Introducing an integrated imaging delivery system in Manitoba.

OBJECTIVE: As a result of the reform of a comprehensive government health plan, an integrated imaging system is being created in the province of Manitoba. The intent of the system is to reduce costs, avoid causing harm to patients, enhance physician referral services and add new programs. METHODS: Evaluation of trends in examinations, equipment, personnel, expenditures and policy in the 1992-93 and 1995-96 fiscal years in Manitoba. RESULTS: The population has remained steady, at 1.1 million. Hospitals have been amalgamated under new authorities, and Manitoba's annual health care spending of $1.8 billion has been reduced by $235 million. Between the 2 years, use of radiography declined from 835,748 to 726,394 examinations per year. Use of mammography, ultrasonography, computed tomography, magnetic resonance imaging and nuclear medicine increased moderately. The total number of radiologic examinations declined from 1,069,579 to 975,044. There was little change in equipment, but the plant aged as a result of freezes on construction and capital spending. Personnel declined by 20 full-time equivalent positions, from 794.3 in 1992-93 to 774.3 in 1995-96. Savings in operations were made as a result of hospital budget restrictions. Total expenditures declined from $100 million to $89 million. The income of imaging specialists did not change because they were paid higher fees for examinations involving newer technology. CONCLUSION: Integration of rural/northern and urban hospital services has followed the plan set out in recent legislation. Savings of up to 20% are expected to be realized through reduction in personnel (saving $1 million), group tendering ($1 million), in-house repair ($1 million), reduction in deployment of equipment ($3 million), integration of services ($1 million), indirect cost reduction ($5 million), practice guidelines ($3.5 million), reduced breast screening costs ($1 million), physician payment reform ($1 million) and rigorous clinical/fiscal audit ($1 million).

Reducing imaging costs in Manitoba, Canada.

Manitoba, Canada, has serious debt and deficit problems and spends one-third of its revenue on health care. Manitoba Health, the single government carrier, has requested a 5-year management plan from the Provincial Imaging Advisory Committee to maintain and improve the present services within reduced funding [1]. The committee members are radiologists, nuclear medicine specialists, physicists, physicians, hospital officials, and senior government staff. In 1993, each Manitoba hospital prepared a 5-year plan for imaging equipment purchases based on projected patient and attending staff needs. The requests for services and new imaging technology exceed planned resource allocations. I was asked by Manitoba Health in July 1993 to prepare a cost restraint position paper with a target of 10% savings to help with government restraint and to allow some transfer of resources for continuing growth in imaging. The approach was to consult widely and to seek methods of significant cost savings that Canadian society might accept (Table 1). Areas of potential savings now are being considered by ad hoc committees appointed by hospitals and Manitoba Health. Several are being implemented on a trial basis.

Diagnostic imaging management in Manitoba: 1995-2000.

As part of a 5-year imaging management plan being developed for the single insurance carrier in Manitoba, the radiologic utilization for the province was reviewed. For the fiscal year 1993 (April 1, 1992, through March 31, 1993), 1,056,694 imaging studies were performed in a total patient population of 1,133,117 in 81 hospitals and 39 offices in which 648 units of equipment were operated by 773.4 full-time personnel at a cost of $100,302,812 ($75,227,109 in U.S. dollars). The skin dose for the total population for the year was 40,112 Gy, compared with 35,513 Gy in 1979. Since 1979, there has been a 9% increase in the number of radiologic examinations (from 972,426 examinations), a greater need for more personnel to conduct ultrasound, mammography, computed tomography, and magnetic resonance imaging examinations, and striking costs escalation (from $25,082,500 to $100,302,812). Reduction of total funding for imaging services will be possible only if the medical service infrastructure and physician behavior are altered, since imaging is a support service. Hospital services must be integrated and the infrastructure reduced, and physicians must adhere to guidelines and practice protocols for requesting consultations.

The influence of referral protocols on the utilization of magnetic resonance imaging: evidence from Manitoba.

The relative scarcity of magnetic resonance imaging (MRI) capacity in most Canadian jurisdictions has created pressures to develop guidelines on appropriate clinical indications for examination by this method. The objective of this study was to assess the influence of referral protocols on the utilization of MRI services. Three neuroradiologists and one radiologist reviewed the indications for MRI for 198 referrals to the facility at St. Boniface General Hospital in Winnipeg (99 from outside Manitoba and 99 from within the province), selected at random from patients seen between Jan. 1 and Dec. 31, 1991, for suspected disorder of the brain or the spine. Out-of-province referrals had not been subject to referral protocols, whereas those from within Manitoba had been subject to such protocols. At least three of the four radiologists agreed on whether an examination was appropriate in 175 of the 198 cases (88.4%). Out-of-province referrals were significantly more likely to be considered inappropriate for MRI: 24 (24%) of the referrals from outside Manitoba were judged inappropriate by three or more reviewers, whereas only 10 (10%) of the referrals from within Manitoba were judged inappropriate (chi 2, p < 0.01). Of the 19 cases that were judged inappropriate for MRI by three or more reviewers and that yielded abnormal findings, unique clinical information was derived from the examination in only 1 (5%); in contrast, of the 85 cases that were judged appropriate for MRI by three or more reviewers and that yielded abnormal findings, unique information was found in 47 (55%).(ABSTRACT TRUNCATED AT 250 WORDS)

Computed tomography for nontraumatic headache: current utilization and cost-effectiveness.

