N. Woznitza

Conceptualisation of the characteristics of advanced practitioners in the medical radiation professions

Professions grapple with defining advanced practice and the characteristics of advanced practitioners. In nursing and allied health, advanced practice has been defined as ‘a state of professional maturity in which the individual demonstrates a level of integrated knowledge, skill and competence that challenges the accepted boundaries of practice and pioneers new developments in health care’. Evolution of advanced practice in Australia has been slower than in the United Kingdom, mainly due to differences in demography, the health system and industrial relations. This article describes a conceptual model of advanced practitioner characteristics in the medical radiation professions, taking into account experiences in other countries and professions. Using the CanMEDS framework, the model includes foundation characteristics of communication, collaboration and professionalism, which are fundamental to advanced clinical practice. Gateway characteristics are: clinical expertise, with high level competency in a particular area of clinical practice; scholarship and teaching, including a masters qualification and knowledge dissemination through educating others; and evidence‐based practice, with judgements made on the basis of research findings, including research by the advanced practitioner. The pinnacle of advanced practice is clinical leadership, where the practitioner has a central role in the health care team, with the capacity to influence decision making and advocate for others, including patients. The proposed conceptual model is robust yet adaptable in defining generic characteristics of advanced practitioners, no matter their clinical specialty. The advanced practice roles that evolve to meet future health service demand must focus on the needs of patients, local populations and communities.

Expanding the role of radiographers in reporting suspected lung cancer: A cost-effectiveness analysis using a decision tree model

INTRODUCTION To assess whether an enhanced role for radiographers in reporting lung cancer chest radiographs is cost-effective. METHODS Costs and outcomes of chest radiograph reporting by reporting radiographer or by a radiologist were compared using a decision tree model. The model followed patients from an initial chest radiographs for suspected lung cancer to the provision of cancer care in positive cases. Sensitivity and specificity of reporting for radiographers and radiologists were derived from a recent trial. Treatment costs and quality adjusted life expectancy were estimated over five years for those diagnosed. Deterministic and probabilistic sensitivity analyses were used to test the robustness of inference to parameter uncertainty. RESULTS For 1000 simulated patients, radiographer reporting decreased detection costs by £8500 and detected 10.3 more cases at initial presentation. After including treatment costs and outcomes, radiographer reporting remained cheaper than radiologist reporting and resulted in 1.4 additional QALYs per 1000 screened patients. Probabilistic analysis indicated a 98% likelihood that radiographer reporting is cheaper and more effective than radiologist reporting after inclusion of treatment costs and outcomes. CONCLUSION Radiographer reporting is a cost-effective alternative to radiologist reporting in lung cancer diagnosis. Further work is needed to support the adoption of radiographers reporting pathway in diagnosis of lung cancer suspected patients.

