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Advanced Practice in Diagnostic Imaging
Nick Woznitza BSc, PgD, PgC, MIR(AP)
Clinical Academic Reporting Radiographer2016 CAMRT Annual General Conference
June 9 – 12, 2016, Halifax, NS
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@xray_nick
Disclosure
• Research Funding: College of Radiographers (UK) & International Society of
Radiographers & Radiographic Technologists
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Overview What is an advanced practitioner?
Why advanced practitioner radiographers?
The path to advanced practice with a journey through the evidence
Challenges and opportunities
4
Overview What is an advanced practitioner?
5
What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”
Canadian Association of Medical Radiation Technologists 2014
“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”
Australia Institute of Radiography 2014
“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.”
Health Education England 2014
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What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”
Canadian Association of Medical Radiation Technologists 2014
“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”
Australia Institute of Radiography 2014
“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.
Health Education England 2014
7
What is an Advanced Practitioner?“Advanced practice in Medical Radiation Technology is defined as a higher level of practice wherein clinical responsibilities routinely exceed the current principal expectations of practice.”
Canadian Association of Medical Radiation Technologists 2014
“Occurs when a practitioner is regularly performing beyond the core practice boundaries of the profession on a regular basis with appropriate availability of resources, educational underpinning and professional mentorship.”
Australia Institute of Radiography 2014
“A role, requiring a registered practitioner to have acquired an expert knowledge base, complex decision-making skills and clinical competences for expanded scope of practice, the characteristics of which are shaped by the context in which the individual practices.
Health Education England 2014
8
Core Advanced Practice Domains Expert Practice
Leadership/Service Transformation
Education
Service Evaluation/Research
Higher Level Practice
Critical Thinking
Complex Decision Making
Autonomy
Leadership
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Clinical Expertise
Evidence-based Judgement
Scholarship & Teaching
Clinical Leadership
Overview
Why advanced practitioner radiographers?
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Why Advanced Practitioner Radiographers?
Improved patient care
Radiographers fundamental to the diagnostic pathway
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Overview
The path to advanced practice with a journey through the evidence
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
First practitioner to see image
Limited radiologist support
Radiographer opinion
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Evolution of Radiographer Image Interpretation
Swinburne (1971) “pattern recognition” by trained radiographers
Berman et al. (1985) “red dot” for MSK trauma
Brealey et al. (2006) excellent accuracy; 81% sensitivity, 95% specificity for “red dot”
Swinburne Lancet 1971;297:589; Berman et al. Brit Med J 1985;290:421; Brealey et al. Clin Radiol 2006;61:604 16
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
Radiographer advanced practice established in the UK
Opportunity (of a lifetime) to develop skills
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Evidence Base – Skeletal Reporting Piper et al. (2005) Structured exam: 27 radiographers; ~2,700 X-rays; sensitivity 93%, specificity 92% and accuracy 93%
Piper et al. (1999) Multisite clinical evaluation: 10 radiographers; 7,170 reports; accuracy 97% - 99%
Brealey et al. (2005) Meta-analysis provided definitive evidence: 28,900 examinations; 92% sens 97% spec
Piper et al. Radiography 2014;2:94; Piper et al. 1999 NHS Executive Report; Brealey et al. Clin Radiol 2005;60:232 19
Radiographer advanced practice established in the UK
Opportunity (of a lifetime) to develop skills
Was this an advanced practitioner role?
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
New role, new challenges
Established AP team: 4 reporting radiographers, 8 sonographers
Comprehensive service developed
Adult chest X-ray interpretation
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Chest X-rays – Definitive Radiographer Reports Piper et al. (2014) Structured examination: 40 radiographers, 4,000 CXRs; 95% sensitivity & specificity, 89% agreement
Woznitza et al. (2014) Clinical audit: 100 cases; 1 radiographer, 3 consultant radiologists; high concordance 92% (Ƙ = 0.83), 96% (Ƙ = 0.91), 96% (Ƙ = 0.91)
Piper et al. Radiography 2014;20:94; Woznitza et al. Radiography 2014;20:223 23
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
An Advanced Practitioner?
