Temporal and geographical variations in diagnostic imaging in Norway.

BACKGROUND: Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services. OBJECTIVE: To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021. METHODS: Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics. RESULTS: More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust. CONCLUSION: As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.

Cost of Low-Value Imaging Worldwide: A Systematic Review.

BACKGROUND AND OBJECTIVE: Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide. METHODS: This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive. RESULTS: Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients. CONCLUSIONS: This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

Low-value MRI of the knee in Norway: a register-based study to identify the proportion of potentially low-value MRIs and estimate the related costs.

OBJECTIVES: The objective of this study is to investigate the proportion of potentially low-value knee MRI in Norway and to provide an estimate of the related costs. DESIGN: Register study based on conditional data extraction and analysis of data from Control and Reimbursement of Healthcare Claims registry in Norway. SETTING: MRI in public specialist healthcare with universal health coverage (Norway). PARTICIPANTS: 48 212 MRIs for 41 456 unique patients and 45 946 reimbursement claims. OUTCOME MEASURES: Proportion of MRIs of the knee that (1) did not have a relevant tentative diagnosis prior to the knee MRI, (2) did not have a relevant alternative image of the knee before the MRI or (3) did not have a relevant code from the specialist care within 6 months after the MRI, and those that had combinations of 1, 2 and 3. Estimated costs for those that had combinations of 1, 2 and 3. RESULTS: Very few patients (6.4%) had a relevant diagnosis code or prior imaging examination when having the MRI and only 14.6% got a knee-related diagnosis code from the specialist care within 6 months after the MRI. 21.8% of the patients had knee X-ray, CT or ultrasound within 6 months before the MRI. Between 58% and 85% of patients having knee MRIs in Norway have no relevant examinations or diagnoses six months prior to or after the MRI examination. These examinations are unlikely to benefit patients and they correspond to between 24 108 and 35 416 MRIs at a cost of €6.7-€9.8 million per year. CONCLUSION: A substantial proportion of MRIs of the knee in Norway have no relevant examinations or diagnoses before or after the MRI and are potentially of low value. Reducing low-value MRIs could free resources for high-value imaging, reduce waiting times, improve the quality of care and increase patient safety and professional integrity.

Radiographers' perceptions of the experiences of patients with dementia attending the radiology department.

BACKGROUND: Patients with dementia frequently present to the Radiology Department. However, stigmas have been recorded amongst radiographers surrounding imaging persons with dementia (PwD). This study aimed to investigate the impact of PwD attending the Radiology Department for imaging and the resultant effects to all patients, radiographers, and the Department from the perspectives of the examining radiographer. METHODS: A paper-based questionnaire of radiographers' perceptions and experiences of individual examinations 'termed an interaction form' was created and made available in a public hospital in Ireland for a period of eight weeks. Radiographers completed the interaction form collecting data regarding individual imaging examinations of PwD. The form comprised sixteen closed and one open-ended question on the radiographers' individual perspectives of PwDs' abilities and distress levels, carers and comforters and their role in the examination, what the radiographer found helpful in the interaction, and any adverse events. Data were analysed using a combination of descriptive analysis and thematic content analysis. RESULTS: Thirty-three interaction forms were completed by the participating radiographers. The modality most commonly represented in the survey was general X-ray (58%). Radiographers reported 84% of examinations for PwD required extra time, with 27% of examinations required repeat imaging and 69% of patients appeared distressed. A carer helped facilitate the completion of 77% of examinations. Qualitative data indicated that distractive and communicative techniques were used by radiographers to make the patient feel more comfortable and help with examination success. CONCLUSION: PwD often require more time for radiological examinations, they often need repeat imaging and re-scheduling of an examination at a more appropriate time. These factors need to be considered when scheduling and performing radiological examinations. Patient distress was frequently encountered, this area may benefit from further research and dedicated practitioner training which could help drive improvements in patient experience.

Variations in wait times for imaging services: a register-based study of self-reported wait times for specific examinations in Norway.

