Dr. Priyank Gupta Rashid Hospital Dubai Health Authority Dubai, UAE

Asymptomatic

Definition: Having or showing no symptom of disease

http://www.merriam-webster.com/dictionary/asymptomatic

You are considered asymptomatic if you: Have recovered from an illness or condition and no longer have

symptoms Have an illness or condition (such as early stage high blood

pressure or glaucoma) but do not have symptoms of it

http://www.nlm.nih.gov/medlineplus/ency/article/002217.htm

Asymptomatic does not mean absence of disease.

Possibility of presence of disease is a premise for investigation

UAE is a multinational, multiethnic & multicultural nation with expat population forming more than 80% of total inhabitants.

Great variability in patient demographics & disease susceptibility & presentation pattern- difficult to have a uniform approach for all.

Different backgrounds of Referring physicians from different schools and training - Different working practice systems.

Differing expectations of patients regarding treatment approaches - some patients expect more investigations while some do not.

Healthcare system – partly social, partly privatized, insurance based system.

Investigation decision influenced by patient affordability, access to imaging, approval to insurance.

At present no coherent system to integrate guidelines with the insurance providers.

Local Scenario

RGDI committee formulated with representatives from radiology departments of all DHA establishments – 4 hospitals & 20 PHC. CT is available in 3 hospitals.

The committee will review the worldwide existing RG & then issue recommendations based on the local need & the best scientific evidence available.

DHA RGDI committee is in the process of carrying out surveys and PACS added procedures monitoring systems (Tagging).

DHA RGDI Committee Role

DHA situation:

Are CT examinations on asymptomatic individuals outside screening program being performed?

Yes - However only anecdotal information available through shared experiences at common forums.

Are these procedures demanded by the patients?

Referrals originate from patients, physicians as well as radiologists

Do(es) your Authority(ties) actively search for the existence of these practices?

An active effort has been initiated this year by RGDI committee to identify such examinations under the common umbrella of Unjustified examinations

Local Scenario

Local Scenario

Does any guideline exist? Is it or would it be allowed from a legal point of view / tolerated in your country? Why? Is this practice controlled/regulated? Does your current regulation mention exposure to asymptomatic individuals? If yes, please provide details.

No Legislation/Guidelines existent as of now specifically addressing this issue.

Current regulations provide only a generalized framework for all radiological exposures but do not specifically refer to the asymptomatic individuals

However, federal regulations do recommend that appropriate justification should be sought before performance of any radiological investigation

DHA situation: RPC- RGDI-PACS team Query run in DHA CT database for following keywords in

Clinical info: Asymptomatic Check-up Follow-up Screening

Apart from the screening program for Breast Cancer using mammography, we do not have any other active screening programs using CT.

The query resulted in 66 examinations: 2011 – 7 patients 2012 – 22 patients 2013 – 16 patients 2014( till sep)- 21 patients

0

5

10

15

20

25

—2011 —2012 —2013 —2014( till sep)

DHA situation:

—CT Abdomen 14

—CT KUB 17

—CT Chest 13

—HRCT Chest 10

—CT Chest & Abdomen 1

—CT Face 4

—CT Orbit 2

—CT Brain 5

—CT Abdomen

21%

—CT KUB 26%

—CT Chest 20%

—HRCT Chest 15%

—CT Chest/Abd

omen 1%

—CT Face 6%

—CT Orbit 3%

—CT Brain 8%

Analysis of Examination types

Case Scenario 1

Previously diseased now asymptomatic (Follow-up CT)

CT KUB for previous h/o renal/ureteric calculus (17)

CTPA for previous h/o PE/ DVT

CT whole body/ specific part for previous h/o cancer (6)

Challenges:

Is follow-up CT necessary in asymptomatic patient?

When to do the follow-up?

How frequently?

What is the available evidence?

Case Scenario 2

Rule out studies:

Without previous imaging:

CT head in a patient with GCS 15 & trivial head injury

CT chest for Suspicious ingestion of foreign body in asymptomatic child

Challenge:

Anxious Patient

Defensive physician

Case Scenario 3 Rule out studies: (Requests for Additional Imaging) With previous imaging:

Doing CT chest in patient with incidentally detected abdominal mass

CT chest in asymptomatic patient with non-specific CXR finding done for pre-employment/ routine medical checkup (14)

CT abdomen for incidentally detected abdominal lesion on USG done for pre-employment/ routine medical checkup (10)

Challenge: Defensive medicine Overcautious / overenthusiastic investigation – One

stop investigation Management of incidentalomas/ indeterminate finding

Case Scenario 4

Rule out studies:

Risk factor present:

CT colonography for family h/o colorectal cancer

CT abdomen for family h/o abdominal cancer

Coronary / cardiac CTA for ruling out IHD

Challenge:

Patient reassurance

Role of media & industry Create panic about dangers of disease adding to patient

anxiety

Excessively publicize certain investigations as best techniques to rule out underlying disease

Case Scenario 5

Medicolegal indication

CT KUB/ CT abdomen for suspected drug carriers / body packers

Case Scenario 6

•Employment benefit Medical imaging examinations, for instance full body

CT, offered by employers to their managerial staff

members, as part of their periodical “medical check-

up”

Common challenges a) Patient wishes.

