[Guides and standards: use of electrodiagnostic testing in the neurological investigation - electromyography and nerve conduction studies]

Parent M, Robitaille H
Record ID 32018004221
Original Title: Guides et normes: Utilisation de l’examen électrodiagnostique dans l’investigation neurologique : électromyographie et étude de conductions nerveuses
Authors' objectives: Electrodiagnostic testing, which consists of electromyography and/or nerve conduction studies, is potentially useful to assess the disease process, etiology, location and severity of injury in several neurological, muscular or neuromuscular conditions. It can therefore help refine the diagnosis and prognosis to guide clinical management. However, there is still some ambiguity about the role of electrodiagnostic testing in the care trajectory. Indeed, it is not a definitive diagnostic test ordered by itself in the same way was a laboratory test, but rather an extension of the physical and neurological examination in the context of a neurology, physical medicine or otolaryngology specialist consultation. The appropriate use of electrodiagnostic testing will therefore rely mainly on the clinical identification, during the initial examination by the front-line clinician, of patients who have probable peripheral nervous system injury for whom electrodiagnostic testing is likely to clarify the diagnosis and improve management. In response to the concerns raised by the Association des neurologues du Québec regarding the potential overordering of electromyography in requests for specialist consultations, the Ministère de la Santé et des Services sociaux (MSSS) asked INESSS to draw up clinical indications for the appropriate use of this testing in neurological investigations.
Authors' results and conclusions: RESULTS: (#1: PREVALENCE OF ELECTRODIAGNOSTIC TESTING): In 2019, half of the neurology consultation requests compiled by the Service d’acheminement de formulaires informatisés et suivis de requêtes (SAFIR) were for a neuromuscular condition with a request for electrodiagnostic testing, most of which for the investigation of carpal tunnel syndrome. • A total of 89,035 electrodiagnostic tests were performed in 2019 (84,509 patients). • A modest average annual increase of 0.85% in the utilization rate1 has been observed since 2011, with the rate increasing to 10.98 exams per 1,000 population, which is comparable to that estimated in the United States (10.74 per 1,000 population in 2016). • 65.9% of the patients who underwent electrodiagnostic testing were 50 years of age or older at the time of the test. • The utilization rate of electrodiagnostic testing varied significantly according to the patient’s region of residence, which indicates a potentially large variation in practices. • The annual billing and operating costs generated by electrodiagnostic testing are approximately $8 million. (#2: DEVELOPMENT OF CLINICAL INDICATIONS): A total of 19 clinical practice guidelines and 8 systematic reviews were selected and analyzed. From them, seven categories of clinical situations for which electrodiagnostic testing may improve patient management were identified: carpal tunnel syndrome, the other mononeuropathies, radiculopathies and plexopathies, polyneuropathies, myasthenia, myopathies, and laryngeal neuropathy. • On the other hand, electrodiagnostic testing is of limited value for clarifying clinical suspicion of a joint disorder, musculoskeletal pain with no neurological symptoms, or a central nervous system disorder (e.g., tremor, parkinsonism or other movement disorder). Information from the guidelines and reviews and input from the advisory committee were amalgamated into 17 clinical indications. CONCLUSION: The clinical indications and the clinical decision support tool are intended to summarize the best-practice evidence, and they encourage careful consideration of symptom severity and atypicality, and the treatment options being contemplated for the identified conditions. The goal is thus to support clinical judgment in identifying clinical indications that might benefit from electrodiagnostic testing in the context of a consultation. Particular emphasis was placed on the most common conditions and presentations, for which the risk of overusing electrodiagnostic testing is higher. The indications and the ensuing clinical decision support tool have the potential to increase the appropriateness of requests for specialist consultations and thus reduce the number of procedures with low diagnostic value. Consideration might be given to periodically measuring their impact, specifically, by measuring the progression in the number of tests, wait times, and changes in practice over time.
Authors' methods: The methodological approach was centred on the research question: What are the clinical indications that do or do not justify the use of electrodiagnostic testing in the context of a specialist consultation to diagnose neurological, muscular and neuromuscular conditions? To contextualize this question for Québec practice, data from 2009 to 2020 from the Régie de l'assurance maladie du Québec (RAMQ) databases, electronic requests for specialist consultations, and institutions’ financial reports were extracted and analyzed. • Clinical practice guidelines and systematic reviews were systematically searched for the existing recommendations regarding the appropriate use of electrodiagnostic testing in adult patients. • The methodological quality of the selected guidelines was assessed using the AGREE II instrument, and the quality of the reviews was assessed using the RAMSTAR tool. An advisory committee of clinicians was formed for the purpose of validating the interpretation of the literature, enhancing the clinical indications and assessing the relevance and acceptability of the indications in the context of Québec practice. • A clinical decision support tool, which can be used during physician visits, has been developed to provide a synthesis of the clinical indications.
Project Status: Completed
Year Published: 2022
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Electromyography
  • Electrodiagnosis
  • Diagnostic Techniques, Neurological
  • Nerve Conduction Studies
  • Practice Guidelines as Topic
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: Gouvernement du Québec
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