BACKGROUND: While the number of medical images has increased substantially, the demand has outpaced access, resulting in long wait times in many countries. Long wait times are a key problem for patient safety and quality of care as they can result in prolonged suffering, delayed diagnosis and treatment, as well as poorer prognosis and loss of lives. Surprisingly, little is known about wait times for imaging services. OBJECTIVE: Investigate wait times for specific imaging services in Norway and to compare wait times with the total number of examinations and their development over time. METHODS: Data from the wait time registry at the Norwegian Directorate of Health from 2018 to 2021 as well as data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and in-patient data afforded by fourteen hospital trusts and hospitals in Norway were analysed. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics. RESULTS: Wait times vary through the months of the year. Conventional X-ray (XR) had the shortest wait times (3.0-4.4 weeks), and Magnetic Resonance Imaging (MRI) and ultrasound (US) had the lengthiest (8.7-12.0 and 7.9-11.4 weeks respectively). The wait times were lengthiest during the summer and winter holidays. Variations in wait times were also found for specific examination types between Norway's four public health regions. In addition, there was variation over time within the health regions. The wait times with the private health providers were substantially lower than with the public health providers. From 2018 to 2021, the wait time for MRIs increased by 6.6%, while the number of examinations (per 10,000) increased by 8.6%. Those regions with the highest number of examinations per 1,000 inhabitants per year had the lowest wait times. CONCLUSION: Wait times for diagnostic imaging procedures varied with time, region, and modality in Norway from 2018 to 2021. Long wait times may entail many negative consequences for patients, professionals, and the healthcare system. Reducing long wait times is an obvious way to improve the quality, safety, and efficiency of care.

Drivers for low-value imaging: a qualitative study of stakeholders' perspectives in Norway.

BACKGROUND: One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services. METHODS: We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation. RESULTS: The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers. CONCLUSIONS: Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging.

The use of low-value imaging: the role of referral practice and access to imaging services in a representative area of Norway.

BACKGROUND: Even though imaging is essential to modern medicine, some examinations are of low value as they do not lead to any change in the management of the patient. The Choosing Wisely (CW) campaign aims to reduce the use of such services. In the Norwegian version of CW, specific magnetic resonance imaging (MRI) of the head, lower back, and knee are amongst others identified as potential low-value examinations. However, referral practice and access to imaging may drive low-value utilisation. By using registry data from 2019 and descriptive analysis, this study aimed to examine the role of referral practice and access to imaging on the use of specific CW-examinations in one representative area in Norway. RESULTS: A total of 237,554 examinations were performed by four public and two private imaging facilities located within the area. Forty-two percent (19,210/45,289) of all MRI examinations were related to CW. Private imaging centres performed most of the CW-imaging. A total of 3700 referrers were identified, and 2.3% were identified as "high-referrers," accounting for 33% of all CW-examinations. Referrers' experience did not influence imaging utilisation. A subset of referrers ("super-referrers," 0.5%) accounted for 10% of CW-examinations. Distance to service had no impact on the use of CW-examinations. CONCLUSIONS: This study provides valuable insight into the use of imaging and referral practice in one representative area in Norway. A great variation in referral practice was observed. Therefore, targeting referrers with high referral rates may be a promising strategy for reducing the use of low-value imaging.

Increased magnetic resonance imaging in prostate cancer management-What are the outcomes?

RATIONALE: Increased attention to cancer care has instigated altered systems for screening, diagnosis, and management of various types of cancer, such as in the prostate. While such systems very likely have improved the quality of cancer care, they also result in the altered use of specific services, such as magnetic resonance imaging (MRI). AIMS AND OBJECTIVE: To study the change in the use of prostate MRI in the Norwegian health care system from 2013 to 2021 and to investigate some reasons for and potential implications of this change. METHOD: Data from the Norwegian Health Economics Administration (HELFO), The Cancer Registry of Norway and Cause-of-death registry at the Norwegian Institute of public health and the health registry of Vestfold Hospital Trust were used for descriptive statistical analysis. RESULTS: The number of MRIs of the prostate increased threefold from 2013 to 2021, representing an extra cost of 2 million USD in 2020. The incidence of prostate cancer was stable at about 5000 cases per year, corresponding to 178 per 100,000 men, indicating no increased overdiagnosis. However, the clinical staging has changed substantially during this period, indicating stage and grade migration. The number of negative biopsies was reduced, and there are three MRIs per reduced negative biopsy. The number of persons on active surveillance increased during the period. However, these changes are partly independent of the increase in the number of MRIs. CONCLUSION: There was a substantial increase in the number of prostate MRIs and thus an increase in costs. This appears to have contributed to the reduction of negative biopsies, improved staging and increased active surveillance. However, as these effects are partly independent of the increase in MRIs, we need to document the outcomes for patients from prostate MRIs as their opportunity costs are substantial.

Implementation of a telemedicine, stroke evaluation service; a qualitative study.

