Reporting radiographers in Norway – A qualitative interview study

IntroductionA number of Norwegian radiographers have attended an advanced programme of education and training in musculoskeletal reporting, some in the UK and some in Norway. The aim of this study was to examine how reporting radiographers, radiologists and managers experienced the education, competence, and role of reporting radiographers in Norway. To our knowledge, the role and function of reporting radiographers in Norway has not yet been explored.MethodsThe study had a qualitative design and was based on eleven individual interviews of reporting radiographers, radiologists, and managers. The participants represented five different imaging departments from four hospital trusts in Norway. The interviews were analyzed using inductive content analysis.ResultsThe analysis identified two main categories: “Education and training”, and “The reporting radiographer”. The subcategories were: “Education”, “Training”, “Competence”, and “The new role”.The study found the program to be demanding, challenging, and time-consuming. However, the reporting radiographers described it as motivating because they gained new competence. The competence of reporting radiographers was regarded as adequate. The participants found that reporting radiographers had a unique competence in both image acquisition and reporting, and they were described as a missing link between radiographers and radiologists.ConclusionReporting radiographers are experienced as an asset for the department. Reporting radiographers not only contribute to musculoskeletal imaging reports but are also important for collaboration, training, and professional development in imaging, and in collaborating with orthopedics. This was seen to increase the quality of musculoskeletal imaging.Implications for practiceReporting radiographers are a valuable resource in image departments, especially in smaller hospitals where the shortage of radiologists is noticeable.     

Ultrasound Practice Redesign to Improve Image Quality: Implementation of a Quality Control Sonographer

PurposeThe aim of this study was to systematically improve ultrasound image quality via the implementation of a quality control (QC) sonographer.MethodsThe position of a QC sonographer was created, whose responsibility was to preview ultrasound examinations performed by other sonographers and audit ultrasound examinations for image quality and protocol adherence. Retrospective audits of examinations performed before and after the implementation of the QC sonographer position were performed. Examinations from 17 sonographers were audited (16 examinations per sonographer), with a sample size of 272 examinations per audit. The QC sonographer graded the following imaging quality parameters (IQPs) as acceptable or needing improvement: gain, depth, color Doppler, spectral Doppler, and protocol adherence. Statistical comparisons were performed by a biostatistician using a χ² test, with P < .05 used as the threshold for significance.ResultsThe baseline audit (September 1, 2015 to November 30, 2015) revealed 439 instances of IQPs that required improvement. A second audit after establishing the QC sonographer role (August 1, 2016 to October 31, 2016) found 176 instances of IQPs that required improvement. A third, follow-up audit (May 1, 2018 to September 30, 2018) found 172 instances of IQPs that required improvement.ConclusionsRemoving a sonographer from the clinical line to work as a QC sonographer resulted in a 60% decrease in parameter errors that was maintained over time. Another benefit of the QC sonographer role is improved sonographer education.     

Ultrasound clinical teaching capacity in England: A scoping exercise

IntroductionThe United Kingdom has a sonographer shortage. Health Education England are working with stakeholders to address these shortages and increase clinical capacity for sonographer education. The aims of this survey were to ascertain current sonographer staffing levels, estimate staffing requirements in five years’ time and review current clinical placement capacity.MethodsAn on-line survey was used to explore the aims of the study. Questions included current and predicted sonographer staffing requirements and clinical capacity for teaching ultrasound. Free text comments were available for expanding on responses.ResultsOf 72 completed responses the mean sonographer vacancy rate was 2.65 and the predicted number of sonographers needed to provide the service in five years was 4.6. Departments were teaching an average of two sonographers and 2 non-sonographers. A small number of departments had further capacity for sonography student training which was not being utilised for reasons including limited capacity, inadequate staffing levels or competing demands of teaching other health care professionals. Extended working days and weekend training lists were used to increase capacity, along with rolling programmes for teaching sonographers and the use of simulation.ConclusionThe survey supported previous publications that have shown sonographer shortages in England and this is predicted to increase over the next five years. Departments were teaching a similar number of sonographers as other health care professionals. Many experienced competing demands, which challenged their ability to increase clinical capacity.Implications for practiceSuggestions for increasing capacity are provided to help grow the sonography workforce. With the advent of new sonography programmes the departments with spare capacity could be utilised to support clinical practice for sonography students in need of a placement on a direct entry programme.     

