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Editorials |
1 From the Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. Received January 5, 2006; final version accepted January 6. Address correspondence to the author (e-mail: dmalone{at}ucd.ie).
Late one evening in 2004, my home telephone rang. It was Dr Harald Stolberg. In typically enthusiastic fashion, he told me, "Dr Tony Proto wants a series for the Evidence-based Practice section of Radiology (1) that will explain to practicing radiologists what evidence-based radiology can mean to them. He says, 'Make it readable!' Would you like to join me as a co-editor?" I accepted (of course) and we laid out the series outline together over the next few weeks. Unfortunately, in January 2005, Harald became acutely unwell and passed away after emergency abdominal surgery and a short illness. It is not my intent to repeat his obituary (2), but no introduction to this series would be complete without acknowledging the vision, drive, and commitment to excellence in radiology that made Harald a champion in the cause of integrating evidence-based practice (EBP) principles into radiology. He was an inspirational figure. After forming and coordinating the production of the article "Evidence-based Radiology: A New Approach to the Practice of Radiology" by the Evidence-Based Radiology Working Group (3) and submitting it for publication in November 2000, he met several of the authors for dinner at the Radiological Society of North America 2000 Annual Meeting—not just to celebrate the conclusion of that task (although we did that) but to ask, "What's next?"
When Harald and I worked on the outline of this series, we considered that "evidence-based" practice has become a catchphrase in recent years. In 2004, professor Paul Glasziou (director of the National Health Service Centre for Evidence-based Medicine [CEBM], University of Oxford, England) revived terminology originally used by David Sackett (4) that we adopted and that will be used throughout the series (Paul Glasziou, written communication, 2004). He noted that to some, EBP identifies a series of centers charged with producing evidence reports and technology assessments to support guideline development by other groups (3). To others, it means the centralized production of guidelines and their integration into practice.
These definitions have in common the assumption that the ordinary practitioner is best served by a centralized process, external to his or her practice. These schools of thought can be termed top-down EBP (4). While centralized academic activity is important and the key to a good evidence base, there is another school of thought about EBP. To this group, EBP is "the integration of best research evidence with clinical expertise and patient values" (4,5). It is a process that was originally developed at McMaster University, Canada, and subsequently refined there and at the CEBM. This approach has roots in the fields of clinical medicine, epidemiology, and adult learning theory (problem-based learning). It is concerned with information, individualized problems, and the use of the Internet and modern informatics to get the best research evidence into practice.
The underlying assumption is that the practitioner is best served by a decentralized but exact five-step approach internal to his or her practice. He or she asks an answerable question, searches the literature to locate evidence produced by the top-down EBP groups, appraises it explicitly, searches primary literature (if necessary) to cover any relevant temporal gaps, and then proceeds to apply and evaluate the best current evidence with due regard for local circumstances (5). In radiology, the radiologic expertise is the central component; research evidence, clinical circumstances (including comorbidities), and, in particular, the patients' and referring physicians' preferences become part of the rational decisions made. This approach is derived from the original evidence-based medicine paradigm (4,5). The principles can be used in any department with access to the Internet to tackle any problem that might be encountered by a practicing radiologist today.
The aims of the process are to bridge the gap between research and practice, make the best use of journal review time, and ensure that decisions about imaging and intervention in patient groups or individual patients are based on the best current evidence wherever possible. Centralized academic activity focuses on identifying the best research and making it readily available via the Internet. This school of thought can be termed bottom-up EBP (4,5).
You may say, "So what?" Well, just imagine that you are at a radiology meeting and have dinner with some colleagues before you return home. It was a good meeting, with interesting presentations. Over coffee, the conversation turns to problems you are all encountering in the day-to-day practice of radiology that you have not solved during the meeting.
One friend, the director of the department of radiology at a teaching hospital, says that he has been wondering whether his thoracic radiologists should be adding routine indirect computed tomographic (CT) venography to their pulmonary embolism CT examinations; it is not widely used elsewhere, it is increasing the cost and radiation dose out of proportion to the benefit, he suspects, and a lot of clinicians are accepting it as an alternative to Doppler ultrasonography (US) of the limb veins when the pulmonary embolism CT scans are negative, reducing the US section referrals and causing conflict within the department. He feels he lacks the information necessary to make a firm statement on the issue.
