DEVELOPMENT OF MEDICAL IMAGING PATHWAYS FOR USE BY PRIMARY CARE PHYSICIANS

Purpose: Adaptation of guidelines for local use can enhance the applicability of and adherence to current best practices.  The primary purpose of this project was to develop pathways that combined current guideline recommendations with local experience to assist regional primary care providers to decide whether, when and how to refer adult patients for imaging when presenting with a headache or low back pain.  Information was also collected to guide the development of an implementation strategy.

Methods: The project was informed by elements of the CAN-IMPLEMENT framework for guideline adaptation.  Each pathway was developed by a multidisciplinary panel of over 25 members that included primary care providers, radiologists and relevant specialists from a range of practice settings. Key steps involved guideline screening and summarization, assessment of guideline skeleton and recommendations by clinician panels, meetings to resolve discordances and consensus building of the final pathway via modified Delphi technique.  Primary care providers were placed in leadership positions to ensure applicability of the format and content to their practice. To develop an implementation strategy, a focus group was conducted to identify barriers and opportunities to pathway acceptance and adherence, followed by a survey that determined priorities and preferences related to focus group themes.

Results: Imaging pathways have been developed for headache and low back pain.  The starting point of each pathway involves subcategories that combine specific symptoms and patient histories that should allow physicians to easily determine which management route to take.  These subcategories are designed to reflect the initial assessment by primary care providers and align with current guidelines.  Clinicians indicated that key barriers to using existing guidelines include lack of awareness and inaccessibility of guidelines.

Conclusions: Using a methodology based on the principles of guideline adaptation and obtaining consensus, imaging pathways have been developed to assist regional primary care providers determine the most appropriate use of medical imaging for patients who present with headache or low back pain.  These pathways are expected to be applicable to the local practice setting and accurately reflect patient presentation to primary care providers. Critical to ensuring uptake of the pathways will be an implementation plan that enables broad dissemination and integrates pathways into clinician workflow.