Referring physicians' experiences of outsourcing radiological examinations – A variety of views on the consequences

IntroductionThere are strengths, weaknesses, opportunities and challenges when outsourcing advanced radiological examinations such as magnetic resonance examinations from university hospitals to external private institutions.AimThe aim of this study was to explore the experiences of referring physicians when their referrals for radiological examinations are outsourced from a university hospital in Stockholm, Sweden.MethodThis qualitative study is a part of a larger study investigating the consequences of outsourcing referrals for radiological examinations from a university hospital to private external units. Ten referring physicians from orthopedic and oncology departments, representing clinics with large volumes of radiological referrals at a university hospital, were interviewed.ResultsThe results showed that the requirements for radiological services differ between these specialties. The overall opinion was that examinations performed by external radiology departments needed additional re-assessment work which causes higher costs for their clinics. This indicates that there is insufficient communication between referring physicians and the radiological department at the University Hospital.ConclusionsFor better planning of radiological services, radiology departments must consider the referring physicians' needs and develop suitable contract when organizing the practice of outsourcing. The management structure in radiology departments and communication between referring physicians and radiologists in the radiology departments should be studied further, to promote better understanding and improve the efficiency of the outsourcing process.     

Ultrasound and Dual-Energy X-Ray Absorptiometry Report Transcription Error Rates and Strategies for Reduction

PurposeRadiologists play an essential role in patient care by providing accurate and timely results. An error-free radiology report is an expectation of both patients and referring physicians. Software is currently available that can eliminate measurement and side types of errors while saving radiologists and sonographers time. The objectives of this study were to evaluate the potential reduction in report errors, estimate the potential time savings associated with implementation, and conduct a cost-benefit analysis of implementing two software programs.MethodsData on the number of measurement errors and side errors in ultrasound and dual-energy x-ray absorptiometry reports were collected, and the time required for data entry that the software would reduce was measured by report type. Generalized estimating equations regression was used to estimate error rates and data entry times and corresponding 95% confidence intervals by report type for radiologists and sonographers. Current wages and report volumes were then applied to the time savings to estimate the annual wage savings. Projected volume increases were applied to the annual estimates to generate a 5-year savings estimate.ResultsOverall, measurement errors occurred in 6% to 28% of ultrasound reports, depending on the report type. Side errors were rare. It was estimated that over 5 years, the software could save $693,777 in radiologist wages and $130,771 in sonographer wages, a total of $824,548 (range, $621,866-$1,039,714).ConclusionsThe use of data integration software would both significantly reduce errors in ultrasound and dual-energy x-ray absorptiometry reports and save a considerable amount of time and money.     

‘Current trends in lower limb Doppler scanning in Ireland’

