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ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 3  |  Page : 117-122

Justification of doctors' referral for radiological imaging among some Nigerian doctors


Department of Radiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication16-Jan-2018

Correspondence Address:
Dr. Emmanuel Osaigbovo Ighodaro
Department of Radiology, University of Benin Teaching Hospital, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1118-8561.223165

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  Abstract 


Introduction: The demand for radiological examination has increased tremendously despite paucity of referring clinicians' knowledge on radiation protection. Reasons to justify these referrals vary. Consequently, the aim of this study is to evaluate the relationship between clinicians' knowledge of radiological imaging dosage to their referral justification and guideline. Materials and Methods: Structured questionnaires were developed with four sections (Section 1, sociodemographic data; Section 2, justification for imaging referral; Section 3, knowledge of radiation dose to patients; Section 4, effect of irradiation). The questionnaires were administered at a previous Nigerian Medical Association National Conference, which took place at Lagos in 2013. Sections 3 and 4 were scored and rated. Results: The respondents gave plausible reasons to refer patients for radiological evaluation despite the observation that majority of them were unaware of the existence of referral guidelines and had poor knowledge on radiation. Only 16 (12.2%) of the respondents had a fair score on knowledge about radiation dose to patients while 110 (84.0%) had poor score. Five (3.8%) of the respondents had good score. Similarly, on identifying effect of radiation, 10 (7.6%) had good score, 4 (3.1%) fair score, and 117 (89.3%) poor score. Conclusion: Most of the referrals of patients for radiological evaluation by the respondents were not based on the standard guidelines. Therefore, it is pertinent that referral guidelines should be developed and implemented and clinicians should be educated and trained on radiation protection.

Keywords: Guideline, justification, radiation dose, referral


How to cite this article:
Ighodaro EO, Igbinedion BO. Justification of doctors' referral for radiological imaging among some Nigerian doctors. Sahel Med J 2017;20:117-22

How to cite this URL:
Ighodaro EO, Igbinedion BO. Justification of doctors' referral for radiological imaging among some Nigerian doctors. Sahel Med J [serial online] 2017 [cited 2024 Mar 29];20:117-22. Available from: https://www.smjonline.org/text.asp?2017/20/3/117/223165




  Introduction Top


Since the discovery of the medical applicability of radiation, there have been increasing demands for radiological services worldwide. This has led to the continuous production and advancement of more sophisticated imaging equipment without concomitant decrease in radiation dosage. As a result, modern imaging modalities such as computed tomography scanners with advancement of its capability (increasing number of detector rows) drastically increase radiation dose to patients. Such man-made sources of exposure to radiation account for about 18% of all sources of ionizing radiation.[1] Out of this man-made or medical sources of radiation, cardiologists (mainly in developed countries) are responsible for a large part, accounting for about 40%.[2],[3] Furthermore, in some countries, the population dose from medical exposures match that from natural background sources.[4] Radiation dose can be cumulative from various investigations and background radiation. This cumulative exposure of patients and population to ionizing radiation is likely to cause cancer in years down the line, with an important yet potentially avoidable public health threat.[5] In fact, in the UK, it is estimated that 100–250 deaths occur each year from cancers directly related to medical exposure to radiation.[1] Consequently, these exposures to radiation pose some health risks and thus, attempts should be made to minimize it.

Most of these ionizing radiation investigation sources are requested for, by physicians, either to aid diagnosis of ailment or in therapy. The benefit of using these imaging modalities is myriad as it contributes significantly to the care and management of patients. However, concerns of overreliance on these imaging modalities on clinical skills have arisen over the last two decades. As a result, clinical skills and acumen are said to be dwindling among recent medical graduates. Unfortunately, several studies have shown that referring physicians have poor knowledge of radiation protection and doses received during radiological evaluations.[1],[6],[7],[8] This observation has similarly been observed among other health professionals.[9] These health professionals and physicians are responsible for radiological referrals and in the performance of the procedure. On the background of poor knowledge of radiation exposure by health-care professionals, patients will be unduly referred for and exposed to radiation, whereas these patients are supposed to be protected and educated by these health-care professionals. The aim of this study is to assess radiation protection knowledge and reasons for justifying radiological requests, as well as to assess the utilization of referral guidelines among clinicians of various specialties in Nigeria.


