A systematic review of the quality and consistency of UK national and international diagnostic imaging recommendations for osteoarthritis

Problem

Audits and observational studies suggest that X-rays are requested for a significant proportion of patients consulting with osteoarthritis (OA), despite mounting evidence against their utility. We sought to identify national and international guideline recommendations on the role of plain radiographs in the diagnosis of OA, and the quality and consistency of these recommendations.

Approach

We undertook a systematic search of eleven electronic databases (including EMBASE, MEDLINE CINAHL, Epistemonikos and Guideline Central) and websites of nine professional organisations (including NICE, Royal College of Radiology (RCR), EULAR and American College of Radiology (ACR)) for the most recent evidence-based guidelines produced by professional organisations on the diagnosis of OA. Non-English and spinal OA guidelines were excluded. Each abstract and full text underwent dual screening. Data extraction was undertaken by a single reviewer using a standard proforma. Two independent reviewers critically appraised each guideline using the AGREE II tool. Narrative synthesis focussed on the nature and consistency of recommendations on the use of radiographs in the diagnosis of OA.

Findings

We included the most recent edition of 18 guidelines published between 1998 and 2019 (any joint (8), knee OA (3), hip OA (2), hand OA (2), wrist (1), foot (1), ankle (1)). Seven guidelines were produced by European organisations, two of which were UK-based (NICE, RCR). Eleven guidelines were produced by organisations representing general practitioners and seven guidelines by organisations representing radiologists. Guidelines scored on average 69% in the AGREE II rigour of development domain but scored poorly on the AGREE II applicability domain (32%). The eleven guidelines targeted predominantly at general practitioners recommended a clinical diagnosis of OA without radiographic confirmation in patients with typical clinical features. Seven guidelines suggested a poor correlation between radiographic features and clinical symptoms but only three explicitly discouraged the routine use of radiography for OA. Guidelines produced by organisations representing radiologists were more supportive of radiography. The ACR guidelines recommended plain radiographs to confirm a clinical diagnosis of OA at the hand, wrist, hip, knee, ankle, and foot. The RCR guideline recommended radiography to confirm clinical OA at the hand, feet, and hip, but not the knee.

Consequences

European guidelines do not recommend radiography to confirm a clinical diagnosis of knee OA. The role of radiography at other joint sites is less clear. The lack of clear, explicit, and consistent recommendations on the role of radiography may provide some explanation as to why radiographs continue to be over-used. Furthermore, guideline recommendations were rarely supported by tools to improve implementation. Research into patient and practitioner factors which determine the use of radiographs could identify targets to reduce the inappropriate use of X-rays in the diagnosis of OA.