Demand for DI grows, not enough resources to deliver: study

OTTAWA – Family physicians and specialists continue to rely on the results of diagnostic imaging exams to make informed decisions for their patients, but Canadian patients are waiting longer than those in other countries for tests.

Canadian general practitioners reported that 40% of their patients often had difficulty receiving specialized diagnostic imaging tests (including CT imaging, mammograms, and MRIs) – substantially higher than the international average of 20%.

The Conference Board of Canada reports in a recent study, “The Value of Radiology in Canada,” that wait times for MRI and CT scans increased between 2011 and 2015, and they continue to vary widely among the provinces. “Diagnostic imaging has been unable to consistently reach national benchmarks, despite continuous efforts at improvement,” the report states.

While governments may be avoiding investments in radiological infrastructure, including both equipment and skilled personnel, the Conference Board of Canada report suggests that such investments may lead to long-term cost reductions.

“Expenditures in diagnostic imaging may create savings and benefits in other healthcare and societal cost centres, resulting in long-term and system-wide returns on investment that are not typically captured in cost-effectiveness analyses. Cost savings can be derived through accurate diagnosis and earlier and more successful treatments. The benefits include reduced morbidity and mortality as well as associated personal costs to patients and their families.”

There are 2,351 diagnostic radiologists currently practising in Canada. The majority of diagnostic radiologists are male (69 per cent), and approximately three-quarters of diagnostic radiologists are aged 35 to 64, with only 6 per cent younger than 34 years.

This breakdown includes interventional radiologists, as they are trained in diagnostic radiology but have undergone further training to become experts in image-guided therapies.

“In 2013-14, the average gross salary for radiologists (among those earning a minimum of $60,000 per year) was $339,566.32. As mentioned earlier, rather than seeing remuneration for radiologists solely as a cost driver for the healthcare system, this report aims to start an informed dialogue on the value of radiology for Canada’s healthcare system for the health of its citizens.”

The Canadian Association of Radiologists (CAR) recommends maximum MRI and CT wait time targets of 24 hours for emergency/life-threatening conditions, 7 days for urgent conditions, 30 days for semi-urgent conditions, and 60 days for non-urgent conditions.

Although the available data do not distinguish between type of priority, wait times for a CT or MRI scan continue to be an issue.

The report notes that wait times in Prince Edward Island and Nova Scotia appeared to exceed the 60-day maximum benchmark for CT scans in 2015. For MRI scans, patients in Prince Edward Island, Nova Scotia, Ontario, Manitoba, Saskatchewan, and Alberta were waiting between 1.5 and 3.4 times longer (or even more) than the 60-day maximum benchmark wait time in 2015.

In addition to the ongoing wait time issues in Canada, there are major strains on medical imaging capacity. For example, Canada is in the lower 50 percent of CT and MRI units per million people, compared with other reporting organisation for Economic Co-operation and development (OECd) countries.

As of 2015, Canada had 15.01 CT units, 9.48 MRI units, and 1.31 PET or PET-CT units per million people. This translates to a total of 538 CT units, 340 MRI units, and 47 PET or hybrid PET-CT units for all of Canada.

Based on the number of radiologists in Canada in 2016 (2,351) and the number of exams in 2014 (5,278,341 CT exams, 1,952,060 MRI exams, and 76,824 PET-CT exams), the average diagnostic radiologist in Canada performs 2,245 CT exams, 830 MRI exams, and 33 PET-CT exams on a yearly basis.

Clearly, overburdened equipment is only one side of the wait times story in Canada. Viewed from the perspective of patients and the public, long wait times are anecdotally attributed to insufficient operating hours, but the data show otherwise. Canadian radiologists are performing more imaging exams than ever before.

Along with the increasing demand for radiology, there will also be growing workforce demands in several subspecialties: mammography, interventional radiology, cardiac imaging, neuroradiology, and pediatric radiology.

Potential areas where the supply may not meet the demand (i.e., where there may be radiology shortages) include mammography, cardiac imaging, and pediatric radiology.

The report says that structured career counselling and mentoring in training programs would give students insight into their role in reducing under-serviced subspecialty areas to ensure greater value to population health and the healthcare system.

For example, research shows that only 15 percent of radiology residents received career counselling during their training, and of this 15 percent, only half thought it was adequate; the majority of radiology residents received their fellowship information from colleagues (68 per cent), staff radiologists (61 per cent), and university websites (58 per cent).

“The Value of Radiology in Canada” makes special note of three forms of radiology that have proven benefits for the health of Canadians: breast cancer screening; teleradiology; and interventional radiology.

• Mammography results in earlier identification of cancer, which provides better outcomes for women along with lower overall treatment costs.
• Teleradiology has transformed the quality of care in many rural areas. When images can be sent over networks from remote hospitals and clinics to radiologists in larger centres, patients are less likely to need to travel. Instead, readings can be done remotely, in a matter of days or even hours.
• Interventional radiology has meant that patients can be treated for problems that at one time required surgery; instead, image-guided IR results in less blood loss, lower rates of infection, and less pain for patients. They are also returned to their homes and jobs faster than before.

The Conference Board report does not mention, however, the emergence of Deep Learning and other forms of artificial intelligence in the realm of radiology. Expert systems, like IBM’s Watson for Health, are able to diagnose radiological images with a growing rate of accuracy.

In future, computers with artificial intelligence may be deployed as radiology assistants and screening systems, to separate “normal” exams from those showing evidence of disease or other problems.

Such systems could greatly increase the productivity of radiologists, in developed nations where the supply or radiologists is not keeping up with the demand for DI tests and readings. They could also help in developing nations, where there is a severe shortage of radiologists.