BACKGROUND: Acute ischemic stroke requires early medical imaging with a computed tomography (CT) scan and immediate thrombolysis treatment. In rural areas, the long distance to the nearest hospital reduce the patients' probability of receiving medical assistance within the 4.5-h period. The aim of this study was to assess how the service was set-up, and how managers and personnel experience the organisation and value of a rural telemedicine, remote controlled CT stroke service. METHODS: Ten semi-structured individual interviews and one semi-structured focus group interview were conducted. The sample included 15 participants involved in the telemedicine service in Hallingdal, Norway. The interview guide consisted of questions on the service, experience of working with the service, value and quality, management, and challenges. Interviews were recorded and transcribed verbatim. Thematic content analysis was used to develop a narrative of the findings. RESULTS: Findings were categorised into three main categories; value of the service, organisation of the project, and from project to permanent service. Participants perceived the service to be valuable for patients and the local community. The service included task shifting from radiographers and junior doctors to the local paramedics. To enable long- term operation of the service the participants suggested management, coordination, and continuous training as important factors. CONCLUSIONS: The service was perceived as valuable to the local community, providing a sense of healthcare security and equitability. Management's involvement, flexibility, and coordination appears to be a key factor for successful implementation and long-term sustainability of the service.

Reducing low-value radiological services in Norway -a qualitative multi-professional study on measures and facilitators for change.

BACKGROUND: Overuse, underuse, and significant variation in the utilisation of radiological services are well documented in the literature. Several radiological examinations are identified as low-value examinations as they do not lead to a change in diagnosis or course of treatment. Even so, such examinations are frequently performed. Many measures for reducing low-value imaging have been carried out with variable outcomes. While there is little evidence as to why some measures work and others do not, adjusting to the context seems important for success. The objective of this study was to investigate which measures stakeholders consider appropriate for reducing the use of low-value imaging and what it takes to make them work. METHODS: Semi-structured interviews were conducted among radiographers, radiologists, radiological department managers, hospital clinicians, general practitioners, and health government/authorities' representatives. The interview guide covered two broad areas: Experience with low-value services, and possible future measures deemed appropriate for reducing low-value services. Data were analysed in line with a qualitative framework analysis. RESULTS: The analysis included information from 27 participants. All participants acknowledged that low-value imaging was a problem, but few had very specific suggestions on reducing this in practice. Suggested measures were to stop referrals from being sent, provide support in assessing referrals, or change the healthcare system. Identified facilitators were categorised as management and resources, evidence, and experienced value. In general, appropriate measures should be practical, well-founded, and valuable. CONCLUSIONS: This study provides insight into various stakeholders' perceptions of suitable interventions to reduce low-value imaging. While many measures for reducing low-value imaging are available, contextual sensitivity is crucial to make them work.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review.

BACKGROUND: Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS: A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS: A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS: A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42020208072.

The assessment of image quality and diagnostic value in X-ray images: a survey on radiographers' reasons for rejecting images.

BACKGROUND: Assessing the quality of diagnostic images is subjective and influenced by factors such education, skills, and experience of the assessor. This study aims to explore the radiographers' assessments of medical usefulness or rejection of X-ray images in specific cases. RESULTS: Eighty-one radiographers from different countries responded to the questionnaire distributed online at the EFRS research HUB at ECR 2020 (a 15% response rate). Forty-two percent of the respondents practiced in the UK and Ireland. In addition to rejecting or keeping images in the presented 30 cases and giving a main reason for the images rejected, the participants explained their choice using comments, 1176 comments were obtained. Sixty percent of the comments were on kept images. The respondents kept on average 63% of the images. In the "Keep", "Could keep", and "Reject" categories on average 84%, 63% and 43% of images were kept respectively. The most common reasons given for rejecting an image were suboptimal positioning and centering. Potential diagnostic value and radiation protection were indicated as reasons to keep an image perceived as of low quality reported in n = 353 and n = 33 comments respectively. CONCLUSIONS: There is an agreement internationally on what makes a good quality X-ray image. However, the opinion on medical usefulness of images of low or poor quality compared to image criteria varies. Diagnostic capability and radiation protection was the rationale used for keeping images not fulfilling image criteria. There seems to be a need for diagnostic quality to be included in image assessment in clinical practice.

Visualizing the Invisible: Invisible Waste in Diagnostic Imaging.

