Optimising diagnostics through imaging informatics: Costs and opportunities

YesIncreasing diagnostic capacity is a national priority to expedite the timeliness and appropriateness of patient treatment interventions. Imaging—encompassing a range of technologies including X-ray, CT, MRI, nuclear medicine and ultrasound—is a key diagnostic service and central to decision-making in most, if not all, disease pathways. However, imaging is an expensive discipline accounting for an estimated 3–5% of the annual NHS budget. As a result, it is imperative that we maximise service efficiency while optimising patient outcomes.The manuscript version differs from the published version

Ultrasound clinical progress monitoring: Who, where and how?

Prior to assessment of final ultrasound clinical competency it is important to monitor clinical progress, provide high quality feedback and encourage skills development. The role of the supervisor, mentor and assessor are fundamental to the on-going progress monitoring of ultrasound trainees. This article forms the second part of a larger project which was to elicit ultrasound practitioners’ opinions on how progress should be monitored, where and by whom. An on-line questionnaire was used to gain opinions from ultrasound practitioners. Totally, 116 responses were received from professionals with an interest in ultrasound assessment. Results suggested that experienced, qualified ultrasound practitioners should undertake the role of supervisor and assessor, having been prepared for that role by the training centre. Formative monitoring should take place both within the clinical department and possibly the training centre, using a range of methods. Following completion of the training, practitioners should have a preceptorship period to consolidate their knowledge and skills for 3 to 6 months or until further competencies have been demonstrated. Formative progress monitoring should be a recognised part of ultrasound training. Essentially, staff undertaking supervision and assessor roles should be supported and trained to ensure a high quality, consistent learning experience for ultrasound trainees. Additionally, they should provide appropriate feedback to the trainee and education centre

Strategies for assessing renal function prior to outpatient contrast-enhanced CT: a UK survey

YesThe purpose of this paper is to identify current UK screening practices prior to contrast-enhanced CT. To determine the patient management strategies to minimize the risk of contrast-induced acute kidney injury (CI-AKI) risk in outpatients. An invitation to complete an electronic survey was distributed to the CT managers of 174 UK adult National Health Service hospital trusts. The survey included questions related to local protocols and national guidance on which these are based. Details of the assessment of renal function prior to imaging and thresholds for contrast contraindication and patient management were also sought. A response rate of 47.1% was received. Almost all sites had a policy in place for contrast administration (n = 80/82; 97.6%). The majority of sites require a blood test on outpatients undergoing a contrast-enhanced CT scan (n = 75/82; 91.5%); however, some (15/75; 20.0%) sites only check the result in patients at high risk and a small number (7/82; 8.5%) of sites indicated that it was a referrer responsibility. The estimated glomerular filtration rate (eGFR) or serum creatinine (SCr) result threshold at which i.v. contrast was contraindicated varied and 19 different threshold levels of eGFR or SCr were identified, each leading to different prophylactic strategies. Inconsistency was noted in the provision of follow-up blood tests after contrast administration. The wide variation in practice reflects inconsistencies in published guidance. Evidence-based consensuses of which patients to test and subsequent risk thresholds will aid clinicians identify those patients in which the risk of CI-AKI is clinically significant but manageable. There is also a need to determine the value of the various prophylactic strategies, follow-up regimen and efficient service delivery pathways. This survey has identified that further work is required to define which patients are high risk, confirm those which require renal function testing prior to contrast administration and how best to manage patients at risk of CI-AKI. The role of new technologies within this service delivery pathway requires further investigation

CT head reporting by radiographers: results of an accredited postgraduate programme

Aim: To evaluate the results of the summative objective structured examination (OSE) for the first four cohorts of radiographers (n ¼ 24) undertaking an accredited postgraduate course in reporting computer tomography (CT) head examinations. Method: The construction of a summative OSE contained twenty five CT head examinations that incorporated 1:1 normal to abnormal pathological examples. All cases were blind reported by three consultant radiologists to produce a valid reference standard report for comparison with the radiographer's interpretation. The radiographers (n ¼ 24) final reports (n ¼ 600) were analysed to determine the sensitivity, specificity and agreement values and concordance for the four cohorts. Results: The four cohorts (2007e2013) of postgraduate radiography students' collective OSE results established a mean sensitivity rate of 99%, specificity 95% and agreement concordance rates of 90%. The final grades indicate that within an academic environment, trained radiographers possess high levels of diagnostic performance accuracy in the interpretation of CT head examinations

