Imaging guidance for GP commissioning

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1 Imaging guidance for GP commissioning First published in 1989, The Royal College of Radiologists (RCR) has produced the referral guidelines, Making the best use of clinical radiology services, to help GPs, clinicians, radiologists, radiographers and other healthcare professionals to determine the most appropriate imaging investigation(s) for a wide range of clinical problems. They provide practical guidance based on the best available evidence, together with expert opinion where evidence is lacking or conflicting. The principal objectives of the RCR s guidelines are: To ensure patients have timely and accurate diagnosis by ensuring doctors and referring clinicians have knowledge of the most appropriate imaging investigation or intervention To reduce unnecessary exposure of patients to radiation To assist in the efficient and equitable utilisation of available diagnostic resources. The process for development of the seventh edition of the guidelines (November 2011) has been formally approved under the NHS Evidence Accreditation Scheme. The full resource consists of 330 guidelines designed to assist the clinician in selecting the most appropriate investigation for a given diagnostic or imaging problem. The guidelines are split into 12 sections: Breast disease Musculoskeletal system Cancer Neurological system Chest and cardiovascular system Obstetrics and gynaecology ENT/head and neck Paediatrics Gastrointestinal system Trauma Interventional radiology Urogenital and adrenal. This summary lists the investigations for guidelines which relate to the most common presentations in primary care. This list is based on investigations rather than the clinical problems to facilitate the commissioning process. It is not intended as a GP s substitute for RCR referral guidelines but rather for those commissioning diagnostics wishing to know which essential radiological investigations to commission. The relevant RCR referral guideline is shown, with links to other related UK guidelines. Commissioners may choose to include other specialised investigations, such as MRI shoulder, which are often resource-intensive and usually only undertaken after discussion with the radiologist or in the context of locally agreed protocols. In these referral guidelines, the doses have been grouped into broad bands to help the referrer understand the order of magnitude of radiation dose of the various investigations. Symbol Examples None Typical effective dose (msv)* 0 0 <1 CXR; XR limb, pelvis, lumbar spine; mammography IVU; NM (eg, bone); CT head and neck CT chest or abdomen; NM (eg, cardiac) 0000 >10 Extensive CT studies, some NM studies (eg, some PET-CT) US; MRI *The average annual background dose in most parts of Europe falls within the 1 5 msv range (0 0). [Key: US=ultrasound; MRI=magnetic resonance imaging; CXR=chest X-ray; XR=X-ray; IVU=intravenous urography; NM=nuclear medicine; CT=computed tomography; PET-CT=positron emission tomography coregistered with CT. Access to the full seventh edition of the RCR guidelines is available via subscription please see for further details.

2 BREAST Mammography 0 B03 B04 B07 B09 B15 Breast screening: women years old (the precise age for invitation will depend on national screening programmes) Breast screening: women >70 years old (the precise age will depend on national screening programmes) Breast screening: women 50 years old who have had augmentation mammoplasty Clinical suspicion of carcinoma in patients with augmentation mammoplasty (implants) Breast inflammation Ultrasound None B08 Breast cancer diagnosis CHEST/CVS B15 Breast inflammation CXR 0 CC05 Suspected pericarditis or pericardial effusion CC07 CC08 CC21 CC23 Suspected valvular heart disease Suspected heart failure and/or myocarditis Pneumonia Pleural effusion suspected NICE CG41. Familial breast cancer Breast Cancer: Manual Update SIGN 59. Community Management of Lower Respiratory Tract Infection in Adults CC24 Haemoptysis (including massive haemoptysis) NICE. The diagnosis and treatment of lung cancer (update) CA12 Lung cancer: diagnosis NICE. The diagnosis and treatment of lung cancer (update) SIGN 80. Management of patients with lung cancer CC12 Suspected deep vein thrombosis (DVT) 2

3 Ultrasound None CC23 Pleural effusion suspected CC05 Suspected pericarditis or pericardial effusion Echocardiography None CC07 Suspected valvular heart disease CC08 Suspected heart failure and/or myocarditis CT CA12 Lung cancer: diagnosis NICE. The diagnosis and treatment of lung cancer (update) SIGN 80. Management of patients with lung cancer ENT Ultrasound None E04 Thyroid nodules GASTROINTESTINAL E08 E09 E10 Neck mass of unknown origin Salivary obstruction Salivary mass US None G21 Palpable mass G27 G28 Jaundice Suspected gall bladder disease or postcholecystectomy pain Barium swallow 0 0 G01 Difficulty in swallowing: high dysphagia Barium enema 0 0 G16 CA23 Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia Colon cancer: diagnosis Colorectal Cancers: Manual Update Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer 3