IntroductionThe clinical need to diagnose and treat above knee deep vein thrombosis (AKDVT) has long been established in literature and in practice. On the other hand, the need to diagnose and treat below knee deep vein thrombosis (BKDVT) continues to be debated in literature. This has resulted in variation in clinical guidelines and protocols nationwide. This research aims to establish if there is a standard practice in Irish ultrasound departments and if so, what that practice is and where sonographers are getting information to inform this.MethodsA questionnaire was designed using SurveyMonkey and distributed using online platforms. The questionnaire aimed to establish the experience of the sonographer, the types of exams performed, protocols/guidelines used as well as scenarios where the sonographer might deviate from protocol.ResultsThe study yielded 90 responses. The research found 49% of sites perform whole leg ultrasound routinely and 46% perform proximal ultrasound only. 41% of respondents said their protocols were based on clinical guidelines however, 22% of participants didn't know what these guidelines were. 49% of respondents were unaware of what treatment a patient would receive in cases where there is a high clinical suspicion of DVT, but the ultrasound is negative for DVT.ConclusionThe research has established a lack of consistency amongst sonographers and scanning practices with a fairly even split (49% of respondents perform whole leg ultrasound and 46% perform proximal only). Not only has the research identified a lack of standardised scanning approach nationwide, but inconsistencies are also seen in the guidelines that inform our department's protocols as well as inconspicuous terms used in radiology reporting and jargon in literature in relation to DVT.Implications for practice1. An inconsistency in practice has been established. Discussions are now needed to decide what guidelines should be implemented into Irish Ultrasound DVT protocols. 2. A national protocol for BKDVT would result in all patients in Ireland having access to the same standard of care. 3. Call for consensus on appropriate training for sonographers undertaking LLDs.     

Radiographers in ultrasound: Motivation and role expansion. A survey of European Federation of Radiographer Societies (EFRS)

IntroductionVariability in non-medical ultrasound practice across Europe has been highlighted in studies. Meanwhile, advanced practice in radiography has undergone rapid development in the United Kingdom (UK). This survey aimed to review results relating to extended role and advanced practice skills, motivation and job satisfaction from a wider survey of radiographers undertaking ultrasound examinations across the European Federation of Radiographer Societies’ (EFRS) community.MethodsFollowing a pilot study, a SurveyMonkey™ on-line questionnaire was disseminated to EFRS member societies to share with their members, and via social media platforms. Quantitative questions for this article related to extended and advanced practice skills, communication of results, job satisfaction, motivation and career development. Theme analysis was used to assess qualitative feedback concerning priorities for future developments within the ultrasound role.ResultsThere were 561 responses, mainly from the UK, Ireland and Spain (81%). The majority (83.4%) of UK sonographers communicate findings to patients, compared with 27.1% in other EFRS countries. More engage with teaching (UK = 90.1%, non-UK 72.9%) compared with activities in the other advanced practice domains. The lowest involvement was the research domain, with only 33% actively involved in research. Radiographers were motivated to undertake ultrasound to develop their knowledge and skills and assume more responsibility.ConclusionWide variations in ultrasound practice were seen across respondent countries. Generally, radiographers are happy with their ultrasound roles, although priorities include legislation for the sonographer role, remuneration, respect or support from medical colleagues, high quality education and role progression opportunities.Implications for practiceThe findings provide a better understanding of radiographer views which can assist radiographer societies and local teams to develop strategies to enhance advanced practice skills development and career prospects in ultrasound.     

A Delphi study on research priorities in radiation therapy: The Norwegian perspective

IntroductionAlthough radiation therapists (RTs) need to engage more in research to establish an evidence base for their daily practice the majority conduct little research themselves. This project is the second stage of a Delphi process aimed at determining research priorities in radiation therapy in Norway. The aim of this article is to prioritize the research areas radiation therapists in Norway think are most important in their own profession.MethodsA questionnaire was administered using responses to a previous questionnaire, which identified the research interests of Norwegian RTs. The survey was sent to all Norwegian departments of radiation oncology, and RTs were asked to form interest groups to discuss and prioritize the research areas.ResultsThere was a 70% response rate, seven of 10 departments participated. The highest ranked research categories were imaging in radiation therapy and radiation therapist education. Seven of the top ten ranked research areas were in these categories.ConclusionPrioritization of research areas and categories provides a useful list of future research for Norwegian RTs, which will enable them to decide whether their research ideas are a high priority, and spend less time deciding on a relevant research topic that needs investigation in their own workplaces.     