Another colleague, whose brother has hepatitis C cirrhosis, has been asked to advise because his brother has developed a small hepatocellular carcinoma and has been offered the choice between transplantation, hepatic resection, and radiofrequency ablation. He wonders which to choose; both his surgeon colleague and his interventional radiology colleague are very convinced of the benefits of their methods and have literature to back up their claims.
This prompts another radiologist, who was a resident with you, to reveal that his interventional colleagues are considering whether to offer a vertebroplasty program at their community hospital, and they are unsure if it is well enough validated to invest the training time and set-up efforts.
You add that you personally have recently introduced CT colonography (virtual colonoscopy) into your department. You often get requests for screening examinations from primary care physicians and other physician groups and have been performing these studies since you read what seemed to be a convincing article in the New England Journal of Medicine in 2003 (6). Although your department has been glad of the referrals, your gastroenterologists are antagonistic and claim that with every case you take, recent literature shows that you are leaving yourself open to future litigation because of missed premalignant polyps that would be detected with colonoscopy (7). You wonder how much of a risk this really is. Simultaneously, they are putting pressure on your department to reduce the amount of imaging performed for occult gastrointestinal bleeding, claiming that capsule endoscopy is a superior technique. You do not want to lose this turf war, but at the same time, you do not want to begin a vigorous offensive if they are correct about capsule endoscopy.
How would you go about dealing with these situations when you go home? They are run-of-the-mill, common problems in today's world. How about trying bottom-up EBP?
That is what this series is about: bottom-up EBP in radiology, which is abbreviated to "evidence-based radiology." We have conceptually split the series into two sections. The first section will describe the basic principles of bottom-up EBP and show how they can be applied to problems that you may encounter in your daily practice, using those problems described above as examples. The second section poses the question, "Where does the bottom-up EBP paradigm fit in radiology today?" All of the authors in this series write from personal experience—they have previously completed and published the type of evidence-based radiology project about which they write.
The authors of the first section include some of the young academic radiologists who are pioneering the application of the McMaster University–CEBM form of bottom-up EBP in radiology education and in the radiology literature (8–13). For the purpose of this series, they have applied EBP principles to the clinical situations described here. I hope you enjoy following up those questions as we go through the series.
In the second section, established academic radiologists (14–17), some of whom were members of Harald Stolberg's Evidence-Based Radiology Working Group (3), have given their time to consider the wider implications of EBP in radiology in regard to radiology education, the technology assessment paradigm, the ethics of radiology practice, and the radiology literature.
Harald Stolberg was there for the start of this series. Although he is, regrettably, with us only in spirit now, this final paragraph of the introduction was written by him and needs no revision or addition:
Radiology is a young specialty. It did not exist in the 19th century and has evolved considerably throughout the 20th century. The incorporation of evidence-based practice techniques holds the promise to contribute to the further evolution of radiology training and practice. We hope you will join us on this journey through a subject that will, we expect, be an important and useful addition to the radiologist's toolbox and resources in the 21st century.
I am sure the series authors will agree when I say that their articles are part of the answer to the question "What's next for evidence-based radiology?" that Harald posed in the millennium year, and they will join me in dedicating the series to his memory.
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FOOTNOTES |
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  L. S. Medina and C. C. Blackmore Evidence-based Radiology: Review and Dissemination Radiology, August 1, 2007; 244(2): 331 - 336. [Abstract] [Full Text] [PDF]
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J. D. Dodd Evidence-based Practice in Radiology: Steps 3 and 4--Appraise and Apply Diagnostic Radiology Literature Radiology, February 1, 2007; 242(2): 342 - 354. [Abstract] [Full Text] [PDF]
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A. V. Proto Radiology 2007: The Year Ahead Radiology, January 1, 2007; 242(1): 3 - 5. [Full Text] [PDF]
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