Hospitals and imaging centres are grappling with DI backlogs
February 7, 2023
Scan our country’s diagnostic imaging (DI) network – across all modalities, provinces and sites – and the picture is clear: Canadians are waiting too long for routine medical imaging exams. “We’ve been arguing that it’s a crisis and action needs to happen now,” said B.C. Radiological Society President Dr. Charlotte Yong-Hing. “We just can’t sit back and study this for the next two years.”
The most pressing problem is wait times for semi-urgent and non-urgent MRI and CT examinations, referred to as priority 3 and 4 (P3 and P4), which should be 30 and 60 days respectively, according to pan-Canadian benchmarks set by the Canadian Association of Radiologists (CAR). Instead, people are waiting 60 days for P3 investigations on average and anywhere from six months to a year for P4 investigations, depending on where they live.
“Among these patients you have those who are awaiting a cancer diagnosis and during that time, they have a progression of disease and sometimes they lose their chance,” said CAR president Dr. Gilles Soulez, a vascular and interventional radiologist at the University of Montreal Hospital Centre (CHUM). According to Soulez, CAR has calculated the economic impact of longer medical imaging wait times to be in the range of $3.5 billion in terms of lost GDP, due in part to people ending up in need of more urgent, more invasive care or not being able to work while they wait.
In B.C., delays are particularly worrying for patients who require further examination after receiving abnormal results on screening tests like breast mammography, where it is estimated people are waiting as long as six months for image-guided breast biopsies and supplemental imaging, said Yong-Hing. The province only tracks wait times for CT and MRI, which are currently at 93 days and 133 days respectively.
“It should be 30 days on average,” she said. “It’s clear that more investment is needed.”
From coast-to-coast, the underlying challenges causing the bottlenecks are similar. Investment in new equipment is needed, both to replace aging technology and to keep pace with growing demand. At the same time, Canada is facing a massive shortage of highly trained medical radiation technologists (MRTs) and sonographers required to run imaging equipment.
There’s also room to speed up workflow and diagnostics by implementing advanced radiology solutions, including clinical decision support, e-referral and emerging AI technologies, said Soulez.
CAR states that investment in medical imaging equipment is at a 20-year low. A recent study by the Conference Board of Canada indicates 35 percent of existing equipment is 10 years or older whereas the ‘golden rule’ is no more than 10 percent – putting Canada below the mean of countries in the Organization for Economic Co-operation and Development (OECD).
Consequently, equipment is prone to downtime, meaning exams need to be delayed and rescheduled. Imaging centres are also losing out on productivity gains because newer, smarter equipment performs faster.
The B.C Radiological Society is advocating for the provincial government to make annual investments of $100 million over the next five years to replace aging equipment and add capacity. “It’s a big issue,” said Yong-Hing. “There’s a big gap and there needs to be sustained investment.”
In Nova Scotia, where a provincial DI operations council – made up of administrative directors and medical representatives – meets regularly to examine challenges, leaders are exploring options such as operational leasing or managed equipment services to address the aging equipment issue.
“Historically, we’ve relied on traditional capital equipment purchases, but I really think there’s an appetite now to explore new ideas and we’re starting to see progress on that,” said Nova Scotia Health Director, DI and Cardiac Investigation, Western Zone, Chris Connolly, who co-chairs the council.
The number one challenge in Nova Scotia right now is excessive wait times for routine studies, which “have gone beyond where we’re comfortable with them,” he added. To bring them back in line with CAR recommendations, the council is working collaboratively with Nova Scotia Health executive leadership, government authorities and other partners to implement a multi-pronged wait-time solution, starting with efforts to recruit and retain staff.
For example, Nova Scotia Health has supported a five-year agreement with Dalhousie University’s School of Health Sciences to offer full-time employment to all graduates in diagnostic medical ultrasound and radiological technology. It is also working with its union partners to offer full-time hours to permanent part-time staff without competition and is looking at a longer-term strategy to attract qualified candidates from outside of Canada as well.
Relying on robust health data analytics, the DI operations council has also developed a business case to present a clear roadmap to the province on how to reduce wait times. “It’s not a request for technology at this point,” explained Connolly. “… It’s about using our current capital asset base and resourcing it appropriately so we can improve access and get those wait times down to within 60 days.”
The objective is to run all modalities into the evenings and weekends, and the business case examines what is required from a system view, including how many additional radiologists and registration and booking clerks are needed, and whether security personnel would be required to keep doors open after hours. “We calculated based on five to eight percent growth on the demand side, so it’s really about future proofing us as well,” he said.