Radiographer reporting in the UK: Is the current scope of practice limiting plain film reporting capacity?

yesObjective: To update knowledge on individual radiographer contribution to plain-film reporting workloads; to assess whether there is scope to further increase radiographer reporting capacity within this area. Methods: Reporting radiographers were invited to complete an online survey. Invitations were posted to every acute National Health Service trust in the UK whilst snowball sampling was employed via a network of colleagues, ex-colleagues and acquaintances. Information was sought regarding the demographics, geographical location and anatomical and referral scope of practice. Results: A total of 259 responses were received. 15.1% and 7.7% of respondents are qualified to report chest and abdomen radiographs, respectively. The mean time spent reporting per week is 14.5 h (range 1–37.5). 23.6% of radiographers report only referrals from emergency departments whilst 50.6% of radiographers have limitations on their practice. Conclusion: The scope of practice of reporting radiographers has increased since previous studies; however, radiographer reporting of chest and abdomen radiographs has failed to progress in line with demand. There remain opportunities to increase radiographer capacity to assist the management of reporting backlogs. Advances in knowledge: This study is the first to examine demographic factors of reporting radiographers across the UK and is one of the largest in-depth studies of UK reporting radiographers, at individual level, to date

Outcomes of delivering a fertility preservation service for women with cancer over a 12-year period at a UK assisted conception unit.

This service evaluation aimed to appraise the delivery of a fertility preservation service for women with cancer which was established in 2005 as part of an Assisted Conception Unit. First, the ACU-database was interrogated between 08/2005 and 01/2017; revealing 174 women received referrals over the 12-year period with a steady referral increase each year. Demographic analyses revealed factors, such as being partnered, to be strong indicators of whether women would seek FP or not. To improve service provision, women who had consented to be contacted for audit, administrative and research purposes, received questionnaires to ascertain their perspectives on the FP decision-making process, their outcomes and ACU after-care. The majority perceived their experience as excellent due to the care they received from ACU staff, speed and efficiency in service delivery. The increasing number of referrals since 2005 is reassuring. However, this audit also highlighted shortcomings of the service, such as limited awareness of the fertility counselling service and lack of after-care. IMPACT STATEMENT What is already known on this subject? There has been an increase in women diagnosed with cancer undergoing fertility preservation (FP) before starting potential gonadotoxic treatment. Offering FP to these women is essential as the ability to have future children is often perceived as equally as important as survivorship, and a source of hope for the future. What do the results of this study add? This study presents a service evaluation, across a 12-year period, of delivering FP services to women with cancer in one UK Assisted Conception Unit (ACU). Women's experiences of the service were evaluated to enhance service delivery and make recommendations for clinical practice. What are the implications of these findings for clinical practice and/or future research? The current service evaluation demonstrated increased rates of FP referral over a 12-year period for women with cancer. While this increasing number is reassuring and reflecting increased awareness among professionals and patients; shortcomings in the care pathway were also found: women reported limited opportunity to see fertility counsellors and desired better after care. This information may also be of benefit to other ACUs seeking to enhance and improve service provision in the care of women with cancer, contemplating fertility preservation