There is extensive waste in diagnostic imaging, at the same time as there are long waiting lists. While the problem of waste in diagnostics has been known for a long time, the problem persists. Accordingly, the objective of this study is to investigate various types of waste in imaging and why they are so pervasive and persistent in today's health services. After a short overview of different conceptions and types of waste in diagnostic imaging (in radiology), we identify two reasons why these types of waste are so difficult to address: (1) they are invisible in the healthcare system and (2) wasteful imaging is driven by strong external forces and internal drivers. Lastly, we present specific measures to address wasteful imaging. Visualizing and identifying the waste in diagnostic imaging and its ingrained drivers is one important way to improve the quality and efficiency of healthcare services.

What can we learn from the SARS-COV-2 pandemic about the value of specific radiological examinations?

BACKGROUND: The SARS-COV-2 pandemic provides a natural intervention to assess practical priority setting and internal evaluation of specific health services, such as radiological services. Norway makes an excellent case as it had a very low infection rate and very few cases of COVID-19. Accordingly, the objective of this study is to use the changes in performed outpatient radiological examinations during the first stages of the SARS-COV-2 pandemic to assess the practical evaluation of specific radiological examinations in Norway. METHODS: Data was collected retrospectively from the Norwegian Health Economics Administration (HELFO) in the years 2015-2020. Data included the number of performed outpatient imaging examinations at public hospitals and private imaging centers in Norway and was divided in to three periods based on the level of restrictions on elective health services. Results were analyzed with descriptive statistics. RESULTS: In the first period there was a 45% reduction in outpatient radiology compared to the same time period in 2015-2019 while in period 2 and 3 there was a 25 and 6% reduction respectively. The study identified a list of specific potential low-value radiological examinations. While some of these are covered by the Choosing Wisely campaign, others are not. CONCLUSION: By studying the priority setting practice during the initial phases of the pandemic this study identifies a set of potential low value radiological examinations during the initial phases of the SARS-COV-2 pandemic. These examinations are candidates for closer assessments for health services quality improvement.

Interventions to reduce low-value imaging - a systematic review of interventions and outcomes.

BACKGROUND: It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS: An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS: The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS: Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.

Telemedicine remote controlled stroke evaluation and treatment, the experience of radiographers, paramedics and junior doctors in a novel rural stroke management team.

BACKGROUND: In the case of ischemic stroke, access to a Computed Tomography (CT) scanner and the start of thrombolytic therapy immediately is imperative. Transport to the nearest hospital from the remote, rural area of Hallingdal in Norway entails a 2-3 h drive. The local medical centre in this area has a CT-scanner operated by radiographers during office hours. Out-of-hours stroke evaluation and treatment has been the focus of a research project. Paramedics position the patient in the CT-scanner. A radiographer at the participating hospital runs a remote-controlled scan and a junior doctor instructs a paramedic in the performance of a neurological examination. The aim of this study was to explore how radiographers, paramedics and junior doctors experience conducting telemedicine-based stroke evaluation and treatment. METHODS: Six semi-structured interviews were conducted with radiographers, paramedics and junior doctors; with remote control, CT examination and stroke management as central issues. Core issues in the interview guide were: communication; cooperation; competence; service quality and training. The study employed thematic content analysis in analysing the data inductively. RESULTS: The analysis gave an overview of the patient flow and communication routines in this service. Further findings were divided into two main themes, "Teamwork" and "Quality". The theme "Teamwork" included three categories "Communication", "Trust and confidence", and "Task and task shifting". The theme "Quality" included two categories "Education and training" and "Safety and routines". The respondents considered the service to be of high quality and that the team functioned at a high level as a result of regular training sessions. However, communication and image reading routines could be improved. CONCLUSIONS: The telemedicine-based, remote controlled, stroke evaluation and treatment was experienced, by the participants, to be well organised and of high quality. Communication and image reading appear to be the salient challenges. Regular training sessions and follow-up, as well as an evaluation of incidents by the project manager, proved to be of great importance in retaining and securing the continued running of the service and ensuring high-quality treatment. Further research is indicated in the comparison of this telemedicine service with stroke treatment given in a mainstream hospital.

Impact of mobile radiography services in nursing homes on the utilisation of diagnostic imaging procedures.

