Background
As previously announced, the Canadian Association of Radiologists (CAR) is redoing its diagnostic referral guidelines. Last released in 2012, the CAR imaging referral guidelines consisted of recommendations for 338 clinical/diagnostic scenarios over 13 sections: Breast Disease, Cancer, Cardiovascular, Central Nervous System, Gastrointestinal System, Head and Neck, Musculoskeletal System, Obstetrics and Gynecology, Pediatrics, Spine, Thoracic, Trauma, and Urological, adrenal, and genitourinary systems.
The development of guidelines is an immense undertaking, and to be able to address the large number of clinical/diagnostic scenarios in a two-year period, traditional guideline methodologies will not suffice. Therefore, staff liaisons at the CAR, including epidemiologists and guideline methodologists, with guidance from the Diagnostic Imaging Referral Working Group, have created a methodologically rigorous approach to expedite the process for the development/ review of these guidelines.
Methodology
An Expert Panel was recruited for each of the 13 sections, and is made up of radiologists, referring clinicians for primary care and specialists referring clinicians, a patient representative, and a guideline methodologist.
Creating the list of clinical/diagnostic scenarios
The first task for the Expert Panel is to create a comprehensive list of clinical/diagnostic scenarios. The list of clinical/diagnostic scenarios from the 2012 recommendations are used as the starting point for discussions. The evidence review team at the CAR also performed a preliminary search of guidelines to identify potential scenarios not covered in 2012.
Rapid Evidence Review using Artificial Intelligence
Using this list of scenarios, a library scientist develops a systematic search strategy, and the evidence review team at the CAR conducts the rapid evidence review. Using a systematic review software, with built-in artificial intelligence, specifically active machine learning, we can identify relevant guidelines quickly. Recommendations from systematically produced guidelines, meeting pre-defined criteria (i.e., those meeting three criteria in AGREE-II, a tool to assess the quality and reporting of practice guidelines), are mapped to each scenario and inform the discussions when formulating the recommendations.
Formulating recommendations using GRADE concepts
Starting with the recommendations identified in the rapid evidence review, the Expert Panel formulates recommendations for each imaging modality (e.g., ultrasound, radiograph, magnetic resonance imaging, computed tomography), ensuring they are contextualized to the Canadian Healthcare system using the concepts in the Evidence to Decision framework of GRADE (e.g., values and preference, equity, accessibility, cost, and resources).
Creating a blueprint
In developing this methodological approach, we have also created a methods manual. This methods manual will be beneficial for the CAR: (1) to allow for consistent application of this approach across the 13 sections; and (2) to allow for a guided approach for future updates. This methods manual will also be made available to other associations developing rapid guidelines, where this approach may be beneficial.
Project Status Update
As of April 20th, 2022, six Expert Panels have been recruited and are in different stages of the guideline development.
- Trauma: The draft guideline includes recommendations for 21 clinical/diagnostic scenarios and is currently undergoing external review and will be available online by the summer of 2022.
- Musculoskeletal system: The draft guideline includes recommendations for 25 clinical/diagnostic scenarios and will soon be sent for external review.
- Obstetrics and gynecology: The draft guideline includes recommendations for 12 clinical/diagnostic scenarios and is currently undergoing internal review from the Expert Panel.
- Breast disease: Meetings are underway to develop recommendations for 23 clinical/diagnostic scenarios.
- Gastrointestinal system: A list of 20 clinical/diagnostic scenarios has been developed by the Expert Panel and the rapid evidence review began on April 25th.
- Head and neck: An expert panel has been recruited and the inaugural meeting will be held in May 2022.
What’s Next?
Each guideline will be uploaded to the CAR website as they become available. Additionally, the CAR is working with partners to begin integration of these recommendations into a clinical decision support (CDS) system.
The CAR will be submitting a manuscript describing the methods in an open-access peer-reviewed journal.
Contact Us
For more information on this project or if you are interested in receiving a copy of the published journal manuscript (once available), please contact the CAR staff liaison: Candyce Hamel ([email protected]), Senior Epidemiologist and Guideline Methodologist.