AFROC analysis of reporting radiographer’s performance in CT head interpretation

Aim: A preliminary small scale study to assess the diagnostic performance of a limited group of reporting radiographers and consultant radiologists in clinical practice undertaking computer tomography (CT) head interpretation . Method: A multiple reader multiple case (MRMC) alternative free response receiver operating characteristic (AFROC) methodology was applied. Utilising an image bank of 30 CT head examinations, with a 1:1 ratio of normal to abnormal cases. A reference standard was established by double reporting the original reports using two additional independent consultant radiologists with arbitration of discordance by the researcher. Twelve observers from six southern National Health Service (NHS) trusts were invited to participate. The results were compared for accuracy, agreement, sensitivity, specificity. Data analysis used AFROC and area under the curve (AUC) with standard error. Results: The reporting radiographers results demonstrated a mean sensitivity rate of 88.7% (95% CI 82.3 to 95.1%), specificity 95.6% (96% CI 90.1 to 100%) and accuracy of 92.2% (95% CI 89.3 to 95%). The consultant radiologists mean sensitivity rate was 83.35% (95% CI 80 to 86.7%), specificity 90% (95% CI 86.7 to 93.3%) and accuracy of 86.65% (95% CI 83.3 to 90%). Observer performance between the two groups was compared with AFROC, AUC, and standard error analysis (p=0.94, SE 0.202). Conclusion: The findings of this research indicate that within a limited study, a small group of reporting radiographers demonstrated high levels of diagnostic accuracy in the interpretation of CT head examinations that was equivalent to a small selection of consultant radiologists

Treating symptomatic uterine fibroids with myomectomy: current practice and views of UK consultants

Background: The demand for uterus-sparing treatments is increasing as more women postpone childbirth to their 30–40s, when fibroids are more symptomatic. With an increasing choice of treatment options and changing care-provider profiles, now is an opportune time to survey current practices and opinions. Using a 25-stem questionnaire, a web-based survey was used to capture the practices and opinions of UK consultant gynecologists on the treatment of symptomatic fibroids, including the types of procedure most frequently used, methods used to reduce blood loss, and awareness and acceptability of treatment options, and to assess the impact of gender and experience of the treating gynecologist. Results: The response rate was 22%. Laparascopic myomectomy is used least frequently, with 80% of the respondents using GnRHa preoperatively to minimize blood loss and correct anemia, while vasopressin is most frequently used to reduce intraoperative blood loss. Female consultants operate significantly less frequently than males. Those with more than 10 years consultant experience are more likely to perform an open myomectomy compared to those with less than 10 years experience. Conclusions: Compared to a similar survey performed 10 years ago, surgical methods remain to be the most common treatments, but use of less invasive treatments such as UAE has increased. Consultants’ attitudes appear to be responding to the patient demand for less radical treatments. However, it is yet to be seen if the changing consultant demographics will keep up with this demand. The low response rate warrants cautious interpretation of the results, but they provide an interesting snapshot of current views and practices

Radiotherapy waiting times for women with breast cancer: a population-based cohort study

Background: Waiting times for cancer patients are a national priority in the UK. Previous studies have shown variation between cancer networks in the time between diagnosis and start of radiotherapy for all cancer patients. Studies of the relationship between delay in receiving treatment and survival of breast cancer patients have been inconsistent. This study aimed to examine factors associated with waiting times for radiotherapy for breast cancer patients. Methods: 35,354 women resident in South East England and diagnosed with breast cancer between 1992 and 2001 who received radiotherapy within six months of diagnosis were identified from the Thames Cancer Registry. Time to radiotherapy was measured from either the date of diagnosis or the start of the previous treatment, whichever was shorter. Unadjusted and adjusted logistic regression models were fitted to examine whether patients received radiotherapy within 60 days of their diagnosis or previous treatment. Results: The adjusted proportions of patients receiving radiotherapy within 60 days varied significantly between different cancer networks (range: 43% to 81%), and decreased from 68% in 1992 to 33% in 2001. After adjustment there was no association between deprivation of area of residence, age or stage and radiotherapy wait. Median time waited to radiotherapy increased over the study period whether measured from the start of chemotherapy, hormone therapy, surgery or the date of diagnosis. Conclusion: This study covered a period of time before the investment following the Cancer Plan of 2000. Results are consistent with other findings suggesting variation between cancer networks and increasing waits over time. Further studies should examine different methods of measuring waiting time, the causes and consequences of waits for radiotherapy and the effect of current initiatives and investments