In addition to expanding the core complement of staff and optimizing resources, the business case also includes a modernization of the province’s referral system. Right now, community physicians and nurse practitioners rely on faxed or emailed forms to request exams. Using an external vendor, the aim is to implement a fully electronic system that will support the medical imaging process from end to end, including intake, triage, adherence to protocols and patient appointment notification.
“Within it, we’re hoping to have decision support so that if a general practitioner says, ‘I’d like to do a bone scan, here are the clinical indications’, the system might suggest that that’s not the best option, that maybe MR or CT is better,” explained Connolly. Assistive software could also help to evaluate whether stroke patients are eligible for endovascular thrombectomy based on subtle findings in a CT scan, he added, so that only those patients who require it are transported to Halifax where it is performed.
Nova Scotia Health vice-president, Operations, Eastern Zone, Brett MacDougall said expectations are high that the business case will be approved, and provincial solutions will move forward in an accelerated fashion.
“We’re not working in two parallel streams; we’re working collectively together so that when the business case is presented to Cabinet and the Treasury Board for approvals, it’s already gone through channels in our health leadership team that has representation from our CEO and Deputy Minister of Health,” said MacDougall. “We’re very hopeful that it will be received positively, and we’ll get the go ahead.”
In B.C., the Radiological Society is calling for immediate government action to address what Yong-Hing calls a “dire shortage” of MRTs. “We’ve got 2,100 now, and we’re 1,400 short just to get to the national average,” she said.
The society is recommending the government introduce incentives for experienced technologists, as well as educational bursaries to attract more students to the program. “This is an issue that’s been growing over time,” she said. “When demand goes up substantially for medical imaging, and you’re not keeping up with technologists, the gap gets even wider.”
To address wait times for breast biopsies and supplemental breast imaging, B.C. radiologists have identified four potential fee code changes they say will promote expansion within the province’s community imaging clinics (CICs), privately owned clinics that provide publicly funded services.
In particular, a new fee code application was made for tomosynthesis or 3D mammography, which is now the standard of care at many Canadian imaging sites.
In the meantime, the society continues to advocate for action. “It’s nice to see there’s some light being shone on the issue,” said Yong-Hing. “We just hope there’s an equal and urgent response to what we classify as a crisis.”
At the national level, CAR is asking the federal government to take a leadership position to help address the backlogs by investing in new medical imaging equipment across the country; developing a robust health human resources strategy; harnessing new and emerging AI technologies to both speed up workflow and assist with assessing and treating disease; and implementing a national directive for clinical decision support tools.
“We need to tackle this problem from different vantage points: equipment, optimizing the workforce and the last one is to work smarter,” said Soulez.
By the end of 2023, the Referral Guidelines Working Group established by CAR to develop evidence-based, peer-reviewed guidelines to support clinical decision-making, will have ‘Canadianized’ roughly 70 percent of the guidelines used in current e-referral and clinical decision support systems, which are built to adhere to either U.S. or U.K. protocols.
A pilot project under way at North York General Hospital in Toronto shows that using clinical decision support decreases imaging examinations by 10 to 15 percent, helping to optimize equipment use and ensuring patients receive the right imaging procedure at the right time.
“We are putting a lot of emphasis on clinical decision support because imaging is very complex now. With all of the protocols with the new technologies, it is very difficult for first- and second-line physicians to be aware of what is the best and most efficient imaging test,” said Soulez. “I believe we can gain the 10 to 15 percent efficiency as observed – the point being that we want to avoid having patients on a wait list who perhaps do not require a medical imaging exam and give that chance to others.”
Emerging AI solutions also hold promise when it comes to shortening wait times for medical imaging, he added, by helping to speed diagnosis and manage workflow.
For example, smart technology exists to ensure patients are well positioned before starting an exam so all parameters will be correct, assisting technologists in their roles and ensuring radiologists get high quality imaging.
Other solutions are geared to solving specific problems, such as early detection of stroke or long cancer, or automating the time-consuming process of calculating measurements to track tumour growth.
“A lot of solutions are coming,” said Soulez. “It’s a little bit of a random process, so we need to organize and have strong collaboration within industry to make these things operational in Canadian workflows.”
On the east coast, Connolly remains hopeful wait times can be shortened. “I think there’s a general feeling of optimism that we’re going to be able to make some inroads,” he said.