can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY.


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.


The following information is recorded for each pathway and recommendation, and is available on request:

  • Inclusion criteria
  • Exclusion criteria

10. Assess And Document The Strengths And Limitations Of Evidence

Summaries of methods used for searching and documenting evidence to support guidance can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY.


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"

All studies that are cited in support of recommendations in each pathway are graded.


11. Arrive At Recommendations And Acknowledge Any Areas Of Uncertainty

Summaries of the iterative processes by which diagnostic recommendations are made can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY.


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 Registrar. 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 may be an indication for specialist referral. However, when there are adequate substitutes for imaging modalities without referral restrictions, these are included in a diagnostic pathway.


Draft pathway documentation is reviewed by the Chief Editor. Following any necessary corrections and amendments, the documentation is then sent to relevant members of the Expert Panel for review and feedback; it is expected that they will consult with and solicit views from their own network of colleagues, both imaging and other clinical specialists.


Based on the feedback received, the pathway document is revised by the Chief Editor and the Registrar. 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 may occur 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 Chief Editor.


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

Risks of ionizing radiation.

The internationally accepted model of risk of ionising radiation (IR) is the ‘no lower threshold linear model’. In this model, no dose of 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 website and the Home Page of each pathway has access to a sidebar that links 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.


A major underlying principle of the suite of guidelines is ‘justification’; that is balancing potential clinical benefit of a test against risk. If the potential clinical benefit outweighs the risk, then the test is justified.


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 website and the Home Page of each pathway has access to a sidebar that links 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 website and the Home Page of each pathway has access to a sidebar that links 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 website and the Home Page of each pathway has access to a sidebar that links via ABOUT IMAGING to relevant information including how to assess and mitigate any risk of excessive bleeding.


13. Document External Peer Review

The processes by which draft evidence-based pathways are subjected to external peer review are described in SECTION 11. Summaries of the processes, membership of Expert Panels and the recording of iterations of draft pathways are available on request.


The Home Page of the website and the Home Page of each pathway has access to a sidebar that links via PERSONNEL to information which identifies the Chief Editor, Registrar, members of the Editorial Panel and all contributors.


14. Update Guidance And Maintain And Improve Guidance Quality

Once a pathway has been finalised (SECTION 11) a Home Page for the pathway is compiled which includes a statement about the “Population Covered By The Guidance”, the “Date Of Review” and “Proposed Date For Next Review”. The "Date of Review” is given as the date that the Editorial Panel reviewed and agreed on the final version of the pathway. The "Proposed Date For Next Review" is given as the Date Of Review plus 36 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 website. 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 website as soon as practical.


A summary of the process for subsequently updating and improving a particular pathway can be accessed from a sidebar via Production in REVIEW AND REVISION OF A PATHWAY; the process is triggered by one of three events:

  1. The Chief Editor is alerted when the period of time since a pathway was last reviewed exceeds 36 months.
  2. The Chief Editor, Registrar 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.
  3. Chief Editor, Registrar 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 Registrar collates the available information for the Chief Editor to review. The Chief Editor decides whether it is appropriate to investigate if a particular pathway requires revision. If the decision is ‘not to investigate’, the "Date Of Review " is updated to the date of the decision.. The "Proposed Date For Next Review" is given as the Date Of Review plus 36 months.


If the decision is ‘investigate’, 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 SECTION 8; to SECTION 13. A summary of the process can be accessed from a sidebar via Production in REVIEW AND REVISION OF A PATHWAY. If and when the pathway is revised and finalised, the "Date Of Review” is given as the date that the Editorial Panel agreed on the final version of the pathway. The "Proposed Date For Next Review" is given as the Date Of Review plus 36 months The final version of the revised pathway is uploaded to the website as soon as practical.


A summary of the process for subsequently updating and improving information for consumers can be accessed from a sidebar via Production in REVIEW AND REVISION OF INFORMATION FOR CONSUMERS. The process is triggered by one of following events:

  1. The Quality Coordinator receives a suggestion that the information should be reviewed, collates information for the Chief Editor who decides that it is appropriate to review and revise the information
  2. The Chief Editor agrees to a revision of a pathway or other material for clinicians and identifies that any associated information for consumers should be reviewed and revised

If the Chief Editor decides that a review and revise the information is not required, the “Date Of Review” is given as the date of this decision. The “Proposed Date For Next Review” is given as the Date Of Review plus 36 months.


If the Chief Editor decides that a review and revision of the information is required, when the revised material is uploaded to the website the “Date Of Review” is given as the date that the Editorial Panel reviewed and agreed on the information. The “Proposed Date For Next Review” is given as the Date Of Review plus 36 months.


The website as a whole is updated with a frequency of not less than four occasions a year. The Home Page of the website and the Home Page of each pathway have access to a sidebar that links 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

A summary of processes for the creation and management of recommendations can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY. Diagnostic flowcharts (algorithms) are developed and supporting evidence and information is added through an iterative process of searching and evaluating evidence, and obtaining expert sub-specialist opinion. The recommendations in each pathway are summarised and published at a discrete webpage.