BACKGROUND: In the last decade, mobile radiography services have been introduced in nursing homes in several countries. Earlier research found an underutilisation of diagnostic imaging among nursing home residents. However, the effects of introducing mobile radiography services on the use of diagnostic imaging are unknown. The purpose of this study was to determine the utilisation of diagnostic imaging among nursing home residents and if there are any differences between hospitals with and without a mobile radiography service. METHODS: Data for 2015 were collected from the radiological information systems of 11 hospitals. The data included information on the anatomical region/organ/organ system, modality, and information on where the examination took place. Using nursing home beds as a proxy for nursing home residents' differences in the use of diagnostic imaging in areas with hospitals with and without mobile radiography services were analysed. The chi-squared test was used to compare the areas. RESULTS: From 11,066 examinations of nursing home residents, 87% were plain radiographs, 8% were CT scans, and 4% were ultrasound examinations. In areas with mobile radiography services, there was a significantly higher proportion of diagnostic imaging used per nursing home bed, 50% per bed compared to 36% per bed in areas without; p = < 0.001. Furthermore, in areas with mobile radiography services, there was a significantly lower proportion of CT and ultrasound used per nursing home bed, 2.5 and 1.4% respectively per bed compared to 4.7 and 2.2% respectively per bed in areas without; p = < 0.001. CONCLUSIONS: This study demonstrate a lower use of radiology by nursing home residents compared to the general population, and indicates that mobile radiography services increase the level closer to the user rate in the general population. The proportions of plain radiographs are significantly higher in areas with a mobile radiography service, while the proportion of more advanced imaging techniques such as CT and ultrasound are lower. The higher use of diagnostic imaging is most likely appropriate because of higher morbidity and lower use of diagnostic imaging among nursing home residents, compared to the general population. Further research is necessary on how to improve diagnostic imaging services for nursing home residents.

Cost analysis of mobile radiography services for nursing home residents in Southeast Norway.

RATIONALE, AIMS, AND OBJECTIVE: Telemedicine applications, such as a mobile radiography service, provide a new way of organizing healthcare services. In order to provide safe and personalised care for nursing home residents during X-ray examinations, mobile radiography services have been implemented. The objective of this study was to analyse the costs of X-ray examinations and treatments for nursing home residents when comparing hospital-based imaging with a combination of hospital-based imaging and a mobile radiography service in Southeast Norway. METHODS: A decision model was developed using the software TreeAge Pro. The model included two alternatives: the mobile radiography service in combination with hospital-based imaging and hospital-based imaging alone. The treatment needed based on the examination results could be given either in the nursing home or at the hospital. Probabilities and costs in the model were derived from previous research, various reports, and hospital data from the Southeast region of Norway. Monte Carlo simulations of 1000 residents were run through the model, and statistical analyses were applied. RESULTS: The analysis showed a mean cost of €2790 per resident for the hospital-based service alone. For mobile and hospital-based services combined, the mean cost was €1946 per resident, including examinations and the immediate treatment given. This difference in costs was significant (p < 0.001). CONCLUSION: A mobile radiography service in nursing homes provides a safe, high quality health care service. The result of this study showed there was a 30% cost-reduction by implementing the mobile radiography service.

Managers' experience of success criteria and barriers to implementing mobile radiography services in nursing homes in Norway: a qualitative study.

BACKGROUND: In order to meet the future challenges posed by ageing populations, new technology, telemedicine and a more personalized healthcare system are needed. Earlier research has shown mobile radiography services to be highly beneficial for nursing home residents in addition to being cost-effective. Despite the benefits, mobile radiography services are uncommon in Europe and Norway. The purpose of this study was to explore success criteria and barriers in the process of implementing mobile radiography services, from the point of view of the hospital and municipal managers. METHODS: Eleven semi-structured interviews were conducted with managers from five hospitals and six municipalities in Norway where mobile radiography services had been implemented. Core issues in the interview guide were barriers and facilitators in the different phases of implementation. The framework method for thematic analysis was used for analysing the data inductively in a research team. RESULTS: Five main categories were developed through the success criteria and barriers experienced by the participants: national health policy, regional and municipal policy and conditions, inter-organizational implementation projects, experienced outcome, and professional skills and personal characteristics. The categories were allocated into three higher-order classifications: macro, meso and micro levels. The main barriers experienced by the managers were financial, procedural and structural. In particular, the reimbursement system, lack of management across healthcare levels and the lack of compatible information systems acted as barriers. The main facilitators were external funding, enthusiastic individuals in the organizations and good collaboration between hospitals and municipalities. CONCLUSIONS: The managers experienced financial, structural and procedural barriers. The main success criteria in the process were external funding, and the support and engagement from the individuals in the organizations. This commitment was mainly facilitated by the intuitive appeal of mobile radiography. Changes in healthcare management and in the financial system might facilitate services across healthcare levels. In addition, compatible information systems across healthcare levels are needed in order to facilitate the use of new technology and mobile services.