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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)
Emergency and acute medical care in over 16s: service delivery and organisation.
Show details8. Primary care access to radiology
8.1. Introduction
Diagnostic radiology plays an important role in the diagnosis and management of patients presenting with an acute medical emergency (AME). This can range from simple imaging, such as plain x-ray - chest x-ray or abdominal x-ray, to more specialist tests such as computerised tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) imaging. There is a strategic drive in the United Kingdom to reduce emergency referrals to hospitals; however, the role of such investigations both in terms of access and same day reporting in a GP setting remains unclear.
While it may be accepted that more specialist tests should be restricted to a hospital setting, there may be a more specific role for plain x-ray radiology, for example, in patients presenting to a GP with a sub-acute breathing problem such as a chest infection, exacerbation of chronic obstructive airways disease or exacerbation of asthma, the role of plain x-ray radiology and reassurance of a normal chest x-ray may avoid unnecessary referral to hospital.
8.2. Review question: Does GP access to radiology with same day results improve outcomes?
For full details see review protocol in Appendix A.
Table 1
PICO characteristics of review question.
8.3. Clinical evidence
No relevant clinical studies comparing GP access to same day radiological investigations with same day results to GP access to radiology without same day results were identified.
8.4. Economic evidence
Published literature
No relevant economic evaluations were identified.
See also the economic article selection flow chart in Appendix C.
The unit costs of GP visits, diagnostic tests and relevant hospital admissions or stays were presented to the committee (see Chapter 41 Appendix I).
8.5. Evidence statements
Clinical
- No evidence identified.
Economic
- No evidence identified.
8.6. Recommendations and link to evidence
| Recommendation | - |
| Research recommendation | RR5. What is the clinical and cost effectiveness of providing GPs with access to plain X-ray radiology or ultrasound with same day results? |
| Relative values of different outcomes |
The guideline committee considered 6 outcomes critical for inclusion in this review: mortality, avoidable adverse events, patient and/or carer satisfaction, quality of life, ED attendance and admission to hospital. The outcome laboratory/diagnostic turnaround for result to a GP was considered important. |
| Trade-off between benefits and harms |
No evidence was identified which compared GP access to same day radiology or ultrasound results with not receiving results the same day. The committee discussed the absence of evidence and decided to develop a research recommendation. The committee noted that, although this is not current practice across the country, there was the potential for improvement in patient care and outcomes from the availability of same day plain x-ray radiology and ultrasound for a specific subset of patients. It may lead to a decrease in ED admissions and earlier diagnosis. In turn, earlier diagnosis could mean quicker treatment and improved patient outcomes, including patient and/or carer satisfaction. Further research would be needed to evaluate this. This could include patients, such as those with asthma, presenting with acute chest pain and the need to rule out a small pneumothorax. The committee accepted that, in general, patients who might benefit from same day results from radiological investigations could be those who might also require specialist investigation or admission to hospital, as opposed to management within primary care; whilst patients with non-acute illness may not require radiology results on the same day. |
| Trade-off between net effects and costs |
No relevant economic evaluations were identified. The unit costs of GP visits, diagnostic tests and relevant hospital admissions or stays were presented to the committee (see Chapter 41 Appendix I). The costs, effectiveness and cost-effectiveness of same day results might be influenced by the equipment used and the type of staff (including the ratio of radiologists to radiographers used in reporting results), Without effectiveness evidence, the committee were unable to assess the cost-effectiveness of same day results and therefore a research recommendation was made. |
| Quality of evidence | No evidence was identified which compared same day GP access to diagnostic radiology results compared to not receiving results on the same day. The committee discussed the absence of evidence and used consensus to develop a research recommendation. |
| Other considerations |
The committee focused the research recommendation on plain x-ray radiology and ultrasound as these investigations were most likely to be of benefit within the community. Ultrasound is included in this recommendation to reflect its growing use in rapid diagnosis, for example, to rule out a pleural effusion. The current approach is for GPs to refer patients to the ED or an AMU if they need same day plain x-ray radiography or ultrasound. Patients would likely prefer rapid diagnosis and management to reduce uncertainty. It would be beneficial to patients to not have to transit through the emergency department to access investigations, particularly to those who are frail or elderly. The group decided not to include more invasive radiological investigations (such as CTPA) within the research recommendation as such patients would likely need specialist review and expert interpretation of results. The committee noted that there were likely to be logistical and staffing difficulties in the provision of same day plain x-ray radiology and ultrasound results. Increased provision of staff training would be required. The committee also noted that a ‘result’ was more than just the radiological images; expert interpretation would also be required for investigations which lay outside the expertise of individual GPs. |
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Appendices
Appendix A. Review protocol
Table 2Review protocol: GP access to radiology
| Review question | Does GP access to radiology and ultrasound with same day results improve outcomes? |
|---|---|
| Guideline condition and its definition | AME. Definition: people with suspected or confirmed acute medical emergencies. |
| Objectives | To determine if enhanced GP access to radiological and ultrasound investigations improves outcomes. |
| Review population | Adults and young people (16 years and over) presenting to a GP with a suspected or confirmed AME. |
| Line of therapy not an inclusion criterion. | |
|
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated) |
GP access to same day radiological (plain x-ray) and ultrasound (including Doppler) investigations with same day results at weekdays (out of hours) and weekends. GP access to same day radiological (plain x-ray) and ultrasound (including Doppler) investigations without same day results. Standard services- GP access to same day plain x-ray radiology during working hours (weekdays) with same day results. |
| Outcomes |
|
| Study design | Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified. |
| Unit of randomisation |
Patient GP surgeries/practices. |
| Crossover study | Not permitted. |
| Minimum duration of study | Not defined. |
| Exclusions | None |
| Subgroup analyses if there is heterogeneity |
|
| Search criteria |
The databases to be searched are: Medline, Embase, the Cochrane Library Date limits for search: None Language: English only. |
Appendix B. Clinical article selection
Figure 1Flow chart of clinical article selection for the review of GP access to radiology
Appendix C. Forest plots
No studies were included.
