All-Russian rating of radiology departments: 2020 competition results

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INTRODUCTION

Issues of medical care quality management and organization in radiology departments (RDs) are always relevant and require continuous monitoring and analytical expertise [1, 2]. Qualitative improvement of the diagnostic process becomes particularly important to continuously increase the number of examinations conducted [3, 4].

The Moscow Regional Branch of the Russian Society of Roentgenographers and Radiologists (MRB RSRR) has been independently evaluating RDs in all regions of Russia since 2018. These ratings aim to identify industry leaders and disseminate best practices within the country. The expert group gradually collects and analyzes information from colleagues through questionnaires and open-source data analysis, and the results of anonymized examinations—radiological, radioisotopic, and ultrasound—were audited. Data analysis on medical facilities forms a picture of the radiology service in Russian healthcare.

Therefore, this study aimed to analyze the functioning of 123 RDs in 2020. The positive trends in the development of diagnostic services across the country and critical points affecting the performance of medical facilities were also identified.

MATERIALS AND METHODS

At the end of the application process, 163 medical facilities were included in the list. The procedure was divided into three stages to comprehensively assess the performance of RDs.

During the first stage, an online survey was conducted. Each participating organization was invited to answer questions on the functioning of the department, equipment, list and features of diagnostic tests, and patient care. Questions were categorized into modality groups, such as computed tomography (CT), magnetic resonance imaging (MRI), radiography (RG), mammography (MMG), positron emission tomography (PET), radionuclide diagnosis (RND), and ultrasound (US) scanning. The total number of questions was 150: 25 for CT, 19 for MRI, 23 for RG, 17 for MMG, 17 for PET, 14 for RND, 16 for US, and 19 general questions. In addition to questions on modalities, specific items regarding the relevance of data provided were included in the survey (e.g., the compliance with current regulatory documentation and completeness of the implementation of Russian and international recommendations).

Each survey question was assessed using a numerical scale: additional points were awarded for each “correct” answer, corresponding to the standards and recommendations, whereas points were deducted for each violation of the department rules and regulations or the use of ineffective solutions. A maximum of 40 points could be scored for the survey, and the threshold score for passing the first stage was 15.

At the second stage, the examinations were audited clinically and technically. Medical facilities provided a set of anonymized examinations with conclusions to the expert group of the NPKTs DiT DZM (Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of Moscow Healthcare Department): each facility provided two pelvic (male) MRI scans, abdominal MRI, contrast-enhanced abdominal CT, low-dose chest CT (LD-CT) if available, chest RG, MMG, PET/CT, and three breast and thyroid US scans. The maximum possible score for the audit stage was 60 points.

At the third stage, information on the medical facility was checked in open sources, that is, official websites and data from reporting forms (such as Form No. 30). No points were assigned for this stage.

At the end of these stages, the total points were calculated, and the winners were selected based on these results. For a participant to be included in the group of prize-winners, threshold points were required: >15, 50, and 70 points for the finalists (a passing score according to the survey results), leaders, and winners, respectively. Each group—leaders and winners—could include any institutions that reached the required points.

RESULTS

Of the 163 participants, 123 RDs completed the first stage of the survey, with 50% taking up to 140 patients per day and 33.33% taking 140–420 patients.

The rating covered 15 cities (Moscow, St. Petersburg, Khanty-Mansiysk, Kazan, Yakutsk, Nizhny Novgorod, Krasnoyarsk, Stavropol, Omsk, Chita, Voronezh, Cheboksary, Irkutsk, Samara, and Tyumen) from seven federal districts. Due to the limited number of cities, these ratings may not be directly scalable to the entire country; however, the presented methodology and results may become the basis for a more extensive study of the radiology services in Russia.

In the first stage, 31 medical facilities reached the final stage, and medical institutions from four regions, that is, Moscow (2 participants), Central, Volga, and Ural Federal Districts were the top five, with scores of 24.04–34.34 points.

