$1.5 billion needed for DI, radiologists say

OTTAWA – The Canadian Association of Radiologists is calling on the federal government for a cash injection of $1.5 billion to improve the state of diagnostic imaging across the country. The request is being made, the association says, to rectify a national crisis resulting from the COVID-19 pandemic. Prior to the novel coronavirus outbreak, wait times for DI exams in Canada already exceeded the recommended 30-day standard. Patients who used to wait 133 days for an MRI exam may now wait twice as long, due to the backlog of exams brought about by the pandemic.

Not only is an investment in new imaging equipment needed to reduce the backlog, so is an outlay in skilled personnel, as well as in communication technology, and re-engineered clinic infrastructure that makes use of current methods of infection prevention and control.

“As the spread of COVID-19 begins to decline in Canada, it is imperative that we have a plan in place to ensure that Canadians are receiving the timely care they need and equitable access to medical imaging, said Dr. Heidi Schmidt (pictured), chief of radiology, Joint Department of Medical Imaging, University Health Network. Dr. Schmidt led a CAR task force on how radiology services can be improved now and in the future.

The full report can be accessed at https://car.ca/wp-content/uploads/2020/10/RAD_Resilience-Report_2020_ENG_FINAL-2.pdf

“Many patients are suffering, and this is costing the economy billions in lost revenue in productivity. Furthermore, Canadians are dying. Without access to proper diagnosis and treatment, patient outcomes will continue to get worse,” said Dr. Schmidt. It is projected that for 2022, wait times for imaging procedures will cost the economy $5 billion in lost GDP, due to patients who are unable to work.

The Task Force found that while the system did work through the pandemic, it was less than ideal. In addition to the human and capital resources required to create a more sustainable system, there needs to be enhanced training and management to be better able to respond to a second wave, another pandemic or other stress on the system.

During the COVID-19 crisis, according to surveys administered by the CAR and CAMRT, overall radiology service output dropped between 50-70% and mammography dropped by over 90%. This service disruption worsened existing wait lists for imaging services, including cancer screening. Many radiology departments, in collaboration with referring physicians, have revisited their wait lists to re-prioritize imaging requisitions to ensure the most urgent requisitions namely Priority 1 (same day – maximum 24 hours) and P2 (maximum 7 calendar days) were processed within the acceptable benchmarks.

This reallocation had a significant impact on less-urgent imaging, namely P3 examinations (maximum 30 calendar days) and P4 examinations (maximum 60 calendar days).

Radiology departments must now prepare for a return to the pre-pandemic volume of imaging requisitions while preserving patient and staff safety and need to catch up from significant delays accumulated during the outbreak until now.

An adequate supply of Personal Protective Equipment must be planned for. Personal Protective Equipment (PPE) is vital for radiologists, radiographers, technologists, sonographers, and other frontline healthcare professionals, as they can help minimize the likelihood of infection.

A shortage of PPE was reported globally at the beginning of the pandemic given the high demand. In Canada, access to PPE was a concern in the early stages of COVID-19 and there were reports of supply limitations. The situation was particularly hazardous for technologists who are in direct contact with patients, and who cannot adhere to social distancing protocols by virtue of their job requirements. Moreover, some technologists may see up to 40 patients in a day and bring mobile services to several hospital areas within a single shift, thereby elevating their personal risk in the absence of adequate PPE.

Communication and Coordination is a major issue. At times, radiologists are required on-site, while at other times remote reading is appropriate. Ensuring that radiologists can work remotely is key to building resilience in the system and increases the availability of radiologists. Remote reading is more than interpreting imaging studies from afar, lines of communication must exist between the radiologists and the care team on site. Creating this capacity will ensure that even in a crisis a local radiologist who knows the local context will be able to provide quality care.

In some jurisdictions, poor communication within departments and between hospitals and clinics led to an uncoordinated approach to service delivery, which hindered resilience and recovery overall. Better coordination between hospitals and clinics providing imaging could lead to targeted prioritization of which exams are best scheduled for which sites, even in instances where there are service reductions due to outbreaks.

Having access to the right equipment is critical. Current operations are not sufficient to address the backlog of imaging requisitions that predates the COVID-19 induced shutdown. Prior to the pandemic, departments struggled to meet demand for imaging on equipment that needed frequent repairs and downtime for servicing. Replacing older equipment will permit more rapid recovery and enhance the ability of radiology departments to ramp up capacity.

The Government saved millions of dollars by deferring imaging exams and other health services during the first phase of the pandemic; it needs to invest that money strategically, use existing equipment more effectively, procure additional equipment to replace aging units, and to hire and retain more highly-trained technologists.

Even prior to the pandemic, the Canadian radiology sector was ill-equipped to meet patient demand for imaging; replacement costs to modernize Canada’s medical imaging equipment are $4.4 billion between now and 2040. Radiology is most effective when it has updated, functional equipment. Efficacy and efficiency contribute to radiology resilience, and the ability to recover ground lost during COVID-19.

The “Golden Rules” for medical imaging equipment replacement and maintenance are clear: at least 60% of installed equipment should be less than five years old, no more than 30% of the installed equipment base should be between six and ten years old, and no more than 10% of the age profile should be more than ten years old.

Canadian radiologists are using equipment that is mostly (66%) over five years old, a fact which also runs counter to the Canadian guidelines for equipment replacement and lifecycle maintenance. It is worth highlighting that 27% of equipment in the radiology sector is 11 years old or more .

For patient care, this is concerning because older equipment does not function with the latest technological advances creating the potential for inferior diagnostic testing, and machines that are more prone to failure and downtime for repairs. Beyond being faster, requiring less service and increasing image quality, newer medical imaging equipment utilizes less radiation than older equipment. Best estimates show a reduction in radiation exposure of 10-30% for a new system over one that is 5 years old.