Fatima, Nosheen

uz Zaman, Maseeh

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eCommons@AKUDepartment of Radiology Medical College, PakistanJuly 2019Evidence-based medicine in cardiac imagingMaseeh uz ZamanAga Khan University, maseeh.uzzaman@aku.eduNosheen FatimaAga Khan University, nosheen.fatima@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolRecommended Citationuz Zaman, M., Fatima, N. (2019). Evidence-based medicine in cardiac imaging. Journal of the College of Physicians and SurgeonsPakistan, 29(7), 597-299.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/351The term evidence-based medicine (EBM) was first coinedby Dr Gordon Guyatt, a physician and epidemiologist atMcMaster University, Canada.1 He defined EBM as"medicine practised on the basis of evidence". Soonafter the publication of this single author article in 1991,1a group of physicians and epidemiologists launched acampaign by the name of EBM Movement.2 Theyemphasised upon greater reliance on up-to-date andpublished research; especially, randomised controltrials (RCT) and systematic reviews (SR). Similarly,evidence based practice is provision of best possiblecare to patients by considering their preference, clinicalsetting and available best evidence by the trainedhealthcare providers. The 28-year journey of EBM ismarked by many success stories. First, it has success-fully captured the agenda that the scientists andphysicians will decide the future of medicine; and indeedthis is a great achievement.3 Next is foundation ofCochrane Collaboration in 1993 in Oxford, UnitedKingdom by National Health Services (NHS) in whichmore than 40,000 volunteers are associated with it, whoare producing more than 400 systematic reviews ofclinical trials annually.4 These systematic reviews are thebases of formulation of clinical guidelines which areregularly published by professional societies for goodclinical practice and decision-making. These systematicreviews also fuel the formulation of appropriate usecriteria (AUC) for judicious use of the procedures anddevices by various professional societies.5 EBM hasrecently launched a campaign demanding pharma-ceutical industry to disclose the data of clinical trialswhich have been funded by them. This agenda hasbeen warmly welcomed and supported by WorldHealth Organization (WHO) and European Union(EU).6,7 Recently, EBM has coined a terminology "over-diagnosis", not leading to reduced mortality associatedwith a particular disease.8 This has been observed forthe significantly increased incidence of thyroid andprostate cancers due to overwhelming use of fine-needle aspiration in thyroid nodule and serum PSAwithout appreciable decline in cancer related mortality.8It is imperative to improve clinical outcome with respectto clinical need and cost; and hopefully, EBM campaignwill produce a positive impact.There are four basic elements of EBM.9 First, a clinicalquestion is formulated which has four pertinentinformation, i.e. Patient, Intervention, Comparison andOutcome (PICO).10 A PICO question could be like"Dobutamine stress echocardiography has betterprognostic value than myocardial perfusion imaging forpatients with acute myocardial infarction". For this PICOquestion, best available evidences are searched fromavailable published data in the form of randomisedcontrol trials as these have lower odds of bias; andstudies with good patients' population, reduce thechances of error. Then these published data arevalidated internally and externally. Finally, the resultsextracted from validated data are applied in clinicalpractice in conjunction with clinical expertise andpatients' preferences. Gathered information about aPICO question is than issued by the professional societyor body in the form of clinical guidelines.9 Usually, theseclinical guidelines have recommendations for practisingphysicians with weightage based on evidences.The recommendations in clinical guidelines are usuallyclassified as Class I: having evidence and/or generalagreement about the usefulness / efficacy of aprocedure or treatment; Class II: having conflictingevidence about the usefulness and efficacy of theparticular procedure or treatment; Class III: there isevidence of a general agreement that particularprocedure is not useful and effective or may be harmful.These recommendations are supported by evidencewhich is further classified on the basis of its origin.Evidence drawn from multiple randomised trials areconsidered strong (Level A) and those drawn from singlerandomised trial or non-randomised trials is consideredfair (Level B). Evidence which is only based onconsensus opinions of experts and not having supportof published data are considered weak (Level C).11Similarly, this validated evidence is also used forAppropriate Use Criteria (AUC) for certain clinicalprocedures and