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Neuroimaging in a memory assessment service: a completed audit cycle

  • Tarun Kuruvilla (a1), Rui Zheng (a1), Ben Soden (a2), Sarah Greef (a1) and Iain Lyburn (a3) (a4)...
Abstract
Aims and method

A clinical audit was used to compare neuroimaging practice in a memory assessment service prior to and 6 months after implementation of guidance, developed from national and European guidelines and adapted to local resource availability, with multislice computed tomography (CT) as first-line structural imaging procedure.

Results

Referrals to the service nearly doubled from the initial audit to the re-audit. Patients having at least one neuroimaging procedure increased from 68 to 76%. Patients with no reason documented for not having imaging significantly reduced from 50% to less than 1%. Despite the larger number of referrals, the mean waiting times for the scans only increased from 22 to 30 days. Variations in practice between the sectors reduced.

Clinical implications

Disseminating evidence-based guidelines adapted to local resource availability appears to have standardised neuroimaging practice in a memory assessment service. Further research into the clinical and cost benefits of the increased scanning is planned.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Tarun Kuruvilla (tarun.kuruvilla@glos.nhs.uk)
Footnotes
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Declaration of interest

T.K. has received educational grants from Pfizer, Novartis, Lundbeck and GE Healthcare to attend conferences. Both T.K. and I.L. have received speaker fees from GE Healthcare.

Footnotes
References
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Neuroimaging in a memory assessment service: a completed audit cycle

  • Tarun Kuruvilla (a1), Rui Zheng (a1), Ben Soden (a2), Sarah Greef (a1) and Iain Lyburn (a3) (a4)...
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eLetters

Neuroimaging in dementia: how best to use the guidelines?

Mustafa Alachkar, SpR in psychiatry
06 April 2014

I read with interest Kuruvilla et al's paper in which an audit cycle was completed on neuroimaging practice after national and European guidance was adapted to local resource availability (1).

I welcome the results of the audit which showed an improvement in the number of patients who have had at least one form of neuroimaging performed from 68% to 76%, and although this improvement was not statistically significant, it seems to suggest a general improvement in the service provided as reflected also in the improved documentation of the reason of not requesting neuroimaging and in not significantly impacting on waiting times. Improvement in the service provided may also be reflected in a patient and relative satisfaction survey that could be carried out.

In a similar study (2), I audited the practice of a memory clinic in Southport, Merseyside against 2006 NICEguidance on dementia which stated that "structural imaging should be used in the assessment of people with suspected dementia...and that MRI is the preferred modality... although computed tomography (CT) scanning could beused" (3). The audit included 75 patients and showed that 56 patients (75%) had at least one neuroimaging procedure performed and that 53 of those (95%) had CT scans and only one patient had an MRI scan. My audit revealed a similar problem with documentation of reasons for not scanning patients, with 31% of patients who were not scanned having no documentation in theirnotes of the reasons why a scan was not performed compared to 50% in Kuruvilla et al's initial audit. In my study a re-audit was not carried out.

An additional aim of my study was to look at whether the diagnosis ofdementia subtype, provisionally made based on clinical interview and usingscales such as MMSE and ACE-R, was changed following neuroimaging. In thisregard the study showed that the diagnosis was changed following a scan in45% of cases, mostly from Alzheimer's or vascular dementia into a mixed type dementia. It also showed that in 38% of case notes reviewed, no provisional diagnosis was documented in the notes, suggesting that clinicians were perhaps uncomfortable about making a diagnosis before a scan is performed.

Bearing in mind that NICE guidelines are partly cost-effectiveness driven, studies such as Kuruvilla et al's provide good support for the usefulness of adapting these guidelines to the local availability of resources which results in better care for dementia patients.

References:

1. Kuruvilla T, Zheng R, Soden B, Greef S, Lyburn I. Neuroimaging in a memory assessment service: a completed audit cycle. Psychiatric Bulletin 2014; 38:24-28.

2. Alachkar M. The use of neuro-imaging techniques in dementia patients; a study in the memory clinic. Poster Presentation at the International Congress of the RCPsych in Edinburgh 2010.

3. National Institute for Health and Clinical Excellence. Dementia: Supporting People with Dementia and Their Carers in Health and Social Care(Clinical Guidance CG42). NICE, 2006.

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Conflict of interest: None declared

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