Sonographer practitioner development in Australia: Qualitative analysis of an Australian sonographers' survey

Sonographer practitioner development involves the expansion and extension of the sonographer role to include reporting on ultrasound examinations. Australian sonographers have not seen the same degree of role extension and expansion as their counterparts in the United Kingdom, despite increasing levels of discussion regarding sonographer practitioner development.The aim of this study was to determine if Australian sonographers want to extend their professional role and what they consider are the important issues associated with role extension. This paper reports on qualitative data derived from a survey of Australian sonographers and investigates if Australian sonographers are interested in extending and expanding their professional role and responsibilities and, if they do, what might be necessary or desirable from a professional point of view for this change to occur.A survey was mailed to all members of the Australian Sonographers Association (ASA) in October 2006. The 31-item survey included 28 closed-ended and 3 opened-ended items to provide both quantitative and qualitative data. The quantitative data will be reported separately. Qualitative data was derived from responses to the opened-ended questions, which asked respondents to elaborate on their attitudes and feelings about role extension and development. Analysis used Nvivo7 software to aid in uncovering common themes from the qualitative data.The analysis focused on the reported incentives or motivations for becoming a sonographer practitioner as well as disincentives or perceived hurdles that would discourage respondents from becoming sonographer practitioners. The three most reported incentives or motivations for becoming a sonographer practitioner were professional recognition, remuneration and increased knowledge. The three most commonly reported disincentives or perceived hurdles that would discourage respondents from becoming sonographer practitioners were legal issues, insurance and further study.     

National Trends in Oncologic Diagnostic Imaging

ObjectiveTo characterize national trends in oncologic imaging (OI) utilization.MethodsThis retrospective cross-sectional study used 2004 and 2016 CMS 5% Carrier Claims Research Identifiable Files. Radiologist-performed, primary noninvasive diagnostic imaging examinations were identified from billed Current Procedural Terminology codes; CT, MRI, and PET/CT examinations were categorized as “advanced” imaging. OI examinations were identified from imaging claims’ primary International Classification of Diseases-9 and International Classification of Diseases-10 codes. Imaging services were stratified by academic practice status and place of service. State-level correlations of oncologic advanced imaging utilization (examinations per 1,000 beneficiaries) with cancer prevalence and radiologist supply were assessed by Spearman correlation coefficient.ResultsThe national Medicare sample included 5,051,095 diagnostic imaging examinations (1,220,224 of them advanced) in 2004 and 5,023,115 diagnostic imaging examinations (1,504,608 of them advanced) in 2016. In 2004 and 2016, OI represented 4.3% and 3.9%, respectively, of all imaging versus 10.8% and 9.5%, respectively, of advanced imaging. The percentage of advanced OI done in academic practices rose from 18.8% in 2004 to 34.1% in 2016, leaving 65.9% outside academia. In 2016, 58.0% of advanced OI was performed in the hospital outpatient setting and 23.9% in the physician office setting. In 2016, state-level oncologic advanced imaging utilization correlated with state-level radiologist supply (r = +0.489, P < .001) but not with state-level cancer prevalence (r = −0.139, P = .329).DiscussionOI usage varied between practice settings. Although the percentage of advanced OI done in academic settings nearly doubled from 2004 to 2016, the majority remained in nonacademic practices. State-level oncologic advanced imaging utilization correlated with radiologist supply but not cancer prevalence.     