The second stage of the independent assessment of the RDs is an audit of the examination packages provided by participants to the NPKTs DiT DZM experts and a review of open sources. From September 18, 2020 to October 11, 2020, 11 organizations out of all finalists submitted examinations. The NPKTs DiT DZM experts checked a total of 182 examinations (22 CT, 44 MRI, 20 RG, 20 MMG, 20 NDCT, 8 PET, and 48 US scans).

The technical audit received special attention, since several medical facilities violated the methodology of conducting examinations. For example, a standard abdominal CT scan should start from the lower lobes of the lungs and cover the area up to the upper third of the femur. Some departments raised the lower boundary of the scanning area to the iliac crests, excluding the pelvic organs, which is a mistake. Individual cases with non-standard targets were not included in the analysis.

Based on the total score at the second stage, the top three were institutions from the Ural, Volga, and Central Federal Districts (24.57, 23.04, and 21.75 points respectively).

After calculating the results of all stages, 31 organizations, 6 leaders, and 5 winners reached the final stage, with 45% of the finalists belonging to the Central Federal District. Medical facilities were represented by municipal (14), private (10), departmental (2), and federal (5) institutions. Based on the type of medical care, the institutions were outpatient (7), inpatient (3), and specialized (21). Thus, the auditing work was highest at municipal and private medical institutions, rather than at departmental and federal ones.

In addition to the list of winners, some databases were created to represent a cross-section of the state of the radiology service in the Russian Federation. These materials are discussed in more detail below (with no reference to specific departments, since this information is excluded from analysis).

GENERAL ASPECTS OF THE RADIOLOGY SERVICE

Making an appointment

For the patient, the interaction with RDs begins with an appointment for the examination. This process is sufficiently elaborated in all participants of the survey based on both the number of recording methods and informing the changes. Regarding the first, the most common form was recording at the attending physician (after an initial or repeated consultation with a specialist), followed by the frequency of recording at the reception desk and by phone. Appointments through an application on the website of a medical institution, in the patient’s personal account, via messenger or a mobile application could be made in rare cases.

The majority of the departments (78%) remind the patient of the examination; of these, only 34% send information on the preparation for the examination in advance. A survey and a conversation between the patient and the physician before the examination is conducted in 56% of cases, an oral interview is held in 38%, and no interaction with the patient is provided in 6% of cases.

Issuing examination findings

The findings are mostly provided on a digital medium (CD or DVD) or on film (23 cases) through a personal account or cloud data storage (16 cases). In the current clinical practice, findings on film are only appropriate for some radiographic offices and when using the operation of the analog equipment. When choosing a new technology, digital media would be a good option. Some private clinics do not give up the “film” to be client-oriented. This is practiced only when a physician does not have an automated workstation and asks for the examination findings on film [5].

Availability of examinations

Aside from the convenience of the appointment, an important factor is the opening hours of the department and the possibility to arrange same-day appointments (in case the patient is ready for the examination). This issue is particularly important to increase the coverage of screening programs [6, 7]. The availability of examinations for emergency patients is best in Moscow and worst in the Volga Federal District (12 points vs. 2 points, respectively).

The ability to perform radiological services on the day of application (Fig. 1) was provided for X-ray examinations and CT and US scans (104, 95, and 78 cases, respectively). For these modalities, both the readiness of the department to receive the patient on the day of application and the patient’s preparation for the examination (for abdominal examinations, MMG, and US of pelvic organs in women of childbearing age) are important. However, in the survey, the researchers were interested in the readiness of the department to receive a patient.

 

Fig. 1. Availability of same-day X-ray examinations.

Note. CT, computed tomography; US, ultrasound; MRI, magnetic resonance imaging; RND, radionuclide diagnosis; PET, positron emission tomography.

 

PET/CT and RND (1 and 3 cases, respectively) were the least available procedures in terms of same-day appointments because of the complicated logistics of delivering radiopharmaceuticals for these types of examinations and the need for careful planning of the required volume, depending on the number of records per day. Moreover, patients require preparation before PET/CT and RND to exclude pseudopositive accumulation of radiopharmaceuticals; however, this is beyond the scope of the survey.