Commentary: radiographer reporting

Radiographers worldwide are integral to the diagnostic pathway and are optimally placed to provide expert comment on radiographs. By nature, the radiographer is the first health care professional to view each diagnostic image, which has been acquired by a focus on the patient. Radiographers are in a unique position to communicate their professional observations directly with the treating clinician in a timely manner and thereby have a significant influence on patient care. Currently, advanced practitioner roles, which incorporate radiographer reporting, are limited to the United Kingdom (UK). The changing nature of health care worldwide has seen several countries including Canada, Australia, Norway and Denmark develop models of advanced radiographer practice which includes definitive clinical reporting. Swinburne first raised the possibility of trained radiographers expanding their role to incorporate preliminary image interpretation, although the pioneering work of Berman et al. is seen as the origin of radiographer preliminary image interpretation. The proposed system of work required radiographers to highlight abnormal trauma skeletal radiographs by placing a ‘red dot’ on the image, which indicated to the casualty officer the possible presence of significant pathology. This method has been shown to reduce diagnostic errors in the Emergency Department. In 2006, the Society and College of Radiographers, while recognising the benefits of the ‘red dot’ system of preliminary radiograph interpretation, also identified several weaknesses, which includes the ambiguity of an absence of a ‘red dot’. Preliminary clinical evaluation (PCE) builds on abnormality detection by radiographers, as PCE requires a concise written statement which localises and describes the pertinent findings. The provision of a written interpretation directs the treating clinician to the area(s) of concern and removes many of the ambiguity of the ‘red dot’ system, such as cases with multiple abnormalities, incorrect interpretation of abnormalities on an abnormal image and communication of uncertainty in the radiographer decision. A survey undertaken of UK radiology departments in 2008 found a significant majority provide a system of radiographer abnormality detection for skeletal trauma imaging; most still use the ‘red dot’, while some provide a PCE or a hybrid system. In parallel to this expansion of radiographer practice, the role of the advanced practitioner has been developed in the United Kingdom which incorporates the provision of definitive clinical reports by appropriately trained radiographers. The performance of radiographers in interpreting skeletal radiographs at the end of an accredited postgraduate training program was promising with high levels of sensitivity (91.6–96.7%) and specificity (92.1–94.0%) reported. A large multi-centre clinical evaluation, consisting of 7179 cases conducted across four sites in the United Kingdom, demonstrated very high levels of accuracy, sensitivity and specificity, 99.1%, 97.6% and 99.3%, respectively, for skeletal trauma reports produced by trained reporting radiographers. A subsequent meta-analysis conducted by Brealey et al. examined the performance of radiographer reporting for 28,900 plain imaging examinations and provided the definitive evidence that trained reporting radiographers can provide clinical reports on skeletal radiographs at a level comparable to consultant radiologists. Trained radiographers now provide definitive clinical reports on skeletal radiographs throughout the U.K., with 59 (41%) of 143 departments providing this service in 2012. In response to evolving service needs, radiographer reporting has expanded in scope beyond skeletal trauma. There is a growing body of evidence that supports trained radiographers who can provide definitive clinical reports for chest radiographs, magnetic resonance imaging (MRI) lumbar spine and knee examinations, and mammograms. Multidisciplinary team working, which incorporates radiographer reporting, has been highlighted in recent a

Chest X-ray Interpretation by Radiographers Is Not Inferior to Radiologists: A Multireader, Multicase Comparison Using JAFROC (Jack-knife Alternative Free-response Receiver Operating Characteristics) Analysis

RATIONALE AND OBJECTIVES Chest X-rays (CXR) are one of the most frequently requested imaging examinations and are fundamental to many patient pathways. The aim of this study was to investigate the diagnostic accuracy of CXR interpretation by reporting radiographers (technologists). METHODS A cohort of consultant radiologists (n = 10) and reporting radiographers (technologists; n = 11) interpreted a bank (n = 106) of adult CXRs that contained a range of pathologies. Jack-knife alternate free-response receiver operating characteristic (JAFROC) methodology was used to determine the performance of the observers (JAFROC v4.2). A noninferiority approach was used, with a predefined margin of clinical insignificance of 10% of average consultant radiologist diagnostic accuracy. RESULTS The diagnostic accuracy of the reporting radiographers (figure of merit = 0.828, 95% confidence interval 0.808-0.847) was noninferior to the consultant radiologists (figure of merit = 0.788, 95% confidence interval 0.766-0.811), P < .0001. CONCLUSIONS With appropriate postgraduate education, reporting radiographers are able to interpret CXRs at a level comparable to consultant radiologists.

Impact of radiographer immediate reporting of chest X-rays from general practice on the lung cancer pathway (radioX): study protocol for a randomised control trial.

