Justification of Medical Imaging WHO's perspective Dr Maria del Rosario Pérez Department of Public Health, Environmental and Social Determinants of Health Regional Workshop on Imaging Referral Guidelines, December 2015, Cairo, EGYPT

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 2 |2 | The definition of “health” Health “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (WHO Constitution,1948)

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 3 |3 | Six leadership priorities in WHO General Programme of Work for 2014–2019 Advancing universal health coverage (UHC) Health-related Millennium Development Goals Addressing the challenge of noncommunicable diseases Implementing the provisions of the International Health Regulations Increasing access to essential, high-quality, safe, effective and affordable medical products Addressing the social, economic and environmental determinants of health.

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 4 |4 | Universal Health Coverage universal health care In 2012 the UN General Assembly adopted a resolution that endorsed the goal of universal health care and gave it a high place on the global health agenda. A health system designed to deliver universal care provides a solid platform for tackling all health problems, for reaching all health goals, in a fair, integrated, and efficient way. Our responsibility: "People expect ready access to medicines and services, and they want quality. They want care from people who care about them" (WHO DG, Feb 2013)

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 5 |5 | Ministerial Meeting on Universal Health Coverage rationalize the use of expensive technologies to protect against the overuse of health services overutilization of health technologies "…Officials can introduce policies that promote generic medicines, and rationalize the use of expensive technologies. In some cases, policy-makers will also need to find ways to protect against the overuse of health services. We also need to think about the overutilization of health technologies. Unlike many other areas of technological innovation, where devices get cheaper and easier to use, advances in medical interventions are usually additive, not replacement technologies…". Ministerial Meeting on Universal Health Coverage Dr Margaret Chan, WHO Director-General, opening remarks Ministerial Meeting on Universal Health Coverage, Geneva, 18 February 2013

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 6 |6 | Advancing Universal Health Coverage encompasses SAFETY and QUALITY

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 7 |7 | Universal Health Coverage includes access to medical uses of radiation Annually worldwide 3,600 million X-ray exams (> 300 million in children) 37 million nuclear medicine procedures 7.5 million radiation oncology treatments

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 8 |8 | Quality of health care Safety Effectiveness Patient-centeredness Timeliness Efficiency Equality

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 9 |9 | Justification of medical procedures is a component of quality of health care

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 10 | Justification of medical interventions as part of good health service delivery

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 11 | Good health services Overuseunderuse misuse unjustified unnecessary doses: "Overuse", “underuse” or “misuse” of medical procedures, unjustified health interventions, unnecessary doses: these are issues affecting health service delivery Appropriate use Appropriate use of radiation in health care is implicit in the concept of good health service.

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 12 | Overuse: what does it mean in medicine? "Application of a procedure where it is unlikely to improve patient outcome" (unnecessary, unjustified) The increasing use of radiation in healthcare per se cannot be taken as evidence of OVERUSE Considerable inequalities between and within countries (e.g. high-, medium- and low-income countries; rural vs. urban areas).

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 13 | Huge disparities in health expenditure and huge disparities in access to health services

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 14 | Radiation Protection in health care risks benefits The ultimate purpose of radiation protection in medicine is to control and minimize radiation risks, while maximizing the benefits of the use of radiation in health care. RISKS BENEFITS

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 15 | Appropriateness in imaging benefit/risk balance When choosing a procedure utilizing ionizing radiation, the benefit/risk balance must be carefully considered. unnecessary There is unnecessary use of radiation when clinical evaluation or other imaging modalities could provide an accurate diagnosis ( e.g. US, MRI ). Cost, local expertise, available resources, accessibility and patient values have to be considered in addition to efficacy.

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 16 | The benefits outweighs the risks when the procedure is: –appropriately prescribed –properly performed. This is not the case if there is no clinical indication or if the radiation dose is higher than necessary for the clinical purpose (e.g. adult protocols used for imaging children) –Do the right procedure ! –Do the procedure right ! Need to reduce unnecessary radiation exposures and associated risks J USTIFICATION OPTIMIZATION OPTIMIZATION

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 17 | Hippocrates ( 460 BC-377 C) justification optimization First do no harm The two principles of radiation protection for medical exposures (justification and optimization) are implicit in the concept of "First do no harm" But in general, health professionals are not familiar with these principles and have a low awareness of radiation doses and risks “ Primum non nocere” The culture of patient safety existed longtime ago…

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 18 | Hippocrates ( 460 BC-377 C) “First do not harm” ???… D.K. Sokol “First do no harm” revisited BMJ 2013;347:f6426 It was suggested that a more accurate formulation would be beneficence non-maleficence At an individual level, clinicians must balance their obligation to benefit the patient (the principle of beneficence) against their obligation not to cause harm (the principle of non-maleficence). These twin obligations go hand in hand and are weighed against each other. “ First do not net harm”

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 19 | JUSTIFICATION BENEFITS RISKS BENEFITS

Regional Workshop on Imaging Referral Guidelines December 2015, Cairo, EGYPT 20 | Some reasons for unnecessary procedures Lack of awareness about radiation doses & associated risks Insufficient access to referral guidelines at the point of care Low confidence in clinical diagnosis & over-reliance on imaging Consumer demand (patient's and/or family's expectations) Self-referral, opportunistic screening, defensive medicine Pressure from other specialists e.g. "What does the CT shows?" Pressure from promotion and marketing of sophisticated technology Lack of dialogue/consultation between referrers and radiologists Non-availability of other appropriate imaging modality (e.g. US, MRI) Fragmentation vs. continuity of health care: unnecessarily repeated examinations