Appointments on weekends were available at 94 (67%) RDs, only Saturday appointments could be performed at 26 (19%) RDs, and 20 (14%) RDs did not work on weekends. Based on modality, X-ray examinations, CT, and MRI were available on weekends (Fig. 2), whereas PET and RND were the least available.

 

Fig. 2. Appointments in radiology departments (RDs) on weekends.

Note. CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound; PET, positron emission tomography; RND, radionuclide diagnosis.

 

Based on the survey results, the availability of screening tests, such as fluorography, MMG, and densitometry, on the day of application is lower than that of MRI or CT scans. The former types of examination are logically explained by the trend toward screening withdrawal, whereas the latter two obviously require more attention in terms of throughput and office efficiency. Another reason for the decreased availability of these examinations may be the peculiarities of medical service pricing.

Patient safety

Patient safety in diagnostic examinations is one of the priority tasks [8]. While radiation safety in Russia is strictly regulated at the legislative level [9], several other aspects are specifically included in the survey. Thus, 92% of radiologists, 54% of radiographers, 40% of nurses, and 25% of US physicians were certified cardiopulmonary resuscitators. However, with the system modernization of primary specialized accreditation for specialists and continuous medical education, the vast majority of the employees will be competent in first aid.

Follow-up after intravenous contrast enhancement in RDs: Patients were released immediately after the examination in 5 cases (4%) or <15 min in 16 (12%) cases; the follow-up lasted for 15–30 min in 68 (50%) cases or >30 min in 47 (35%) cases. Notably, some program participants omitted this item from the survey.

Unfortunately, regardless of the measures taken to prevent accidents and medical errors, they are inevitable in practice. Global experience shows the feasibility and effectiveness of recording, such incidents for subsequent analysis; however, domestic medicine lags behind in this direction [2]. Nevertheless, the survey demonstrated that 70% of departments take measures to prevent accidents in one form or another. Joint reviews of complex cases are conducted as needed in 86 (62%), weekly in 49 (36%), and not conducted in 3 (2%) cases. The complaint registry is available in 64 of 136 RDs.

One medical institution did not have internal quality control, whereas only 29 of 135 respondents engage external experts for auditing. The auditing practice implemented by the NPKTs DiT DZM showed the high efficiency of this approach with low labor costs [9].

To the question “Do you actively use second opinion?,” the answer “Yes, via email” was given by 67 (48%) respondents; “Yes, via PACS/RIS” by 51 (37%) respondents; and 21 (15%) respondents do not use the option (data by modalities are detailed in Fig. 3).

 

Fig. 3. Characteristics of second opinion requests in RDs: а, general information on its availability; b, data on modalities for which specialists most commonly request a “second opinion.” Most frequently (94%), further CT scan examination is required.

Note. CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound; PET, positron emission tomography; RND, radionuclide diagnosis.

 

Remote description of examinations may be regarded as a “privilege” for a physician; however, during the coronavirus disease 2019 pandemic, this turned out to be a necessity [4]. In addition, this approach greatly increases the availability of expert opinions from experienced specialists [5, 10]. Our data showed that 30% of radiologists describe patients’ scans directly in the office where examinations are performed; 30% of cases reported that the physician’s office is remote, but is located in the same building; and 40% of respondents practice remote description, in particular, by experts from other medical facilities. While some complex examinations require the direct presence of a radiologist, a separate office is still necessary for proper and effective work.

DIAGNOSTIC EQUIPMENT AND EXAMINATION METHODOLOGY

CT scanners are installed in 100 RDs, which are all equipped with automatic injectors for administering contrast agents. Remarkably, 22 machines have ≥128 slices, and 18 have dual-energy CT (DECT) function.

The list of examinations performed varies from department to department and obviously depends on the equipment and peculiarities of the patient flow. The prevalence of different types of CT scans is shown in Fig. 4. Apparently, LD-CT, which is performed in 65 out of 100 departments, and whole-body CT are the most common (54). Furthermore, 28 RDs perform CT-guided surgeries, including minimally invasive interventions.