Medicare Policy Initiatives and the Relative Utilization of “Double-Scan” CT

PurposeCommonly called “double scans” by the media, combined pre- and postcontrast thoracic and abdominal CT examinations have been the focus of recent CMS policy initiatives. The aim of this study was to examine trends in the relative utilization of double-scan CT before and after 2006 legislation mandating relevant Medicare reporting initiatives.MethodsMedicare Physician Supplier Procedure Summary Master Files from 2001 through 2012 were used to identify claims for thoracic and abdominal CT examinations. Double-scan rates by billing physician specialty and place of service were analyzed over time. Rates of double-scan CT between radiologists and nonradiologists were compared using t tests.ResultsFrom 2001 to 2006, double-scan rates for thoracic and abdominal CT examinations declined by 1.7% and 7.5% for radiologists, respectively (from 6.0% to 5.9% and from 22.6% to 20.9%) but increased by 15.8% and 23.6% for nonradiologists (from 5.7% to 6.6% and from 28.8% to 35.6%). From 2006 through 2012, double-scan rates declined by 42.3% and 35.2% (from 5.9% to 3.4% and from 20.9% to 13.5%) for radiologists but only by 31.8% and 8.1% (from 6.6% to 4.5% and from 35.6% to 32.7%) for nonradiologists. Double-scan rates were significantly lower for radiologists than nonradiologists for all years for abdominal CT (P < .001) and for all years after 2006 legislation for thoracic CT (P < .05).ConclusionsReductions in thoracic and abdominal CT double-scan rates followed legislation mandating CMS initiatives designed to reduce costs and radiation. For nonradiologists, double-scan rates were consistently higher and declined more slowly than those for radiologists. Medicare policy initiatives directed toward imaging utilization seem to influence behavior differently for radiologists compared with nonradiologists.     

The role of the sonographer – An investigation into the scope of practice for the sonographer internationally

IntroductionThere is global variance in the role of a practicing sonographer. Literature examining global sonographic roles and scope of practice is limited, despite the international applicability of ultrasound imaging. This study aimed to examine the common and divergent features of a practicing sonographer internationally, and their impact upon the development of a global standard of practice.MethodsAn ethically approved mixed-methods online survey was conducted. The purposive sample included all 75 current elected council members of the ISRRT [International Society of Radiographers and Radiological Technologists], an international professional organisation.ResultsThirty-six individuals from at least 32 different countries responded, reflecting the sonography profession in all four ISRRT regions. The results suggest that sonographer education requirements differ widely, from on the job training (16%, 6/36) to undergraduate or postgraduate schooling (44%, 16/36). Registration and accreditation bodies were present in the jurisdiction of 41% (14/34) and 35% (12/33) of respondents respectively, though many were voluntary, physician-focused or non-specific to sonographers. Five of 11 (45%) respondents suggested that the sonographer–radiologist relationship is individual-dependent, and not primarily positive or negative. Ten of 28 (36%) suggested that other professionals do not know the role of the sonographer.ConclusionThe majority of ISRRT council member respondents believe that an international scope of practice could benefit and be implemented in their jurisdiction (26/28, 93% and 22/33, 67%). The key advantages noted were standardisation of education and improved professional mobility. However, lack of sonographer education and radiologist acceptance are important potential barriers.Implications for practiceAn international scope of practice could be beneficial and implementable in most ISRRT jurisdictions. Professional mobility and education standardization are the primary advantages. Insufficient sonographer education and physician acceptance are the key potential obstacles.     

Order Entry Protocols Are an Amenable Target for Workflow Automation

PurposeOrder entry protocol selection of advanced imaging studies is labor-intensive, can disrupt workflow, and may displace staff from more valuable tasks. The aim of this study was to explore and compare the behaviors of radiologic technologists and radiologists when determining protocol to identify opportunities for workflow automation.MethodsA data set of over 273,000 cross-sectional examination orders from four hospitals within our health system was created. From this data set, we isolated the 12 most frequently requested examinations, which represent almost 50% of the entirety of advanced imaging volume. Intergroup comparisons were made between behavior of radiologic technologists and radiologists or residents when determining protocol. Frequencies of changes were calculated. Common parameters of changed examinations were identified.ResultsThe overall change rate for both radiologists and residents (4%) is very low and comparable to the overall change rate of radiologic technologists (1%). The change rates for the 12 most ordered examinations were calculated and compared individually. Most examinations that underwent change involved a patient with a low estimated glomerular filtration rate, a patient with a contrast allergy, or a provider ordering a general examination but in fact wanting an organ-specific protocol or an angiographic study.ConclusionOrder entry protocol selection of the most frequently ordered advanced imaging examinations was rarely a value-added activity because these examinations are rarely changed. Changes follow predictable patterns that make order entry protocol selection of most radiology orders for advanced imaging amenable to workflow automation.     