A retrospective study was performed at two teaching hospitals--one in the United States and one in Canada--to determine the results of computed tomography (CT) examinations of the head in patients with nontraumatic headache. Of 1111 examinations performed over a 3-year period, 120 (10.8%) demonstrated an acute intracranial abnormality, such as hemorrhage, infarction or tumour; the frequency of such abnormalities was highest among inpatients and subjects over 40 years of age. Cranial and extracranial abnormalities, such as sinusitis and metastases to the calvarium, were found in 40 (3.6%) of the cases. Chronic abnormalities, such as cerebral atrophy or remote infarction, were the most significant findings in 202 (18.2%) of the cases. The cost of finding each case of acute intracranial abnormality was $5962 (US); for subarachnoid hemorrhage among patients in the emergency department, it was $15,837 (US).

The radiology relative value scale: its development and implications.

In a proactive response to federal government cost-containment pressures, the radiology profession, under the leadership of the American College of Radiology (ACR), in 1988 developed a relative value scale (RVS) for radiologic procedures. Like earlier radiology RVSs, its relative values reflected the physician work and practice costs involved in each procedure. The RVS was constructed by using (a) three types of data (magnitude estimation, charges, and practice costs) obtained by means of surveys and (b) expert consensus panels involving participants from all fields and many organizations in radiology. The RVS was accepted, essentially in toto, by Medicare. Subsequently, the RVS has required much work to correct errors by Medicare and the insurers that administer it, to improve procedure codes, and to develop codes and relative values for new procedures. By moving proactively, radiology preserved fee-for-service against a major threat, reduced payment cuts from those that seemed to be impending, and gained a unique degree of control over its payments. However, the new payment system is complex and does not reward efficacy, cost-effectiveness, or quality.

Policy development for CT and MRI services in Manitoba.

Economic forces are changing Canadian medicine. There are four hospitals in Manitoba with CT services and eight were planning to add services based on public subscription, internal transfer of resources and expected growth. The Ministry of Health requested an in depth report and review. Analysis of clinical activity for 287 disease categories from 13,996,240 physician claims and 149,480 hospital discharges reveal that 33,552 CT examinations are reasonable for 1.1 million people. The cost of operating each scanner is one million dollars per year. A formal review process of the report by the 12 hospitals and 7 selected experts was conducted. An advisory committee of all interested parties recommended that no further resources be allocated without proven clinical need and that a strong management committee be reactivated. MRI growth for nervous disease is expected to replace much CT activity in the next five years.

Screening mammography program delay recommended by Manitoba working group: issues for radiology.

UNLABELLED: Assignment: A working group, appointed by government, examined the advisability of implementing a mammography screening program and prepared a cost analysis. ANALYSIS: Present Manitoba activity (45,695) is a mixture of clinical mammography (10,000) and unorganized screening, mammographies (35,695) at an annual screening cost of $2.8 million. Canadian policy reports, program descriptions in other countries and critical reviews were analyzed. A steady-state clinical and financial model was constructed. A controlled screening program enrolling 80% of women 50-69 years will cost $2.6 million per year plus $0.65 million new clinical costs limited to 4 years. Recommendations; Six were made: delay implementation awaiting more evidence of benefit, discourage use in asymptomatic women under 50 years, develop information programs for women and health professionals, establish an advisory group and participate in research directed to a eventual decision.

Physician payment reform: issues for Canadian radiologists.

Policy decisions taken by the US Congress in the 1980s to restrain health care costs included the designation of diagnostic-related groups, the creation of scales of relative value and legislation to introduce free-for-service payment to physicians in 1992; discrepancies in the system are to be corrected by 1996. Under federal contract a system of resource-based relative-value scales was created for all medical disciplines except radiology, which by special legislation prepared its own experience-based relative-value scale. The scales are based on magnitude estimation of the work of physicians and analyses of actual costs. Codes for medical services have been published, which include a weighting for each service in relation to all others. Multiplication by a conversion factor establishes the fee to be paid by the carriers acting for the Health Care Financing Administration. The relative values will be updated every 5 years. Publication of this information for US Medicare patients (the disabled, the elderly and those with end-stage renal disease) will likely have a profound effect on the physician payment system in Canada. Under the reformed system the lifetime earnings of all physicians will become more similar. Four problem areas are discussed in the paper: self-referral, administrative complexity, malpractice and the plight of those without medical coverage. Resolution of these problems is being actively sought.

