Choosing Wisely – Canada

Five Tests and Treatments to Question

1. Don’t do imaging for lower-back pain unless red flags are present
2. Don’t do imaging for minor head trauma unless red flags are present
3. Don’t do imaging for uncomplicated headache unless red flags are present
4. Don’t do computed tomography (ct) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option
5. Don’t do an ankle x-ray series in adults for minor injuries

Patient information: Common Tests, Treatments, and Procedures You May Think You Need.

Choosing Wisely – USA

Five Things Physicians and Patients Should Question

1. Don’t do imaging for uncomplicated headache
2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam
4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Choosing Wisely – Australia/New Zealand

Tests, Treatments and Procedures for Healthcare Providers and Consumers to Question

1. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
2. Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
3. Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
4. Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
5. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
6. Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
7. Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ?50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
8. Don’t initiate management of low risk prostate cancer without discussing active surveillance.
9. Don’t routinely use more than one fraction for palliation of non-complex bone metastases.
10. Don’t routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
11. Do not proceed with any treatment for localised prostate cancer unless the man has been offered a consultation with a urologist and a radiation oncologist, and taken time to consider the advantages and disadvantages of each treatment option.

Choosing Wisely – UK

Recommendations for Clinicians: Royal College of Radiologists

1. MRI is indicated only in specific circumstances. Clinical featrues will often be sufficient to guide management without the need for imaging.
2. Morton’s neuroma is essentially a clinical diagnosis and investigations are generally unnecessary. If the diagnosis of forefoot pain in uncertain, use XR to assess forefoot bones, joints and alignment, In experienced hands, US with dynamic assessment can confirm a diagnosis of Morton’s neuroma and guide injection treatment if required. It is helpful when clinical suspicions is high and conservative measures have failed.
3. Us is the investigation of chose in the assessment of rotator cuff and surrounding soft tissues. It may be used to guide injection, It is reserved for cases with unresponsive to first line treatment and clinically guided injection. It is indicated preoperatively if the surgeon requires assessment if rotator cuff integrity.
4. Imaging is not normally required for Parkinson’s diseases (PD). MRI is useful no differentiating PD from vascular parkinsonism and atypical parkinsonism syndromes in the differential diagnosis of parkinsonian syndromes (progressive supranuclear palsy, multiple system atrophy and corticobasal degeneration). CT is the alternative when MRI is contraindicated. NKM imaging with dopamine transporter is recommended in difficult cases to differentiate true PD and the parkinsonian syndromes from essential tremor and other movement disorders.
5. Routine follow up imaging is not always appropriate. IREFER guidelines are available, which help you determine what is best for your patients. XR may be required by specialists to assist management decisions e.g. for instituting and modifying drug treatment and referral for joint replacement. Routine follow up is otherwise not appropriate.

• From the government of Canada: Safety Code 35: Safety procedures for the installation, use and control of X-ray equipment in large medical radiological facilities
• HARP (Healing Arts Radiation Protection). Guidelines for radiation safety in all x-ray facilities in Ontario.
• NCRP-147. This report goes over recommendations and technical information regarding the design and installation of the structural shielding that medical x-ray facilities must have.