Biomedical subjects
Publications and source records attributed to R G Evens.
While the proposal is of increasing interest, the creation of an oncologic diagnostic radiology subspecialty would complicate an already difficult administrative organization, impact negatively on presently existing subspecialties, and be costly in terms of space and equipment.
An important national study by the Graduate Medical Education National Advisory Committee (GMENAC) predicts a large oversupply of diagnostic radiologists in 1990. The three radiologist members of the study panel strongly disagree with this conclusion because the estimates of supply are too high. The GMENAC estimate of need for diagnostic radiologists (approximately 20,000) is the best available, and the supply in 1990 will approximate this number.
This report summarizes the findings of a national study to examine the future requirements for and supply of radiologists. By 1990, there is expected to be a moderate shortage of the therapeutic radiologists, coupled with a substantial oversupply of diagnostic radiologists.
Plain radiographic examinations were performed on 388 patients (adult and pediatric) using either a calcium tungstate or rare-earth screen. Radiographs were compared for overall image quality, mottle, contrast, density, and detail. The rare-earth screen produced radiographs with significantly more mottle than did the standard screen. However, this was almost never of diagnostic importance. A small but significant decrease in overall image quality also was found with the rare-earth screen. This was the result of minor differences between the grading of optimal and good. A major advantage of rare-earth screens is a 50% or more reduction in radiation exposure. The results here show that rare-earth screens may be used in plain radiographic examinations without a clinically important decrease in image quality.
Radiology is confronted now by exciting but challenging times. The excitement derives from dramatic technological advance; the challenge from the economic constraints on health care delivery. The large and growing expense of providing health care is readily apparent and high technology medicine can too easily be blamed for the growth. The pressures for improved service at no extra cost will demand much of the negotiating skills of our specialty and our ability to survive administrative confusion and fragmentation. Equally, manpower planning is a feature of modern medicine. Often this is done from inadequate data and as a specialty we must continue to think constructively about our own future in this context, not least in recognizing the contribution of women to our specialty. Forces also to be recognized are decentralization, electronic information transfer, concerns about radiation exposure and litigation. Not least we need to be better able to define our specialty as its scope is now changing rapidly. For the future I hope that we can be part of the development of the controls which we must inevitably face; we should lead in instituting cost-accounting in our departments; we must be at the leading edge of technological change in both imaging and data transfer, and we must be both more business-like as well as act effectively as the patient's advocate. Radiology has an important and growing responsibility in patient care and most of the technological advances both improve that care and can be justified economically. I am proud to be a radiologist in 1984.
The costs of nuclear magnetic resonance (NMR) imaging have been carefully accounted during its early use at one institution. Capital requirements total $2,250,000 ($750,000 for construction and $1,500,000 for equipment). The annual operational costs are estimated at $907,000. At the current estimated patient procedure volume of 1,500 per year, an economic break-even point analysis indicates a required charge of $775 per patient procedure. This compares with the current break-even point charge for computed tomography of $342. If patient throughout can be increased to 12 procedures per day, the NMR break-even point charge would be reduced to $402.
Costs associated with the clinical use of positron emission tomography (PET) at the Mallinckrodt Institute of Radiology are analyzed according to the two major components: radiopharmaceutical production and imaging. Estimated annual costs are +584,500 for PET radiopharmaceutical production and +644,250 for PET imaging (1982 U.S. dollars). The economic break-even point charge to cover expenses is +615-+2,780 per clinical procedure, depending on several variables, especially procedure volume. Charges for PET clinical procedures will be among the highest of all charges for diagnostic imaging procedures, perhaps even higher than these estimates at some institutions. Several technologic and procedural approaches to reducing costs are suggested, the most promising being the anticipated availability of positron-emitting radionuclides from commercial suppliers.