  Methods Top


The questionnaire used in this study was adapted from literature review, restructured, and developed after a pilot study was conducted on ten doctors from different disciplines of the University of Benin Teaching Hospital. The questionnaires were administered at a previous Nigerian Medical Association National Conference, which took place at Lagos in 2013. At this conference, medical doctors from both public and private hospitals all over the country were in attendance. The questionnaires were distributed by hand delivery during the conference and collected from a designated point where the respondents were told to place them after filling in the questionnaire. Permission to conduct the study was granted by the conference organizers. A total of 150 questionnaires were administered while 134 were returned filled which give a response rate of 89.3%. All the respondents were literate and filled the questionnaire without the assistance of an interpreter. There was no responder identifier in the questionnaire.

The questionnaire has four sections with the first section fielding questions on sociodemographic data. The second section had questions on the reasons that justify referral for imaging evaluations request. Section 3 has questions to assess knowledge on radiation dose to patients from various imaging modalities while the questions in Section 4 were on the effect of radiation. Each correct response in Sections 3 and 4 was allocated one point, while wrong responses did not attract negative scores. Correct responses in Sections 3 and 4 of each responder were scored and rated. The maximum point in Section 3 was 7 and in Section 4 was 6. Section 3 was then rated into poor - 0–2 points; fair - 3–4 points; and good - 5–7 points. Section 4 is rated into poor - 0–1 points; fair - 2–3 points; and good - 4–6 points. Statistical analysis was done using Statistical Package for Social Sciences, (SPSS, Chicago, Illinois, USA) version 17.


  Results Top


There were 112 (85.5%) males and 19 (14.5%) females, with a male to female ratio of 5.9:1. The professional status of the respondents is as follows: Consultants 44 (33.6%); senior residents 25 (19.1%); registrars 9 (6.9%); senior house officers 1 (0.8%); house officers 1 (0.8%); medical officers 8 (6.1%); senior medical officers 17 (13.0%); principal medical officers 7 (5.3%); chief medical officers 8 (6.1%); chief medical directors 2 (1.5%); others 9 (6.9%). The respondents were from various medical disciplines [Table 1] with those in family medicine been the most numerous, 20 (15.3%), followed by obstetricians and gynecologists, 19 (14.5%).
Table 1: Medical specialties of the participants

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The respondents considered the following factors as “very important” before referring patients for imaging evaluation [Table 2]: consideration of radiation dose to patient 58.8%; effect of radiation on diagnosis 78.6%; effect on treatment 71.8%; effect on the patient's future 65.6%. Conversely, fewer proportion of the respondents consider these factors as not important, do not feel these factors should be considered, or do not have an idea. About 26.9% of the respondents knew of an ailment's investigational referral guideline in their center, out of which 77.1% had used such guidelines while 62.9% frequently used it and 11.4% very frequently used it to refer such cases for radiological evaluation. About 24% of the respondents refer patients for imaging evaluation even when such investigations may not affect the patient's outcome. Furthermore, 54.8% of these respondents do so at a frequency of <10%. Pressure of work, passing the burden to another department, giving impression to the patient and their relatives that attention is being given, and compensate for insufficient history/clinical examination and pressure of work were considered not important in referring patients for imaging evaluation in approximately one-half of each of these reasons. However, the majority (48.9%) of respondents opined that possible normal finding for requested imaging evaluation (which may reassure patients and their relatives) is enough reason for making radiological referrals.
Table 2: Distribution of responses to questions on imaging justification by respondents

