FDG PET in Preoperative Assessment of Colorectal Liver Metastases Combining “Evidence-Based Practice” and “Technology Assessment” Methods to Develop Departmental Imaging Protocols

In today's environment of progressively evolving and expensive imaging modalities, radiologists are asked to justify the use of resources to patients, referring physicians, hospital management, and third party payers. With this aim, the radiologist may use “top-down” or “bottom-up” “evidence-based practice” (EBP) techniques. “Top-down” suggests that the practitioner should wait until a higher authority, external to their practice, generates a solution to practice dilemmas (e.g., National Institute for Health and Clinical Excellence [NICE] guidelines). “Bottom-up” however, is based on the theory that the ordinary practitioner is best served by a decentralized approach to problem solving that is internal to their practice. The technology assessment framework modeled by Mackenzie and Dixon comprehensively assesses the effects of imaging using levels of efficacy including diagnostic performance, diagnostic impact, and therapeutic impact, impact on health and cost effectiveness. In this article, we describe how issues regarding new imaging modalities in ordinary radiology practice can be addressed by using stepwise “bottom-up” EBP techniques combined with the technology assessment framework. We also detail how EBP techniques form an integral part of practice-based learning among radiology residents as part of noninterpretive residency training. The following clinical scenario is used: Your hospital's chief hepatobiliary surgeon writes to your department regarding the lack of access to 18-fluoro-2-deoxy-d-glucose positron emission tomography in the preoperative assessment of patients with colorectal cancer liver metastases under consideration for hepatic resection. How would you approach this problem? Here is how we would do it.