devices, which are released byprofessional societies. A procedure is consideredappropriate for which the expected health benefitsexceed expected risk by a wide margin.5 Contrary toclinical guidelines, AUC are often consensus of experts'opinion with a weak scientific basis. There is also apossibility that if a physician feels that he or she wouldbe judged on the basis of AUC, it is quite possible thatthe physician may use a diagnosis that fits with AUC andJournal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (7): 597-599 597EDITORIALEvidence-based Medicine in Cardiac ImagingMaseeh uz Zaman and Nosheen FatimaDepartment of Radiology, The Aga Khan University Hospital,Karachi, PakistanCorrespondence: Prof. Maseeh uz Zaman, Section ofNM & PET/CT Imaging Services, Department of Radiology,The Aga Khan University Hospital, Karachi, PakistanE-mail: maseeh.uzzaman@aku.eduReceived: December 24, 2018;  Revised: January 19, 2019;Accepted: March 08, 2019not the real one for that required procedure. However, itis also important to understand that there is significantdiscordance between AUC published for nuclearmyocardial perfusion imaging from different societies.12It can be argued whether we have EBM in cardiacimaging? A recently published study revealed thatmedicare billing for medical imaging had increased from$7 billion in 2000 to $14 billion in 2005.13 Furthermore,approximately one-third of billing amount involvedcardiovascular medical imaging which were adopted atan extraordinary cost with insufficient evidence ofbenefits to patients.13 Another study published in 2009revealed that 30-50% of cardiac procedures performedwere appropriate and basic reasons were marketmessages, high patient demand and defensivemedicine, leading to the vicious circle of the so-calledUlysses syndrome.14 However, the most importantconcern has been raised by American Heart Association(AHA) in its scientific statement published in 2014. Thisstates that the radiation exposure to US population frommedical imaging has increased six-fold since 1980 andover 40% of this has been contributed by the cardio-vascular imaging and intervention.15 This importantfact indeed draws attention to sensitize the medicalcommunity about the importance of EBM in cardiacimaging, particularly to minimize the lifetime attributablerisk for radiation associated cancer in exposees.It is imperative to understand the possible obstacles inimplementation of EBM in cardiac imaging. The mostimportant obstacle is over-reliance on the reliability ofclinical trials and systematic reviews. For example, twosystematic reviews about the impact of beta-blockers onmortality in acute myocardial infarction had totallydifferent outcomes; one favoured and the other deniedthe role of beta blocker in reducing mortality.3 Over-reliance on statistical significance of results of publisheddata is another considerable obstacle. Statisticalmethods used in analysis need to be carefully studied asinappropriate use could make a non-significant p-valueto a statistically significant one. Therefore, while readingpublished studies, one must consider clinical as well asstatistical significance of data mentioned in a clinical trialor systematic review. It is also not uncommon to haveincomplete and conflicting recommendations byprofessional societies, that clinicians feel to be well awayfrom real practice. It is also important to understand thatthe non-availability of certain equipment and patients'preferences are also important hurdles in imple-mentation of EBM in cardiac imaging. Lastly, thefinancial aspect, associated with cardiac imaging likereimbursement by insurance companies or financialmalpractice among referring physicians and cardiaclaboratories, is also an undeniable obstacle.3For effective implementation of EBM in a cardiac imaging,a multifaceted approach is considered most appropriate.We must acquire clinical information from educationalmaterials, like review articles and meta-analyses, withrecently published guidelines and AUC by the relevantprofessional societies. We must educate staff andphysicians about AUC for specific clinical questions.Studies have shown considerable variation in raters atdifferent levels of training in identifying inappropriatenuclear cardiac imaging procedures.16 With appropriatetraining, improvements have been observed for appro-priate use of transthoracic echocardiography (TTE) andCT angiography (CTA), but not for trans-esophagealechocardiography (TEE) and stress imaging.17 Whileperforming cardiac imaging, one must perform completeevaluation and documentation that procedure meetsrelevant AUC criteria. In institute having PictureArchiving and Communication Systems (PACS),Computerized Physician Order Entry (CPOE) andfrequent reminders about the importance of appropriatecardiac imaging procedures, can be