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Most of the respondents do not know the estimated dose from a single chest x-ray when compared to annual natural radiation, radiation dose a patient absorbs from a single chest x-ray, and estimated dose of several radiological evaluations when compared to a chest X-ray [Table 3]. Despite about 82% of the respondents affirming that they were aware of any detrimental effect of ionizing radiation, most of them have not heard of deterministic or stochastic effect of radiation, and over 85% of the respondents could not categorize some of the listed effects of radiation into stochastic or deterministic effect [Table 4]. The respondents' knowledge of radiation dose to patients and knowledge on the effect of irradiation was poor with frequencies of 84.0% and 89.3%, respectively [Table 5]. The number of respondents with maximal points was 1 (0.8%) each on knowledge of radiation dose to patients and knowledge on the effect of irradiation.
Table 3: Distribution of responses on questions on physicians' knowledge of radiation dose to patients

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Table 4: Distribution of responses on the biological effects of radiation

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Table 5: The frequencies of scores and rating of the respondents' knowledge of radiation dosage to patients and the effects of irradiation

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In addition, we found out that the proportion of orthopedic surgeons and anesthetists with poor scores was 33% and 50%, respectively. Most of the other specialty had poor score and specialty with the lowest proportion of those with “poor score” on the knowledge of radiation dose to patient was 72%. However, the number of respondents from anesthesia and orthopedic surgery was small which makes it difficult to assess such specialties. The least proportion with poor score by the other disciplines on the effect of radiation was 67%.


  Discussion Top


Justification of imaging request and optimization of imaging evaluations are the cornerstones of radiation protection.[10] For an imaging request to be justified for a patient with a specific set of conditions, the physician uses available appropriateness criteria and referral guidelines to decide. A higher proportion of the respondents considered radiation dose to patients, effect on diagnosis, effect on treatment, and effect on the patient's future as very important reasons to justify requests for imaging. Accordingly, this gives an impression that despite the poor knowledge on radiation protection by the respondents, they have good reasons to justify imaging requests. The observation that about 69% of the respondents were unaware of the existence of referral guidelines in their centers is contrary to the reasons given to justify radiological evaluation requests that were given by majority of the respondents as the presence and utilization of guidelines is crucial in the reduction of patients' radiation dose and justification of imaging referrals. However, it is important to point out that about 77% of those who knew about imaging referral guidelines in their centers do use it and more than one-half assert that they frequently use it. Other studies have similarly shown that referral guidelines are not commonly used.[2],[3],[9]

Justification of medical imaging is a fundamental aspect of the “as low as reasonably achievable principle” which aims to minimize radiation dose. Hence, justification and optimization of medical imaging are pivotal to patient protection, ensuring that only those that will benefit from it are exposed and that the procedure is done using the best protocol.[5] Justification of medical imaging becomes even more pertinent in this era of increasing radiation exposure from modern advanced equipment and overreliance on health-care machines that emit ionizing radiation. Awareness of radiation protection and imaging justification, appropriateness of the imaging evaluation and its audit are important tools geared toward facilitating and enhancing justification.[5] Unfortunately, clinicians are often at conflict with radiologists who deny their radiological evaluation request which the radiologist deem inappropriate. This is worrisome as the practice of medicine should go beyond clinicians holding on to patients as “theirs,” to achieving collaborative multidisciplinary practices centered around ultimate patient care and benefit. Consequently, several referral guidelines were developed to enhance justification of medical imaging. Enforcing the implementation of these guidelines, making them easily available (e.g., in mobile electronic devices), and improving education of clinicians and radiologist are crucial to sustenance of guideline use and justification of imaging radiation utilization. Unfortunately, in this study, about one-fourth of the respondents refer patients for imaging evaluation even when patients' management outcome may not be affected. Details of the reason for this action were not probed further. However, imaging evaluation may be required to ascertain if the patient has been managed for the right diagnosis or to rule out complication or coexisting pathology.

Most of the physicians in this study had poor knowledge on radiation dose to patient and on the biological effect of irradiation. Furthermore, majority of the respondents could not correctly estimate the doses of various imaging modalities in comparison with radiation dose from a chest X-ray examination. The respondents in our study performed less than those in the study by Soye and Paterson,[6] in which 20% knew the effective dose of a single chest X-ray in comparison with 3% in our study. Magnetic resonance imaging and ultrasound were also included in the questionnaire. These imaging modalities do not emit or utilize ionizing radiation. Surprisingly, 28.2% and 27.4% of the respondents attributed radiation dose to abdominal ultrasound and cerebral magnetic resonance, respectively. Similar observations have been reported in the literature.[6],[8],[11] It is obvious that physicians have poor knowledge of radiation dosage from medical imaging devices which make their ability to justify radiological examination request questionable, especially as most of these clinicians do not use referral guidelines. In the USA and the UK, proper utilization of appropriate criteria and referral guidelines led to up to 40% reduction in the number of request for radiological evaluations.[5]

