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

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

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

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

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

Anatomical and/or pathological predictors for the “incorrect” classification of red dot markers on wrist radiographs taken following trauma

OBJECTIVE: To establish the prevalence of red dot markers in a sample of wrist radiographs and to identify any anatomical and/or pathological characteristics that predict “incorrect” red dot classification. METHODS: Accident and emergency (A&E) wrist cases from a digital imaging and communications in medicine/digital teaching library were examined for red dot prevalence and for the presence of several anatomical and pathological features. Binary logistic regression analyses were run to establish if any of these features were predictors of incorrect red dot classification. RESULTS: 398 cases were analysed. Red dot was “incorrectly” classified in 8.5% of cases; 6.3% were “false negatives” (“FNs”)and 2.3% false positives (FPs) (one decimal place). Old fractures [odds ratio (OR), 5.070 (1.256–20.471)] and reported degenerative change [OR, 9.870 (2.300–42.359)] were found to predict FPs. Frykman V [OR, 9.500 (1.954–46.179)], Frykman VI [OR, 6.333 (1.205–33.283)] and non-Frykman positive abnormalities [OR, 4.597 (1.264–16.711)] predict “FNs”. Old fractures and Frykman VI were predictive of error at 90% confidence interval (CI); the rest at 95% CI. CONCLUSION: The five predictors of incorrect red dot classification may inform the image interpretation training of radiographers and other professionals to reduce diagnostic error. Verification with larger samples would reinforce these findings. ADVANCES IN KNOWLEDGE: All healthcare providers strive to eradicate diagnostic error. By examining specific anatomical and pathological predictors on radiographs for such error, as well as extrinsic factors that may affect reporting accuracy, image interpretation training can focus on these “problem” areas and influence which radiographic abnormality detection schemes are appropriate to implement in A&E departments

The role of the advanced clinical practitioner in breast diagnosis : a systematic review of the literature

Increasing prevalence in breast cancers, workforce shortages and technological advancements have increased the need to further develop advanced practice in breast diagnosis. The Advanced Clinical Practitioner training programme has been introduced to support this need. The aim of this work was to systematically review studies that explore advanced practice in mammography to assess the potential impact of the introduction of a specific Advanced Clinical Practitioner training programme in breast diagnosis within the UK. A systematic PRISMA review of the literature published between 1999 and January 2020 was carried out. A total of 17 studies were included in the review. Four themes were identified in the literature in relation to advanced practice in breast imaging: multidisciplinary practice; roles and responsibilities associated with advanced practice; development and progression; embedding and sustaining advanced practice. It was evident across all themes that advanced practice is vital in supporting better care for patients attending breast imaging in light of workforce shortages. Although advanced practice and its benefits are well established in breast imaging, persistent barriers were acknowledged such as role ambiguity, recruitment issues, lack of support from some radiologists and poor funding. Findings suggest that introducing a more formalised pathway to advanced practice into breast imaging through the implementation of a specific Advanced Clinical Practitioner apprenticeship training programme may overcome many of the challenges evidenced in this review. The findings of this review will help inform the development of the Advanced Clinical Practitioner apprenticeship programme specific to breast diagnosis. [Abstract copyright: Copyright © 2020 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation

Greater use of 3D conformal, Intensity Modulated Radiotherapy (IMRT) and external beam partial breast irradiation following local excision (LE) for breast cancer has necessitated a review of the effectiveness of immobilisation methods to stabilise breast tissue. To identify the suitability of currently available breast (rather than thorax) immobilisation techniques an appraisal of the literature was undertaken. The aim was to identify and evaluate the benefit of additional or novel immobilisation approaches (beyond the standard supine, single arm abducted and angled breast board technique adopted in most radiotherapy departments). A database search was supplemented with an individual search of key radiotherapy peer-reviewed journals, author searching, and searching of the grey literature. A total of 27 articles met the inclusion criteria. The review identified good reproducibility of the thorax using the standard supine arm-pole technique. Reproducibility with the prone technique appears inferior to supine methods (based on data from existing randomised controlled trials). Assessing the effectiveness of additional breast support devices (such as rings or thermoplastic material) is hampered by small sample sizes and a lack of randomised data for comparison. Attention to breast immobilisation is recommended, as well as agreement on how breast stability should be measured using volumetric imaging. Keywords: Breast, immobilisation, positioning, reproducibility, review.</p

Musculoskeletal ultrasound imaging - An exploration of physiotherapists' interests and use in practice

Background Musculoskeletal ultrasound imaging (MSKUSI) has gained popularity; several professions have expressed an interest in this application but the clinical use by physiotherapists has not been fully researched. Objectives To explore physiotherapists’ interests and use of MSKUSI in practice. Design Sequential mixed-methods; questionnaire followed by semi-structured interviews. Method A questionnaire was developed and distributed to gain initial information, (75 responses). Analysis informed topic-guide development and enabled a purposive-sampling strategy for semi-structured interviews that explored physiotherapists’ interests, education and clinical use of MSKUSI (n = 11). Interview data were analysed thematically. Results Five themes were identified: 1. Professional skill set – physiotherapists’ suitability for MSKUSI. 2. Factors that have impacted physiotherapists’ ability to use MSKUSI. 3. Physiotherapists’ motivation to use ultrasound - improving patient focused care. 4. Quality assurance strategies. 5. Application of biopsychosocial model. Themes revealed links between physiotherapists’ core skills, knowledge and professional experiences that align with MSKUSI requirements. Some participants reported support accessing education but many described challenges finding appropriate mentorship. Participants observed education did not always reflect practice typical of physiotherapists. Application of clinical reasoning processes utilised by physiotherapists was regarded as integral to patient-focused scanning. Conclusions Physiotherapists’ professional training and musculoskeletal practice are seen as a foundation for education in MSKUSI. Accessing education can be challenging, in particular mentorship that fully incorporates the biopsychosocial model. Proposed roles for MSKUSI for physiotherapists include verification of clinical assessment findings for diagnosis and facilitation of patient education. The potential to streamline patient pathways and optimise resource management warrants investigation

Musculoskeletal ultrasound imaging – Integration with the biopsychosocial model

Background and Method Musculoskeletal ultrasound imaging, (MSKUSI) has become a popular imaging modality in recent years and is being utilised by a variety of professions in clinical environments beyond radiology departments. A previously published study exploring physiotherapists' interests and use of MSKUSI in practice included in-depth interviews of participants, (n=11). The data from this qualitative study were analysed thematically and five themes were identified; one was ‘Application of the biopsychosocial model’, the basis of this paper. Result The theme, ‘Application of the biopsychosocial model’ drew together three categories of analysed data: clinical reasoning, professional variance and communication opportunity. ‘Clinical reasoning’ reflected the participants' value on subjective assessment information and the integration of ultrasound imaging with physical examination findings. ‘Professional variance’ observed the scanning processes undertaken by physiotherapists tended to vary from other professionals, the physiotherapists perceived their use of dynamic imaging was greater, in particular scanning in symptom provoking positions. Another variance observed was the style of communication that physiotherapists used when scanning, this was categorised as a ‘communication opportunity’ as it represented an event that could be utilised to promote patient understanding of their presentation, link imaging findings to proposed management and enhance compliance with rehabilitation strategies. Participants emphasised their responsibility when communicating with patients to avoid language that could promote unhelpful behaviour, e.g. catastrophisation. Conclusion Participants placed value on integrating musculoskeletal ultrasound imaging into the biopsychosocial model, further research to explore the impact of this approach on patients’ clinical outcomes and reported experiences is required