4 CT (incl colonography) MSK G16 G21 CA23 Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia Palpable mass Colon cancer: diagnosis XR 0 M07 Osteomyelitis M10 M11 M13 M14 M15 Soft tissue mass Bone pain Metabolic bone disease Suspected osteomalacia with pain Suspected osteoporotic collapse Colorectal Cancers: Manual Update Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer M16 Arthropathy: presentation SIGN 123. Management of early rheumatoid arthritis M19 M20 M21 M23 M24 Shoulder instability Sacroiliac pain Non-traumatic hip pain including suspected avascular necrosis Knee pain with locking Painful prosthesis Ultrasound None M10 Soft tissue mass 4

5 MRI None M05 M07 M10 M11 M21 M23 Acute back pain with potentially serious (red flag) features Osteomyelitis Soft tissue mass Bone pain Non-traumatic hip pain including suspected avascular necrosis Knee pain with locking DEXA 0 M13 Metabolic bone disease NEUROLOGICAL MRI None N02 TIA NICE CG88. Low back pain N03 Demyelinating and other white matter disease NICE CG08. Multiple sclerosis N04 Space-occupying lesion N14 Epilepsy (adult) NICE CG20. The epilepsies CA01 Brain and spinal cord tumours: diagnosis National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual CT 0 0 N01 Acute stroke SIGN 108. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention NICE CG68. Stroke DH. National Stroke Strategy easy access version DH. National Stroke Strategy National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) 5

6 O&G N02 N04 N05 CA01 TIA Space-occupying lesion Headache: sudden onset, severe; subarachnoid haemorrhage Brain and spinal cord tumours: diagnosis Ultrasound None OG01 Screening in pregnancy NICE. Antenatal care OG04 OG05 OG06 OG07 OG08 OG09 OG10 OG12 CA42 Possible early intrauterine pregnancy failure Postmenopausal bleeding: to exclude significant endometrial pathology Suspected pelvic mass Pelvic pain, including suspected pelvic inflammatory disease and suspected endometriosis Lost intrauterine contraceptive device (IUCD) Recurrent miscarriages (3 or more) Infertility Suspected polycystic ovary syndrome Ovarian cancer: diagnosis National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual RCP. National clinical guideline for stroke, Third edition NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual SIGN 61. Investigation of Post-Menopausal Bleeding RCOG. Guideline 32. Management of Acute Pelvic Inflammatory Disease RCOG. Guideline 17. The Investigation and Treatment of Couples with Recurrent Miscarriage NICE. CG24. Fertility assessment and treatment for people with fertility problems NICE. CG24. Fertility assessment and treatment for people with fertility problemsf RCR. Imaging for Oncology 6

7 PAEDIATRICS CA48 Cancer of the uterine body: diagnosis XR 0 P03 Inhaled foreign body (suspected) in children P22 P36 Ingested foreign body in children Focal bone pain in children Ultrasound None P24 Projectile vomiting in infants P28 P30 P34 P35 P37 P40 Acute abdominal pain in children Palpable abdominal/pelvic mass in children Hip pain in children: suspected irritable hip Limp (no trauma) in children Clicking hip: suspected developmental dysplasia of the hip (DDH) in infants Impalpable testis in children MRI None P17 Back pain in children TRAUMA XR 0 T10 Neck injury with pain NICE. Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury T14 T15 Thoracic and lumbar spine trauma with pain but no neurological deficit, or patient not able to be evaluated Thoracic and lumbar spine trauma with neurological deficit with or without pain T16 Pelvic injury with inability to weight-bear NICE. The management of hip fracture in adults T19 Shoulder injury 7

8 T20 T21 T22 T23 T24 T25 T26 T32 Ultrasound None T26 MRI None T15 T25 Elbow trauma Wrist injury: suspected scaphoid fracture Knee trauma: fall/blunt trauma Acute ankle injury Foot injury Stress fracture Soft tissue injury: foreign body eg, metal, glass, painted wood, thorns Sternal injury Soft tissue injury: foreign body eg, metal, glass, painted wood, thorns Thoracic and lumbar spine trauma with neurological deficit with or without pain Stress fracture CT 0 0 T01 Head injury NICE. Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury UROGENITAL/ADRENAL Ultrasound None U02 Renal failure U10 U11 U12 U20 U21 Lower urinary tract symptoms Scrotal mass or pain Suspected testicular torsion Microscopic haematuria Macroscopic haematuria 8

9 CA32 Kidney cancer: diagnosis CT U04 Suspected ureteric colic U21 Macroscopic haematuria XR 0 U20 Microscopic haematuria U21 Macroscopic haematuria Urological Cancers. The Manual 9

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