Managing the unmanageable: A qualitative study exploring sonographer experiences of and training in unexpected and difficult news delivery

IntroductionUltrasound is used to diagnose pregnancy complications such as miscarriage and fetal health conditions. Within the UK, findings identified during ultrasound examination are delivered by sonographers as standard. However, little is known about the experiences of sonographers when delivering unexpected news (DUN), the impact this has on them, or their preferences for training on news delivery.MethodsQualitative interviews were completed with fourteen sonographers and were analysed using an inductive thematic approach. Key themes were identified.ResultsParticipants said that obstetric ultrasound often involves ‘managing’ the patient encounter, including: navigating (unrealistic) patient expectations; handling their own responses to unexpected findings; and managing interaction by moderating emotional expression and communication practices to deliver patient-centred and empathic care. Persistent uncertainty of outcomes, prognosis and patient reactions, alongside high workloads, and frequent siloed working, makes DUN challenging for sonographers. DUN was experienced as emotionally burdensome, and sonographers employed personal coping strategies to reduce stress/burnout. However, the greatest mitigation for stress/burnout was support from peers, though accessing this was challenging. Peers were also described as key sources of learning, especially through observation.ConclusionChallenges associated with DUN are an enduring experience for sonographers. Facilitating regular ongoing support and training would enable sonographers to cope with negative aspect of the role, including the emotional burden of DUN.Implications for practiceLong patient lists are prioritised to deal with high demand for services. However, sonographer wellbeing needs to be a key priority to avoid stress and burnout. This means facilitating protected time to access support from colleagues, multidisciplinary working where possible, and regular access to training to support DUN. Training focusing on communication practices, alongside dealing with emotional burdens of the role would be beneficial.     

Day of Week,Site of Service,and Patient Complexity Differences in Venous Ultrasound Interpreted by Radiologists Versus Nonradiologists

ObjectiveNationally, nonradiologists interpret an increasing proportion of lower extremity venous duplex ultrasound (LEVDU) examinations. We aimed to study day of week, site of service, and patient complexity differences in LEVDU services interpreted by radiologists versus nonradiologists.Materials and MethodsUsing carrier claims files for a 5% national sample of Medicare beneficiaries from 2012 to 2015, we retrospectively classified all LEVDU examinations by physician specialty (radiologist versus nonradiologist), day of week (weekday versus weekend), site of service, and patient Charlson Comorbidity Index (CCI) scores. Pearson’s χ² was used to test statistical significance.ResultsOf 760,433 LEVDU examinations for which provider specialty could be determined, 439,964 (58%) were interpreted by radiologists and 320,469 (42%) by nonradiologists. On weekends, radiologists interpreted 75% (66,094 of 88,244) and nonradiologists 25% (22,150 of 88,244) (P < .0001). Of LEVDU examinations interpreted by radiologists, 57% were performed in the inpatient or emergency department settings, and 70% of LEVDU examinations interpreted by nonradiologists were performed in the private office or outpatient hospital setting. Radiologists interpreted a slightly larger proportion (17%) of their examinations on patients with more comorbidities (CCI of ≥3) than nonradiologists (15%) (P < .0001).ConclusionCompared with nonradiologists, radiologists interpret a disproportionately larger share of weekend (versus weekday) LEVDU examinations and a considerably larger proportion in higher acuity settings. Additionally, the patients on whom they render services have more comorbidities. To optimize around-the-clock patient access to necessary imaging, emerging quality payment programs should consider the timing and sites of service, as well as patient complexity.