A microcomputer system has been developed and installed at the Mallinckrodt Institute of Radiology to monitor the moment-to-moment activity in a radiology department. Data about department performances are collected, summarized, and displayed in graphs and tables on terminals at stations throughout the department. The system is currently used to monitor a wide variety of functions including patient waiting time, report production time, film-library operations, equipment maintenance, and room use. Since the displays are updated in real-time, it is possible to identify and address problems as they occur, thereby providing a method of evaluation that leads to improved performance as related to patient care.
Data are reported from 94 medical computed tomography (CT) installations that operated 153 CT units in 1981. All CT installations began operation before 1977 and are the most experienced CT facilities in the United States. Sixty-five per cent of studies are head CT, and 68% of body CT procedures are in the abdomen and pelvis. Intravenous contrast material is used in almost 70% of body and 80% of head examinations. On average, each CT unit performs 62 patient procedures in a 56 hour week and is estimated to be operating at 90% capacity. The total typical charge is $324 for head CT and $362 for body CT. CT equipment with scanning times of less than 10 seconds per image is more efficient and examines more patients per hour. CT installations are continuing to increase in overall patient volume and in the percentage of body examinations, even in the most experienced CT installations.
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Economic factors will have considerable impact on the development, distribution, specifications, and use of any new technology. Costs and revenues of CT in 1980 have been analyzed and used to develop a "model" for installation and operation of a future new imagine method. It is likely that any new method will be expensive, have a high proportion of fixed costs, and will require frequent (efficient) use in order to financially break even with charges acceptable to patients, physicians, and third-party payers. While expenses can be reduced, an associated reduction in quality of care is probable. An economic analysis also suggests that distribution of any new technology to smaller volume radiologic practices will be difficult and probably delayed for several years.
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The use of computed tomography (ct) and ultrasound as imaging procedures for evaluating suspected pancreatic disease makes the use of arteriography unnecessary in most patients. CT, ultrasound, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography are usually definitive studies for diagnosis and choice of therapy. Arteriography is an important procedure for patients with rare vascular neoplasms or when CT and ultrasound findings are ambiguous.
A minicomputer system has been developed to assist in the transcription, distribution, and long-term storage of radiology reports. Reports are dictated in the traditional manner by a radiologist and then entered into specially programmed computer terminals by a transcriptionist. Completed reports are electronically distributed throughout the department and the hospital. Inactive reports are stored by the computer on microfiche. At one institution, the system is used to produce all of the reports in the radiology department, a total of approximately 200,000 reports per year.
The economic concern and controversy associated with the rise of computed tomography (CT) have been blown out of proportion. While CT is regarded by many people as an expensive procedure, in reality any increase in cost as the result of installation and continued use of a CT unit in the diagnostic radiology department is more than compensated for by the savings achieved by the concomitant reduction in other procedures, including exploratory surgery and angiography. Unless CT continues to be used in an increasing number of institutions and clinical situations, the potential savings from CT will not be realized.
Nuclear magnetic resonance (NMR), an established scientific technique, can now be considered for use in diagnostic radiology because of recent technological advances. Unfortunately, the relevant atomic nuclei detectable by NMR (e.g., 12C, 31P, and 15N) exist in very low concentrations in living subjects except for 1H (protons). Current equipment requires scanning times of several minutes for proton profiles, and even longer for other nuclei. A very important limitation is our lack of information regarding NMR detectable differences in pathologic conditions. While NMR is not currently at a state of diagnostic imaging use, its potential is promising. Research in its use in medicine and funding of engineering and clinical evaluation projects should be encouraged.
Utilization and economic data from head computed tomography (HCT) units providing more than 2 1/2 years' experience are compared with data from installations in 1976. The average unit operates 60 hr/wk, examining 63 patients. Nearly half the examinations are "double" studies, requiring about 53 minutes. The annual total technical cost is approximately $383,000. Charges have been reduced since 1976. While technical charges are lower in high-volume institutions, professional charges are higher. Usual charges and expected net revenues are above Medicare maximum allowable charges. Most units meet the national guidelines. There is considerable variation in data from individual facilities; a "typical" HCT unit cannot be defined.