Anxious patient due to past or peer experiences

Lack of authentic information

Imaging provides objective evidence & reassurance

b) Role of industry/ Financial/ Self-referral Referrer/ Service Providers take advantage of knowledge deficiency,

patient anxiety & lack of awareness on the risk-benefit ratio and promote unwarranted investigations

c) Defensive medicine. Imaging safeguards the referrer as well as provider against litigation.

d) Role of media. Exaggerated publicity in reporting a medical mistake increased

public sensitivity about the subject practitioners practicing defensive medicine

Exaggerated publicity about risk & effects of Cancer & the ability of investigations being able to detect early disease increased demand both by patients as well as referrers

Gaps to Bridge a) Information Gap – Lack of available evidence

with radiologists regarding role of imaging in IHA

b) Awareness Gap – Lack of knowledge in the referring physicians regarding risks of CT Inadequate assessment of benefit vs risks of doing CT

c) Dissemination Gap – Lack of reliable source available to patients to inform risks vs benefit of use of CT

Local Scenario – Plan of Action

5. How do (did) you react on these practices? (What would you do?)

At Institutional/ Organizational level: Identify the source or originator – patient or referrer Establishing a patient-referrer- provider dialogue Understand the concern- reassurance or any other reason Educate patients & referrers about relative risks vs benefits Establish shared responsibility Perform the study if both the referrer as well as patient

provide consent – no legislation available to authorize the provider the right to deny the investigation

Local Scenario – Plan of Action

How do (did) you react on these practices? (What would you do?)

At Regional/ National Authority level (Plan Of Action) Map the occurrence of these practices by establishing a

registry /notification system Collaborate with all stakeholders to develop consensus

regarding conditions in which use of CT for IHA may be justified

Develop common actions with health authorities, social security providers and private insurances to ensure compliance by not reimbursing unjustified CT examinations.

Ensure compliance to guidelines by conducting on-site inspections & audits of the referrals

Local Scenario

Are CT examinations on asymptomatic individuals outside screening program reimbursed by the national health and pensions organization or by private insurance companies?

At present public or private insurance providers follow their own justification criteria for reimbursement procedure. Depends on case to case basis - patients family history, past medical / surgical history, risk factors etc.

Are these practices/services advertised? Are these services provided by public and/or private entities? Are you aware of some kind of advertisement on this service in your country? If yes, does it seem to you that it is a small or large scale phenomenon?

No system available to monitor such activities. No data available to comment.

Local Scenario How would you suggest creating awareness to this

focus-group? General Measures: Develop national awareness campaign:

Organize workshops on justification in imaging for the health-care providers like physicians, referrers, nurses (e.g. WHO- IAEA workshops)

Introducing radiation safety education in medical school & residency curriculum. Making radiation safety a part of mandatory education for practicing physicians

Making radiation risk & safety communication & informed consent an integral part of radiology referral request

Provide information to public on benefits and risks regarding CT examinations through print or electronic media

Organizing radiation awareness weeks/days to create awareness in general population about role of imaging

Local Scenario

How would you suggest creating awareness to this focus-group?

Specific Measures: Establish need: Introducing pre-approval for such requests & Adopting a

policy on providing radiologist consultation to the referrer as well as asymptomatic patient presenting for such CT investigations–

To understand patient’s concern To provide available evidence & explain risk vs benefit to patient To take informed consent

Establish Evidence: To maintain a registry & conduct periodic audits on such requests and share the results with referring clinicians to assess the clinical utility & long-term significance of doing CT for IHA in different categories of asymptomatic patients

Establish Guideline: Establish a dedicated group/committee consisting of radiologists as well as specialists to make recommendations on the indications in which CT in asymptomatic patients is justified

Summary CT examinations on asymptomatic individuals is not

considered a common practice. However, there is an increased concern on the rising utilization trends due to increased availability & access to CT

Specific guidelines are needed for conditions in which the use of CT in IHA may be justified.

A regulatory framework to address the issue specifically is necessary to ensure compliance to guidelines

There is a need to increase awareness regarding justification in imaging among the public as well as the health care providers to help both take an informed decision

Regular audit should be an integral part of imaging practice to highlight unjustified imaging & identify knowledge or practice gaps.

Concerted effort by all stakeholders will ensure appropriate use of imaging