BASH GPwSI Group Audit: what do we image and why? Steven Elliot GPwSI Tier 2 Neurology Salford

Aim Assess adherence to and relevance of the BASH guidelines on imaging patients with suspected brain tumour

Objectives Record all patients seen Record numbers of patients scanned Record reasons for scans Reflect on non-guideline scans

Standards 95% of scans would be red or orange flags as stipulated by guidelines

Red flags Papilloedema New epileptic seizure New onset cluster headache Abnormal findings on examination/neurological symptoms History of cancer especially lung/breast Significant alteration consciousness, memory, confusion or co-ordination.

Orange flags Aggravated by exertion/Valsalva Headache associated with vomiting Headache which has increased in frequency New onset >50 Headache waking from sleep Confusion

Methods 3 month baseline measurement 2010 Standard audit tool Anonymised collated analysis Reflection and recommendation Personal and/or group re-audit 2011

Baseline results 14 GPwSIs 3month period 895 patients 270 scans (30.16%) 173 (64%) Red or orange flags 54 red flags 16/270 “positive” (5.6%) Average scan rate 32.86%

Activity

Indication for scan

Indication 13

Positive scans Indication 7 Intracranial hypotension Bilateral subdurals Grade 1 Chiari Left orbital abnormality Mild Chiari Chiari Indication 8 Sinus thickening Indication 9 1cm lesion right temporal lobe Aneurysm Indication 13 CVST Multiple emboli Frontal lobe infarct Aneurysm Infarct left parietal lobe Left parietal infarct Glioma

Conclusions Not adherent Need for personal reflection Need for group reflection Not clear that guidelines are relevant Need for non-cancer indications What do we do about the anxious patient? True positive rate 1.5%

Planning re-audit Change scanning habits? Change criteria? Give up!

Suggested criteria 1

New criteria 2 New undifferentiated headache where a pattern has not emerged after 8 weeks Headache aggravated or precipitated by exertion or Valsalva manoevre, cough or sex and not migraine Headache associated with vomiting and not migraine Headache which has increased in frequency/severity in the last six months despite appropriate treatment

New criteria 3 New headache in age >50 whose onset is less than 6 months ago Headache that wakes from sleep that is not migraine Thunderclap headache Patient whose anxiety is not relieved by explanation and is aware of the implications of incidental findings

New criteria 4 New daily persistent headache Headache suggestive of low intracranial pressure Recent onset headache in HIV or immmunocompromised

Re-audit Suggestions? Agree criteria Repeat recording of activity in January to March 2012 Any volunteers?