 

Fig. 4. Prevalence of CT scans performed in the RDs of the rating participants.

Note. CT, computed tomography; LD-CT, low-dose computed tomography.

 

Among the departments that participated in the survey, 68 were equipped with US diagnostic machines, and most were equipped with convex, linear, and transvaginal transducers (Fig. 5).

 

Fig. 5. Transducers of ultrasound diagnostic devices.

 

The rating of the most common examinations is headed by breast and male pelvic US scans (60 and 57 medical facilities, respectively). In 46 departments, minimally invasive US-guided interventions are performed, namely, therapeutic punctures and drainage, fine-needle aspiration biopsy of the thyroid gland, and prostate and internal organ biopsies (liver, kidneys, pancreas, and others). Less frequently, hepatic elastometry, peripheral nerve US scanning, and compression elastography (28, 24, and 23 medical institutions, respectively) are performed.

The analysis showed that at least among the rating participants, the availability of X-ray machines is lower than that of CT scanners. A total of 91 devices (including 60 mobile and 44 dental) are installed in these medical institutions; and 76 of these are digital.

Most medical facilities (77) perform fluoroscopy; however, special examinations are not available in all institutions (Fig. 6).

 

Fig. 6. Availability of specialized X-ray examinations.

Note. TBI, traumatic brain injury.

 

A total of 63 departments are equipped with mammographs, and the proportion of digital devices is comparable to X-ray machines (86% vs. 84%). The most common examinations are ductography and targeted MMG (61 and 59 departments, respectively). The availability of mammographic examinations is shown in Fig. 7.

 

Fig. 7. Availability of mammographic examinations.

 

A total of 22 machines are equipped with tomosynthesis, and 28 have a biopsy attachment: 21 and 17 departments with vertical access and horizontal table, respectively. Vacuum aspiration biopsy is less available, that is, only in 11 out of 63 departments.

In terms of work organization, all rating participants perform MMG in two views, and <3% of examinations are repeated due to technical problems. Moreover, the Bi-RADS scale is used in 59 departments; however, physicians in only 44 departments are additionally certified in MMG.

The departments of the rating participants have 84 MRI scanners with 1.5, 3, and <1.5 Tesla induction (58, 21, and 5 departments, respectively). Most manufacturers include a minimum set of radiofrequency coils for the most common examinations (head and neck, abdomen, and small pelvis) as the standard equipment. However, a peculiarity of this modality is the frequent “profiling” of the MRI office on a small group of examinations, depending on the particular medical facility. Thus, cardiac MRI, tractography, and surgical interventions (MRI-guided biopsy) are performed in 27, 36, and 6 surveyed departments, respectively.

One of the most common non-standard examinations is MR angiography, which is performed in 76 departments. However, this applies primarily to angiography of the brachiocephalic arteries. Concurrently, only 32 and 23 departments perform aortic examinations and angiography of the lower extremities, respectively.

PET (including CT) is not as widespread as the other diagnostic methods; however, only five departments are equipped with this type of machines. The PET part of the equipment in most cases (three of five) has four detector rings, and CT has ≥64 slices. All departments have their own production of radiopharmaceuticals, whereas four of five have only fluorodeoxyglucose. In practice, examinations are performed using 11C-methionine, 18F-choline, 18F-tyrosine, 18F-DOPA, 18Ga-PSMA, and 18F-PSMA.

Regarding the examination features, all departments (with few exceptions) use means to ensure patient and staff safety; however, the automatic administration of radiopharmaceuticals is used only in one medical institution. Furthermore, two of five PET departments only examine cancer patients.

Based on scoring results, the top ten RDs were determined. This list included a wide variety of medical facilities with capacity ranging from 70 to 1,200 people per day and an average of 459 (Fig. 8).

 

Fig. 8. Number of visitors per day in the top ten RDs based on the rating.

