Collaboration, campaigns and champions for appropriate imaging: feedback from the Zagreb workshop

Abstract Leading radiologists and representatives from national radiation protection regulatory authorities and health ministries from 19 countries of the European region worked together with five experts at the workshop on justification and appropriate use of imaging in Zagreb, Croatia, from 26 to 28 October 2017 jointly organised by the IAEA and the European Society of Radiology. The workshop served as a forum to exchange information on challenges and solutions for improving justification and the appropriate use of diagnostic imaging. Common barriers to improving the use of imaging referral guidelines were discussed and the need for increased collaboration identified. Examples of good practices were presented, including use of Clinical Decision Support (CDS) systems to facilitate rapid and good justification decisions. The workshop identified some of the needs of European countries for achieving more appropriate imaging proposing wider use of collaboration, campaigns and champions. Main messages • Drivers for appropriate imaging in Europe are similar to those elsewhere globally. • Implementing imaging referral guidelines is the main barrier to more appropriate imaging. • Clinical Decision Support systems (CDS) facilitates good referral practice and justification decisions. • Collaboration, campaigns and champions may improve awareness, appropriateness and audit.


Introduction
Justification and appropriate imaging have been key topics in global efforts pulling together drivers from evidence-based practice, radiation protection and value-based imaging [1][2][3][4][5][6][7]. Regional efforts in Africa, the Middle East, South East Asia, Latin America and the Far East [8][9][10][11][12][13] have complemented more established efforts in North America [14,15] and Western Europe [16]. The wish to consolidate efforts in some countries, particularly in the Eastern European region, led to the organisation of the Zagreb workshop from 26 to 28 October 2017. This regional workshop was held in Zagreb, Croatia, by the International Atomic Energy Agency (IAEA), co-sponsored by the Government of the Republic of Croatia, City of Zagreb, and the European Society of Radiology (ESR), and supported by the World Health Organisation (WHO). Leading radiologists and representatives from national radiation protection regulatory authorities and health ministries were invited, with 40 participants from 19 countries working with 5 experts. Common barriers to appropriate imaging of patients and asymptomatic individuals were identified with good practices shared and collaborative solutions sought (Tables 1). Common barriers, suggested solutions and good practices Participants identified common barriers and solutions for more appropriate imaging of patients and asymptomatic individuals not referred by a doctor, giving useful examples from their local practices (see Tables 2 and 3). All participants pointed out that imaging referral guidelines were not officially used in their countries. The most common barrier was the difficulty in implementing imaging referral guidelines and tools for better use. Some countries had managed to provide the distribution and some promotion of imaging referral guidance. For example, in Poland 100,000 copies of the adopted and translated guidelines have been distributed. Several institutions in Croatia, Russia and Sweden have piloted Clinical Decision Support systems (CDS) bringing guidance closer to referrers. Use of CDS systems such as the ESR iGuide [1] and RCR iRefer [3] will rapidly facilitate good referral practice and justification decisions through adopting, adapting and translating where needed.
Many smaller countries reported the difficulty with resources, both human and financial. Training and educational needs were also common. Portugal provided a good example of collaboration through a common language. With eight Portuguese-speaking countries in four regions (Angola, Brazil, Cabo Verde, Guinea Bissau, Mozambique, Portugal, San Tome et Principe and Timor-Leste), efforts for radiation safety, the burden of cost and value of benefits are shared. Plans have also been made for collaboration through the Russian language in several Eastern European Region countries.
Clinician awareness, acceptance and co-operation posed a problem in several countries. Workflow solutions such as multi-disciplinary clinical meetings enabled better communication and education of clinician colleagues in the Baltic States.
In some countries outside the European Union there was a wish for stronger and transparent legislation to provide a regulatory framework and means for inspection. This was  particularly apparent in countries where the culture was for referrers to order rather than request investigations, losing the opportunity for radiologists' valuable input as to the most appropriate imaging investigation, if any is needed. The need for a radiological practitioner as gatekeeper was clear. The under-provision of equipment in some countries precluded the use of the best test first but it was accepted that in these health economies latitude and flexibility should be exercised correctly.

Discussion
In Europe as in other regions of the world, there are common needs for better justification of medical exposures leading to more appropriate imaging, less waste and more sustainable use of imaging resources [17]. The same drivers for appropriate imaging are apparent in Europe as in Africa, America and Asia. The inequity and iniquity of over-utilisation and underutilisation of radiology within the same jurisdiction exist in most countries with 20-45% of examinations deemed inappropriate [18]. The nirvana of uniform requesting, use and provision of imaging will need different approaches in different countries [19]. Examples of good practices and the wish for collaborative efforts identified several common areas for progress (Table 4). It was clear that the need for greater collaboration would provide benefits faster, sharing the burden of work. Initiatives that have already been taken up or will be shortly are:

Conclusion
The needs of European countries for achieving more appropriate imaging are becoming clearer and concise. The putative principles of collaboration, campaigns and champions may be the way forward for the accepted axiom of awareness, appropriateness and audit.
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