The Home Page of each pathway contains a brief statement which identifies the population to whom the guidance applies. Also a sidebar provides 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 recommendations
  • 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 has access to a sidebar that provides a link via ABOUT IMAGING to information regarding the assessment and mitigation of risks associated with:

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

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

A summary of the process by which a sequence of diagnostic recommendations is developed for a particular clinical condition and eventually published at a discrete webpage can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY. The core of each pathway's webpage is a diagnostic flow chart. Each flow chart clearly presents different options for achieving a diagnosis in a particular clinical scenario, each of which is 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 has access to a sidebar that provides a link via ABOUT GUIDANCE to the “Status of Recommendations” provided in the pathway.


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

A summary of processes for the creation and management of guidance can be accessed from a sidebar via Production in CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY.


When a new pathway is developed and finalised, the "Date Of Review” is given as the date that the Editorial Panel reviewed and agreed on the final version of the pathway. The "Proposed Date For Next Review" is given as the Date Of Review date plus 36 months. This information is provided on the Home Page of each pathway.


When the Chief Editor is advised that a pathway may need to be revised but decides on the basis of the available information that a review and revision will not be required, the “Date of Review” is updated to the date of this decision. The "Proposed Date For Next Review" is updated to the Date Of Review plus 36 months. This information is provided on the Home Page of each pathway.


When the Chief Editor is advised that a pathway may need to be revised and decides that a review is required, following the completion of the review and any revision the “Date of Review” is updated to the date that the Editorial Panel reviewed and agreed on the final version of the pathway. The "Proposed Date For Next Review" is updated to the Date Of Review plus 36 months. This information is provided on the Home Page of each pathway.


The following information is recorded for each pathway and is available on request:

  • Search date
  • Search period
  • Search terms
  • Inclusion criteria
  • Exclusion criteria

The final version of a new or revised pathway is uploaded to the website as soon as practical.


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

SECTION 5 and SECTION 7 describe the process by which stakeholder groups are identified and engaged in guidance development. In drafting and finalising materials for the pathways including text and images, all participants including the Chief Editor, Registrar, 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.

SECTION 6 and a link from the sidebar via Production to INITIAL ENGAGEMENT WITH CONSUMERS provides information on how patient representatives were engaged in the development of information for consumers; recommendations were made relating to 'format and presentation', 'content', 'subject' and structure' of the information. A link from the sidebar via Production to CREATION OF NEW INFORMATION FOR CONSUMERS and REVIEW AND REVISION OF INFORMATION FOR CONSUMERS provide further information on how information for consumers is developed and managed. Information for consumers is drafted in a form that 'most people in the community of Western Australia can understand most of the time'; there is minimum use of medical terminology, and sentences and words are as short and simple as possible.


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 website and the Home Page of each pathway have access to a sidebar that has the following links:

  • WHAT'S NEW
    • Each time the website 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.
  • CONTACT US
    • Email links are provided to the following:
    • The Chief 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 website; 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 website and the home page of each pathway have access to a sidebar that links 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 website and Home Page of each pathway have access to a sidebar that links 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 website and the Home Page of each pathway have access to a sidebar that links via Production to CREATION OF A NEW PATHWAY and REVIEW AND REVISION OF A PATHWAY. Processes are reviewed bi-annually and are assessed against the criteria of 'completeness' and 'currency'. The processes are revised if appropriate, and revisions are uploaded to the website. The "Date Of Review" is updated to the date that the Chief Editor reviewed and agreed on the final version of the processes.


The review of the CREATION OF A NEW PATHWAY includes the conduct of vertical audits:

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

The outcomes of the audits are reported to the Editorial Panel and action is taken to revise the processes if necessary, and to ensure compliance with the processes.


Data on the access and use of the website is collected, analysed and reported to the Editorial Panel.


A method that has been used to audit compliance between recommendations and diagnostic practice has been published [2]


22. Ensure Editorial Independence From The Funding Body

It is the policy of DIP not to accept funds from any source that would make funding conditional on any control over processes for producing and updating the content of Diagnostic Imaging Pathways. All agreements with funding bodies are thoroughly reviewed by the Chief Editor, Editorial Panel and Steering Committee 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 website and the Home Page of each pathway have access to a sidebar that links via EDITORIAL INDEPENDENCE to this policy.


23. Ensure Full Disclosure Of Funding Sources And Mechanisms

The Home Page of the website and the Home Page of each pathway have access to a sidebar that links via EDITORIAL INDEPENDENCE to information about past and current funding sources. The website is updated whenever new grants are received for the production and update of the content of Diagnostic Imaging Pathways.


It is the policy of DIP not to host or display commercial information, and not to receive any support, financial or otherwise, from commercial entities. The Home Page of the website and the Home Page of each pathway have access to a sidebar that links via EDITORIAL INDEPENDENCE to this policy.


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

The Chief Editor, Registrar, members of the Editorial Panel and contributors are required to complete and sign a 'Conflict Of Interest Disclosure Form'. The Home Page of the website and the Home Page of each pathway have access to a sidebar that links 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 and updated 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 Chief Editor and Registrar access the register prior to sending materials out for review and development, and avoid involving individuals who have declared a conflict of interest.


The Home Page of the website and the Home Page of each pathway have access to a sidebar that links via Production to PROCESSES FOR CREATING AND MANAGING CONTENT. These summarise how pathways and recommendations are developed, reviewed, revised and approved. The pathways and recommendations are reviewed iteratively by members of Expert Panels and other contributors including medical imaging and clinical specialists. They are approved by an Editorial Panel comprising subspecialty imaging specialists, GPs and consumer representatives. 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. The processes mitigate 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


Date reviewed: June 2017

Date of next review: June 2019