BackgroundDiagnostic capacity and suboptimal logistics are consistently identified as barriers to timely diagnosis of cancer, especially lung cancer. Immediate chest X-ray (CXR) reporting for patients referred from general practice is advocated in the National Optimal Lung Cancer Pathway to improve time to diagnosis of lung cancer and to reduce inappropriate urgent respiratory medicine referral for suspected cancer (2WW) referrals. The aim of radioX is to examine the impact of immediate reporting by radiographers of CXRs requested by general practice (GP) on lung cancer patient pathways.MethodsA two-way comparative study that will compare the time to diagnosis of lung cancer for patients. Internal comparison will be made between those who receive an immediate radiographer report of a GP CXR compared to standard radiographer GP CXR reporting over a 12-month period. External comparison will be made with a similar, neighbouring hospital trust that does not have radiographer CXR reporting. Primary outcome is the effect on the speed of the lung cancer pathway (diagnosis of cancer or discharge). Secondary outcomes include the effect of the pathway on efficiency including the number of repeat CXRs performed in a timely fashion for suspected infection and the effect of immediate reporting of GP CXRs on patient satisfaction.DiscussionThe radioX trial will examine the hypothesis that immediate reporting of CXRs referred from GP reduces the time to diagnosis of lung cancer or discharge from the lung cancer pathway.Trial registrationInternational Standard Randomised Controlled Trial Number ISRCTN21818068. Registered on 20 June 2017.

Immediate reporting of chest X-rays referred from general practice by reporting radiographers: a single centre feasibility study

Aim To investigate the feasibility of radiographer-led immediate reporting of chest radiographs (CXRs) referred from general practice. Materials and methods This 4-month feasibility study (November 2016 to March 2017) was carried out in a single radiology department at an acute general hospital. Comparison was made between CXRs that received an immediate and routine report to determine the number of lung cancers diagnosed, time to diagnosis of lung cancer, time to computed tomography (CT), and number of urgent referrals to respiratory medicine. Results Forty of 186 sessions (22%) were covered by radiographer immediate reporting. Of the 1,687 CXRs referred from general practice, 558 (33.1%) received an immediate report (radiographer or radiologist). Twenty-two (of 36) CT examinations performed were following an abnormal CXR with an immediate report (mean 0.8 scans/week). Time from CXR to CT was shorter in the immediate report group (n=22 mean 0.9 days SD=2.3) compared to routine reporting (n=14; mean 6.5 SD=3.2; F=27.883, p<0.0001). Time to multidisciplinary team (MDT) discussion was shorter in the immediate reporting group (mean 4.1 SD=2.9) compared to routine reporting (mean 10.6; SD=4.5; F=11.59, p<0.0001). No apparent difference was found for time to discussion at treatment MDT. Conclusion It is feasible to introduce a radiographer-led immediate CXR reporting service. Patients can be taken off the lung cancer pathway sooner with the introduction of radiographer immediate reporting of CXRs and this may improve outcomes for patients. A definitive study assessing outcomes is required to determine whether this will have an impact mortality and morbidity for patients.

Digital training platform for interpreting radiographic images of the chest

INTRODUCTION Time delays and errors exist which lead to delays in patient care and misdiagnosis. Reporting clinicians follow guidance to form their own search strategy. However, little research has tested these training guides. With the use of eye tracking technology and expert input we developed a digital training platform to be used in chest image interpretation learning. METHODS Two sections of a digital training platform were planned and developed; A) a search strategy training tool to assist reporters during their interpretation of images, and B) an educational tool to communicate the search strategies of expert viewers to trainees by using eye tracking technology. RESULTS A digital training platform for use in chest image interpretation was created based on evidence within the literature, expert input and two search strategies previously used in clinical practice. Images and diagrams, aiding translation of the platform content, were incorporated where possible. The platform is structured to allow the chest image interpretation process to be clear, concise and methodical. CONCLUSION A search strategy was incorporated within the tool to investigate its use, with the possibility that it could be recommended as an evidence based approach for use by reporting clinicians. Eye tracking, a checklist and voice recordings have been combined to form a multi-dimensional learning tool, which has never been used in chest image interpretation learning before. The training platform for use in chest image interpretation learning has been designed, created and digitised. Future work will establish the efficacy of the developed approaches.

Increasing radiology capacity within the lung cancer pathway: centralised work-based support for trainee chest x-ray reporting radiographers

Diagnostic capacity and time to diagnosis are frequently identified as a barrier to improving cancer patient outcomes. Maximising the contribution of the medical imaging workforce, including reporting radiographers, is one way to improve service delivery.

Letter in response to 'The conceptual model of advanced practice does include research'

This letter refutes the suggestion made the authors of other letters to the Editor that the proposed model of the characteristics of advanced practitioners excludes research