The way that ionizing radiation damages cells is by alteration of the DNA molecules either by ionization or by generation of free radicals. Ionizing radiation affects cell in two ways; deterministic or stochastic. Deterministic effect (also called nonstochastic) is a cause and effect relationship between ionizing radiation and tissue reactions such that a threshold exists after which the severity of the complication depends on the amount of radiation absorbed. These effects may become visible within days or months of exposure and produce a predictable pattern of tissue reaction.[12] Stochastic effect, on the other hand, occurs by chance and may occur without a threshold level of dose. The probability of occurrence of stochastic effect is proportional to the dose and severity is independent of the dose. The main stochastic effect is carcinogenesis which can occur several years later. In our study, about 89% of the respondents had poor rating on categorizing the effects of irradiation with most (about 86%) of the respondents having no score point. A question of how these clinicians would recognize radiation-induced complications from radiotherapy or cumulative dose arising from radiological examination or interventions in their follow-up patients comes to fore.


  Conclusion Top


There is poor knowledge on radiation protection, effects of irradiation, and awareness/utilization of guidelines across most of the disciplines of the clinicians. Such knowledge is particularly useful in the justification of radiation use which will drastically reduce radiation dose to the population. Consequently, it then becomes necessary for appropriate guidelines to be implemented, utilized, and awareness created among clinicians and other health workers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bury B. X-ray dose training: Are we exposed to enough. Clin Radiol 2004;59:926-7.  Back to cited text no. 1
    
2.
Picano E, Vano E. The radiation issue in cardiology: The time for action is now. Cardiovasc Ultrasound 2011;9:35.  Back to cited text no. 2
    
3.
Picano E, Vañó E, Rehani MM, Cuocolo A, Mont L, Bodi V, et al. The appropriate and justified use of medical radiation in cardiovascular imaging: A position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology. Eur Heart J 2014;35:665-72.  Back to cited text no. 3
    
4.
Justification of Medical Exposure in Diagnostic Imaging. Proceedings of an International Workshop on Justification of Medical Exposure in Diagnostic Imaging. Brussels: International Atomic Energy Agency; 2009.  Back to cited text no. 4
    
5.
Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet 2004;363:345-51.  Back to cited text no. 5
    
6.
Soye JA, Paterson A. A survey of awareness of radiation dose among health professionals in Northern Ireland. Br J Radiol 2008;81:725-9.  Back to cited text no. 6
    
7.
Zewdneh D, Dellie ST, Ayele T. A study of knowledge and awareness of medical doctors towards radiation exposure risk at Tikur Anbessa specialized referral and teaching hospital, Addis Ababa, Ethiopia. J Pharm Biol Sci 2012;2:1-5.  Back to cited text no. 7
    
8.
Shiralkar S, Rennie A, Snow M, Galland RB, Lewis MH, Gower-Thomas K. Doctors' knowledge of radiation exposure: Questionnaire study. BMJ 2003;327:371-2.  Back to cited text no. 8
    
9.
Briggs-Kamara MA, Okoye PC, Omubo-Pepple VB. Radiation safety awareness among patients and radiographers in three hospitals in Port-Harcourt. Am J Sci Ind Res 2013;4:83-8.  Back to cited text no. 9
    
10.
The International Commission on Radiological Protection. Recommendation of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP 2007;37:1-332.  Back to cited text no. 10
    
11.
Arslanoglu A, Bilgin S, Kubal Z, Ceyhan MN, Ilhan MN, Maral I. Doctors and interns doctors knowledge about patients' ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol 2007;13:53-5.  Back to cited text no. 11
    
12.
Authors on behalf of ICRP, Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, et al. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs – threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012;41:1-322.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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