 

Certainly, all of these organizations are well equipped and have at their disposal a wide range of equipment, including additional options. Each of the 10 RDs has a data storage and transmission system and remote description capabilities, follows the standardized protocols and international guidelines (such as PI-RADS and BI-RADS), audits examinations, and carefully implements measures to ensure safety of both patients and staff.

CONCLUSIONS

The results of the competition provided an insight into the level of organization among RDs in different regions of the Russian Federation. The main advantage of the participation of medical institutions in this competition is the opportunity to have an independent assessment of the department’s work by the expert council of MRB RSRR, identify strengths and weaknesses, and receive personal recommendations. Such competitions are primarily aimed at improving the quality and safety of X-ray examinations.

The methodology of the competition is improved every year. Hopefully, the number of rating participants will increase in the future, and a single RD standard will be created across the country.

ADDITIONAL INFORMATION

Funding source. This article was prepared as part of research (No. in the Unified State Information System for Accounting of Research, Development, and Technological Works, EGISU: АААА-А21-121012290079-2) under the Program of the Moscow Healthcare Department «Scientific Support of the Capital’s Healthcare» for 2020–2022.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. The largest contribution is distributed as follows: D.S. Semenov ― drawing up a questionnaire, collecting information, collection and analysis of literature, writing text; O.U. Panina ― collection and analysis of literature, working with data, writing text; A.N. Khoruzhaya ― counting and analysis of data, writing text, finalizing the article; N.D. Kudryavtsev ― counting and analyzing data, writing text; Yu.A. Vasilyev ― data analysis and statistics; N.V. Ledikhova ― drawing up a questionnaire, expert support; I.M. Shulkin ― creation of a research plan, preparation of a questionnaire; S.P. Morozov ― concept and formation of the research question.

About the authors

Dmitriy S. Semenov

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Email: d.semenov@npcmr.ru
ORCID iD: 0000-0002-4293-2514
SPIN-code: 2278-7290
Scopus Author ID: 57213154475
ResearcherId: P-5228-2017

Researcher of the Department of Innovative Technologies

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

Olga Y. Panina

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of Moscow Health Care Department

Email: olgayurpanina@gmail.com
ORCID iD: 0000-0002-8684-775X
SPIN-code: 5504-8136
ResearcherId: AAG-6447-2020

младший научный сотрудник отдела инновационных технологий

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

Anna N. Khoruzhaya

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Email: a.khoruzhaya@npcmr.ru
ORCID iD: 0000-0003-4857-5404
SPIN-code: 7948-6427
ResearcherId: AAG-5184-2020

младший научный сотрудник отдела инновационных технологий

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

Nikita D. Kudryavtsev

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Email: n.kudryavtsev@npcmr.ru
ORCID iD: 0000-0003-4203-0630
SPIN-code: 1125-8637
Scopus Author ID: 57213148303
ResearcherId: AAG-1869-2020

младший научный сотрудник отдела инновационных технологий

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

Yuriy A. Vasilev

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department; City Clinical Oncological Hospital No. 1 of the Moscow Health Care Department

Email: dr.vasilev@me.com
ORCID iD: 0000-0002-0208-5218
SPIN-code: 4458-5608

MD, Cand. Sci. (Med.)

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051; Moscow

Natalya V. Ledikhova

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Email: n.ledikhova@npcmr.ru
ORCID iD: 0000-0002-1446-424X
SPIN-code: 6907-5936

заместитель директора по медицинской части

Russian Federation, 127051, Москва, ул. Петровка, д. 24, стр. 1

Igor M. Shulkin

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Email: i.shulkin@npcmr.ru
ORCID iD: 0000-0002-7613-5273
SPIN-code: 5266-0618

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

Sergey P. Morozov

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department

Author for correspondence.
Email: morozov@npcmr.ru
ORCID iD: 0000-0001-6545-6170
SPIN-code: 8542-1720
Scopus Author ID: 57200964938
ResearcherId: T-9163-2017

MD, Dr. Sci. (Med.), Professor

Russian Federation, 24, build. 1, Petrovka st., Moscow,127051

References

Supplementary files