Expert Practice
Leadership/Service Transformation
Education
Service Evaluation/Research
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Justification of Medical Exposures Radiographers act as gatekeepers
Legislation in UK regarding medical radiation exposures: IR(ME)R 2000
Canada: Safety Code 35 (2008) & CAR Standards (2000)
Referring clinician required to explain clinical benefit, detailed to enable exposure
Ionising Radiation (Medical Exposure) Regulations 2000 HMSO; Soya & Paterson Brit J Radiol 2008;81:725 ; Safety Code 35 Health Canada 2008; Standards for General Radiography CAR 2000
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Image Acquisition & Quality
Request queries
Assist/mentor junior radiographers & assistant practitioners
Initial interpretation
Plain imaging queries & patient questions
Lead quality audits
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
Chest X-rays – Agreement of Experts
Random stratified sample of CXRs
Two independent expert consultant chest radiologists, blinded to clinical report
Reports compared for agreement: Kappa [Ƙ ] and McNemar statistics
193 cases included; 79 (41%) normal clinical report
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0.64 0.610.68 0.66
0.52
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CC1-RR CC2-RR CC1-CR CC2-CR CC1-CC2
Kap
pa
Stat
isti
c
Observers
Observer Agreement: Kappa
p < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.001
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Diagnostic Accuracy – Adult Chest X-rays 10 consultant radiologists & 11 reporting radiographers
106 adult chest x-rays with robust reference standard diagnosis
Normal reporting conditions
Reporting radiographers must be comparable to consultant radiologists
Royal College of Radiologists and College of Radiographers 2012 31
Diagnostic Accuracy – Figure of Merit
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Observer Peformance
RR CR
Radiologist average performance 0.79 (0.76 – 0.81)
Radiographer average performance 0.83 (0.81 – 0.85)
t = 11.585; p < 0.001
0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
RR CR
Lesi
on
Lo
calis
atio
n F
ract
ion
Non-Lesion Localisation Fraction 32
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
Contribution to Patient Care Patient focused care
Rapid rise in workload
Political/economic climate
34Royal College of Radiologists & College of Radiographers 2012; Royal College of Radiologists 2012; Price et al. Radiography 2007;13:18
Contribution to Care: Service Evaluation
Woznitza et al. (2014) Service evaluation at single department
Retrospective interrogation of Radiology Information System
o Efficiency: Waiting Times, Radiographer Reports
o Effectiveness: Report Turnaround Time, Discrepancies
Re-audits in 2015 and 2016
Woznitza et al. Radiography 2014;20:258 35
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0
20000
40000
60000
80000
100000
120000
140000
160000
180000
0
10
20
30
40
50
60
70
80
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
DEP
AR
TMEN
T A
CTI
VIT
Y
REP
OR
TIN
G T
IME
(HO
UR
S)
XR CT MRI Activity
Contribution of Advanced Practitioners
3 Consultant Radiologists
6 Consultant Radiologists
4.5 Consultant Radiologists
2013-14 2014-15 2015-16
Contribution to Care: New Services Radiographer-led immediate ED skeletal reporting service
Role for radiographer-led discharge?
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RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
Consultant Practitioner? Level 1 tertiary referral neonatal unit
14,000 cot days per annum
~3,000 x-rays annually
2010: Not reported by radiology department
Implement radiographer–led plain imaging reporting service
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Response to Demand: Neonatal Reporting Reporting radiographer interpreting skeletal and adult chest x-rays
Bespoke, intensive training programme
Benefits?
All x-rays reported, next working day
90% by radiographer
Weekly MDT; radiographer deputises for consultant paediatric radiologist
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42
RadiographerSenior
RadiographerAustralia to
UKMSK Clinical
ReportingAdult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
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Radiographer
Senior Radiographer
Australia to UK
MSK Clinical Reporting
Adult Chest Reporting
Advanced Practitioner
Research & Service
Evaluation
Consultant Practitioner
Overview
Challenges and opportunities
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Challenges
No defined pathway/characteristics
Integration
Communication
What are the opportunities?
Where there is need!
Emergency Department CIHI (2012) ED capacity an issue; overcrowding, long waits, possibility of poor care
Are you making best use of the MDT?
Radiographer preliminary clinical evaluation
Radiographer-led discharge?
46Canadian Institute for Health Information 2012; McConnell et al. Radiography 2012;18:184; Snaith Radiography 2007;13:13
Health Promotion: Lung Cancer Lung cancer has a significant impact on health
Most common cause of cancer death
Poor 5 year survival: Canada 17%; UK 10%
Byrne et al (2014): 48 day wait from abnormal imaging to biopsy for lung cancer role for AP rads to decrease waiting times?
47Canadian Cancer Society’s Advisory Committee on Cancer Statistics 2015; Office of National Statistics (UK) 2016; Cancer Research UK 2015; Byrne et al. Can Assoc Radiol J 2015;66:53
Health Promotion: Lung Cancer Prevention: smoking cessation intervention
Risk stratification: patient history & referral
Early diagnosis: LDCT lung cancer screening
48NLST N Eng J Med 2011;365:395; Canadian Partnership Against Cancer 2014; Field et al 2016 Thorax 2016;71:161
Conclusions Advanced radiographer practice improves patient care
Growing evidence base for radiographer advanced practice, including clinical reporting
Radiographer reporting contributes to patient focused radiology service
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Conclusions
“professional guidelines could be changed as a result of popular pressure and published peer-reviewed audit/research”Gibbs Radiography 2013;19:164
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