Appendix D. Clinical evidence tables
No studies were included.
Appendix E. Economic evidence tables
No studies were included.
Appendix F. GRADE tables
No studies were included.
Appendix G. Excluded clinical studies
Table 3Studies excluded from the clinical review
| Study | Exclusion reason |
|---|---|
| Apthorp 1998 1 | Incorrect interventions. MRI not in protocol |
| Benamore 2005 2 | Incorrect interventions. CT not in protocol |
| Blois 20123 | Incorrect comparison (GP screening for abdominal aortic aneurysm versus ultrasound technician) |
| Bui 20044 | 1/3 of population under 16 years old. |
| Bury 19875 | Narrative paper |
| Carey 19896 | No outcomes of interest |
| Castro 20077 | Incorrect interventions (retinal digital images) |
| Chan 19998 | Inappropriate comparison |
| Chaptini 20109 | Incorrect interventions (ambulatory cardiac single-photon emission computed tomography) |
| Collie 1999 10 | Incorrect interventions. MRI not in protocol |
| Detar 196011 | Qualitative study |
| Duncan 200512 | Not a comparative study |
| Durham 199913 | Not a comparative study |
| Farrell 197714 | Not a comparative study |
| Fassiadis 200515 | Incorrect interventions (screening for abdominal aortic aneurysm) |
| Frohwein 200116 | Narrative paper |
| Geary 200717 | Not review population |
| Gravil 199818 | Incorrect comparison (treated in hospital versus treated at home) |
| Guldbrandt 201519 | Incorrect population (lung cancer patients) |
| Haber 197820 | Narrative paper |
| Hahn 198821 | Narrative paper |
| Halvorsen 198922 | Incorrect comparison (GP versus radiologist interpretation) |
| Hammond 200023 | Narrative |
| Hawksworth 195124 | Case series |
| Howard 2005 25 | Incorrect interventions. Neuroimaging not in protocol |
| Hussain 199927 | Incorrect comparison (comparing images sent via differing transition methods) |
| Hussain 200426 | No outcomes of interest |
| Ingeman 201528 | No outcomes of interest |
| Katerndahl 198229 | Narrative |
| Kiuru 200230 | Incorrect comparison (GP sending some x-rays to hospital for interpretation versus sending all). |
| Kuritzky 198731 | Incorrect interventions (interpretation of x-rays by GP versus radiologist) |
| Laerum 200132 | Narrative |
| Lahde 200233 | Not an intervention study |
| Laine 199834 | Incorrect comparison (comparing ultrasound, clinical exam and radiography) |
| Laws 200635 | Not a comparative study. No outcomes of interest. |
| Leiro-fernandez 201436 | Incorrect interventions (system to alert pulmonologists of lung cancer suspicion) |
| Li 199937 | Incorrect interventions (screening for glaucoma) |
| Li 201138 | Incorrect interventions (ocular telehealth) |
| Maurin 201439 | Not review population |
| Mclain 198540 | Inappropriate comparison (GP versus radiologist interpretation) |
| Merrington 198141 | Narrative |
| Miller 200642 | Not a comparative study |
| Mjolstad 201243 | Inappropriate comparison |
| Morioka 200744 | No outcomes of interest |
| Olayiwola 201145 | Incorrect interventions |
| Osmond 197746 | Narrative |
| Oswald 196447 | Narrative |
| Oswald 196448 | Narrative |
| Paakkala 198849 | Inappropriate comparison (GP versus radiologist interpretation) |
| Pavlicek 199950 | No outcomes of interest |
| Pickhardt 200651 | Not a comparative study |
| Qureshi 200152 | Does not match protocol (diagnostic accuracy of Doppler ultrasound) |
| Rawson 196553 | Inappropriate comparison (GP versus hospital clinician) |
| Redmond 201354 | Inappropriate comparison (GP versus radiologist interpretation) |
| Rogers 201055 | Narrative paper |
| Romero-aroca 201056 | Incorrect interventions (screening for retinopathy) |
| Smith 199357 | Not a comparative study |
| Speets 200658 | Not a comparative study |
| Stoddart 198959 | Not a comparative study |
| Strasser 1987A60 | Unclear when results were received by the GP for control group. |
| Suramo 200261 | Incorrect interventions (accuracy of ultrasound scans performed by GPs) |
| Taylor 200762 | Incorrect interventions (retinopathy screening) |
| Thomas 2010 63 | Incorrect interventions. CT not in protocol |
| Verstraete 200864 | Incorrect interventions (MRI) |
| Yates 201670 | Incorrect comparison (access versus no access) |
| Waite 200665 | Incorrect interventions (CT) |
| Weiner 200566 | Inappropriate comparison |
| Whitfield 197367 | No outcomes of interest |
| Wilson 200568 | Incorrect interventions (retinal imaging) |
| Wordsworth 200269 | No outcomes of interest |
Appendix H. Excluded economic studies
No studies were excluded.
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