The excretory urogram bowel preparation--is it necessary?

A prospective randomized study was undertaken to determine whether prior bowel preparation improves the diagnostic quality of the excretory urogram. From August 1986 to May 1987, 107 outpatients having an excretory urogram on an elective basis were randomized into 3 groups: group 1 received castor oil, group 2 received x-ray preparation and group 3 received clear fluids 24 hours before the study. The quality of the bowel preparation and the excretory urogram was graded separately on a scale of 1 to 5. More than 71 per cent of the bowel preparations were graded as 4 (very good) or 5 (excellent) and more than 91 per cent of the films were graded as 4 or 5 in all 3 groups. The quality of the excretory urogram was graded as 5/5 in a greater number of group 3 cases. Patients reported a high incidence of side effects from both bowel preparations, while no adverse effects were reported from those in group 3. The administration of a bowel preparation compared to that of clear fluids alone made no difference to either the quality of the bowel preparation or the diagnostic quality of the film.

Changes in diagnostic investigation and improved detection of colon cancer, Manitoba 1964-1984.

Detection of colon cancer has improved in Manitoba over the last 20 years with decreases in diagnostic delay and failure. Between 1981 and 1984 diagnostic delay, resulting from initial false-negative examinations, occurred in 5.7% of patients. Diagnostic failure, because all investigations were negative in patients found to have cancer of the colon within one year, was 0.66%, compared with 9.5% and 5.8% respectively between 1964 and 1969. In the intervening time double-contrast barium examinations and colonoscopy were introduced and became more widely used, with a corresponding decline in single-contrast examinations. The mortality rate in the general population was unchanged despite an increased incidence, while 1980 survival rates suggested that women cancer patients were living longer than previously as well as longer than their male counterparts.

Radiology and the Health Policy Agenda for the American People.

Eleven radiologists appointed by the major radiological societies participated for the past 5 years in the development of the Health Policy Agenda for the American People. The Agenda is an action plan to address a wide variety of serious problems in medicine. The first phase involved establishment of 159 principles, broad value statements that were the foundation of the project. Phase 2 involved the development of policy proposals on 38 urgent issues for action in medical science; education; health resources; delivery mechanisms; evaluation, assessment, and control; and payment for services. These proposals are summarized in this report. The activities and recommendations of representatives for the field of radiology are described. The Agenda has been released, and an implementation phase has begun. It will likely be of great importance to the practice of radiology over the next decade. Important issues can be addressed by acting with the coalitions that are being formed from among the more than 150 participating organizations.

Equilibrium of medical and radiology services in Manitoba.

Diagnostic imaging policy for the one million people of Manitoba was reviewed. Four complete data collections of diagnostic imaging activity, physician claims, vital statistics, and disease incidence from existing registries were assembled. Mammography, Hodgkin disease, and regional enteritis were analyzed briefly. Studies of protocols for patient access to computed tomography, imaging in head injury, and actions by society indicated that new technology and procedures can be accommodated at manageable public expense. To overcome emerging problems, several initiatives have been considered, including a proposed Canadian Health Council to moderate policy, a personal health identification number to link information, and imaging investigation directed by radiologists.

Managed reduction of unnecessary skull radiography.

A program to reduce unnecessary skull radiography for trauma was instituted in a teaching hospital in 1970 and eventually proved successful. In 1970, 2 976 skull examinations were made for all purposes and this fell to 791 examinations in 1983. A similar reduction occurred concurrently in the other university teaching hospital departments without the formal program. Only recently has this trend begun in urban hospitals and there is still no change in rural hospitals and urban private radiology offices. The reasons for the decline are attempts to moderate radiation dose, cost containment, clinical use of high yield criteria, and early employment of computed tomography head scanning for trauma. The savings in skull radiography match the related costs of computed tomography with improved patient care.

Canadian diagnostic radiology manpower 1982.

By accurate count there were 1 417 Canadian diagnostic radiologists in active practice in 1982 compared with 1 293 in 1977. Between 1966 and 1975 an average of 69 were certified each year by the Royal College of Physicians and Surgeons of Canada, while between 1970 and 1979 the number had fallen to an average of 59, with about four more entering practice following certification in Quebec or by recognition of American or British qualifications. The age of radiologists has risen and a larger proportion are women. Comparison with other data indicates that Canadian radiology manpower is now in balance. Continuation of manpower monitoring is necessary as a potential shortage of radiologists may occur because of the reduced number being trained, of physician immigration restrictions, of moderately less career-time in the work force on the part of women radiologists, of further advances in imaging technology, and of the demands of interventional radiology.