1. Successful experiences for the availability and use of referral guidelines. Denis Remedios Clinical Radiologist, Northwick Park Hospital London, UK

2. European efforts, barriers and solutions The need for referral guidelines in Europe Similarities and differences in European countries The European Commission initiatives for improved justification and Referral Guidelines

3. Awareness: cost, safety, efficacy http://www.gponline.com/News/article/1 089232/cancer-plan-undermined-pcts/ Daily Mail, 8.9.11

4. EC pan-European dose estimation project: Procedure frequencies (including dental exams)

5. EC pan-European dose estimation project: Per-capita effective doses in Europe

7. DG ENER Directorate D4 http://www.euratom.org/ http://www.euratom.org/

8. Euratom 97/43, Article 6.2 http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/97 43_en.pdf http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/97 43_en.pdf

10. Interpretation of 97/43: UK http://www.legislation.gov.uk/uksi/2000/1059/pdfs/uksi_20001059_en.pdf http://www.legislation.gov.uk/uksi/2000/1059/pdfs/uksi_20001059_en.pdf

11. iRefer: Making the best use of clinical radiology services The Royal College of Radiologists has published guidelines for >20 years since 1989. 7 th edition 2012 (accredited by NHS Evidence)

12. EC Referral Guidelines 2000

13. EC guidelines on clinical audit for medical radiological practice http://ec.europa.eu/energy/nuclear/radiation_protection/doc/publication/159.pdf http://ec.europa.eu/energy/nuclear/radiation_protection/doc/publication/159.pdf

14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948911/

15. Guidelines Workshop, September 2012, Billrothhaus Vienna http://link.springer.com/article/10.1007%2Fs13244-013-0299-8#page-1

16. EC Guidelines Project 1. The conduct of an EU-wide study on the availability, development and implementation of referral guidelines for radiological imaging in the EU Member States. This web -based survey took place in the spring of 2012. 2.The organisation of a European Workshop with relevant representatives from the EU Member States. This workshop was held in Vienna on 20-21 September 2012. 3.The formulation of conclusions and recommendations for national and/or Community action.

19. Austrian Referral Guidelines http://orientierungshilfe.vbdo.at/ http://orientierungshilfe.vbdo.at/

20. Guidelines Survey: Preference for source of imaging referral guidelines to be used in Europe

21. To whom should guidelines be available?

22. Preferences for the future of imaging referral guidelines in Europe

23. Guidelines: potential barriers to distribution

24. Suggested solutions to barriers

25. Preferred methods for monitoring

26. Availability of Guidelines in Europe: at time of survey and after the Workshop

27. EC Guidelines project: Conclusions 1.Clearer and stronger European measures to encourage both availability and use of referral guidelines. Such measures should be made centrally or through European competent authorities. 2.European Guidelines. These may be produced initially by a combination of existing national Guidelines, developed using accepted methodology, under the auspices of a European professional organisation. European Guidelines must contain dose information and must include separate advice for children, the pregnant women and the unborn child. 3.Development and integration of Clinical Decision Support (CDS). This should interface with existing electronic requesting systems (computerised physician order entry systems) and radiology information systems. 4.Encourage educational initiatives. Such initiatives should complement European Medical ALARA Network (EMAN) [2] and Medical Radiation Protection in Education and Training (MEDRAPET) [3]. Referrers, radiologists and radiographers will benefit. Initiatives such as life-long-learning should be encouraged. 5.Both external audit and local internal audit are needed for monitoring. External audit has been addressed through a previous European project [4], but further measures to promote local internal audit are needed.

29. >90% Appropriateness through radiologists’ amendment of 12% CT requests and 9% MRI requests UK: Appropriate imaging through vetting (authorisation) The radiologist as gatekeeper http://www.ncbi.nlm.nih.gov/pubmed/25037149 http://www.ncbi.nlm.nih.gov/pubmed/25037149

30. RCR National audit of appropriate imaging: GP requested CT investigations % retrospectively appropriate (Kind courtesy of Mr Karl Drinkwater, RCR Audit Officer) target

31. Figure 12 RCR Audit of appropriate imaging. Clinical Radiology 2014 69, 1039-1044DOI: (10.1016/j.crad.2014.05.109) RCR National audit of appropriate imaging: Education & promoting a radiation safety culture Imaging request (for opinion) not order Referrer not prescriber 4Rs : referrer, radiologist, radiographer, regulator. Corporate responsibility for quality and safety: clinical governance Delegation of task of justification (but not responsibility) from radiologist to radiographer for low dose or protocol driven procedures

32. http://www.comare.org.uk/documents/COMARE12thReport.pdf

33. COMARE: Conclusions

34. http://www.rcr.ac.uk/docs/general/pdf/RCRstatementre12thCOMAREreportFINA L.pdf

35. Individual Health Assessment in the UK: Amendment of IR(ME)R following COMARE 7 http://www.legislation.gov.uk/uksi/2011/1567/note/made http://www.legislation.gov.uk/uksi/2011/1567/note/made

36. Incorporation of COMARE report into RCR imaging referral guidelines

37. Imaging Referral Guidelines in Europe and the UK: Good practices 1.Collaborative efforts between professional societies, policy makers and regulators Evidence-based guidelines by societies, endorsed by regulators Top down for legislation & support of guidelines Bottom up for buy-in, gate-keeping and efficiency 2.Implementation tools: Education eg MEDRAPET http://www.medrapet.eu/http://www.medrapet.eu/ Clinical Decision Support 3.Clinical audit for monitoring to encourage appropriateness. Internal audit for problem solving, external audit comprehensive. 3Es: Evidence-based practice, Education, Efficiency