installed. Whenphysician enters an order for a cardiac imagingprocedure, the software asks few clinical queriespertinent to AUC for that particular imaging. Effectivecommunication among staff, nurses and referringphysicians can also help by convincing the referringphysician about an appropriate imaging against his orher patient's clinical query. To address financial issues,one can link the reimbursement with practice of EBM asper clinical guidelines and AUC. American Congress haspassed a bill in 2014: "As of 2017, claims withoutdocumentation that AUC criteria were consulted, will notbe paid by medicare".18 It also states that documentationis the responsibility of the referring physician but thepayment would be at risk for the performing physicianand this has indeed created conflict between them.Evidence-based medicine has become an explicitelement of medical professionalism, rendering to launcha successful campaign that physicians and scientists willdecide the future of medicine. It has introduced cultureof clinical guidelines and AUC for better clinical decision-making in cardiology and other faculties of medicine.However, it has also contributed tension between thedifferent sectors of healthcare. Despite these obstacles,there is optimism for EBM future in cardiac imaging as itwould reduce probability of radiation-associated cancersby curtailing inappropriate and unjustified radiation-based procedures. To achieve this aim, there is aunanimous call for more evidence to support evidence-based cardiac imaging in future. It is believed that "lackof evidence does not mean absence of evidence."REFERENCES1. Guyatt GH. Evidence-based medicine. ACP J Club 1991; 114:A16.2. Evidence-based medicine working group. Evidence-basedmedicine: A new approach to teaching the practice ofmedicine. JAMA 1992; 268:2420-5. Maseeh uz Zaman and Nosheen Fatima598 Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (7): 597-5993. Sheridan DJ, Julian DG. Achievements and limitations ofevidence-based medicine. J Am Coll Cardiol 2016; 68:204-13.4. Cochrane library oversight committee. Measuring theperformance of the Cochrane library. Cochrane Database SystRev 2012; 12:ED000048. 5. Armstrong W, Eagle KA. "Appropriate use criteria inechocardiography: Is no change the same as no benefit?".JAMA Intern Med 2013; 173:1609-10.6. Moorthy VS, Karam G, Vannice KS. Rationale for WHO's newposition calling for prompt reporting and public disclosure ofinterventional clinical trial results. PLoS Med 2015; 12: e1001819.7. La Santos Quintana A. PMþ: EU's clinical trials regulation 'astep in right direction' parliament magazine, 2014. Available at:https://www. theparliamentmagazine.eu/articles/sponsored_article/pm-eu%E2%80%99s-clinical-tr ials-regulation-%E2%80%98-step-right-direction%E2%80%99. [Accessed22.12.2018].8. Welch HG, Black WC. Overdiagnosis in cancer. J Natl CancerInst 2010; 102:605-13.9. Sackett DL, Straus SE, Richardson WS. Evidence-basedmedicine: How to practice and teach EBM. ed 2nd, ChurchillLivingstone, Edinburgh 2000. 10. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. Thewell-built clinical question: A key to evidence-based decisions.ACP J Club 1995; 123:A12. 11. Budoff MJ, Achenbach S, Blumenthal RS,  Carr JF, Goldin JG,Greenland P, et al. Assessment of coronary artery disease bycardiac computed tomography. Circulation 2006; 114:1761-91. 12. Winchester DE, Wolinsky D, Beyth RJ, Shaw LJ. Discordancebetween appropriate use criteria for nuclear myocardialperfusion imaging from different specialty societies: A potentialconcern for health policy. JAMA Cardiol 2016; 1:207-10. 13. Farmer SA. CV testing practices for incident HF vary widelyacross hospitals. JACC Cardiovasc Imaging 2014; 7:690-700. 14. Picano E. The risks of inappropriateness in cardiac imaging. IntJ Environ Res Public Health 2009; 6:1649-64.15. Reza Fazel R,  Gerber TC, Balter S, Brenner DJ,  Carr JJ,Cerqueira MD, et al. Approaches to enhancing radiation safetyin cardiovascular imaging. Circulation 2014; 130:1730-48. 16. Ye S, Rabbani LR, Kelly CR, Kelly MR, Lewis M,  Paz Y, et al.Can physicians identify inappropriate nuclear stress tests?Examination of inter-rater reliability for the 2009 appropriateuse criteria for radionuclide imaging. Circ Cardiovasc QualOutcomes 2015; 8:23-9. 17. Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changesin appropriateness of cardiac imaging. J Am Coll Cardiol 2015;65:763-73.18. http://www.cardiovascularbusiness.com/topics/imaging/acc-examines-impact-medicare-changes-imagingEvidence-based medicine in cardiac imagingJournal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (7): 597-599 599

Evidence-based medicine in cardiac imaging

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Evidence-based medicine in cardiac imaging

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