Radiology subspecialisation in Africa: A review of the current status

Effect of teleradiology on patient waiting time and service satisfaction in public hospitals, Northwest Ethiopia: a quasi-experimental study

BACKGROUND

Limited access to onsite radiologists in Low- and Middle-Income Countries (LMICs) poses challenges for health facilities in delivering timely radiology services resulting in prolonged patient waiting times and dissatisfaction with the insufficient radiology services. In recent years, teleradiology has emerged as a potential solution to improve the timely diagnosis and treatment process. Therefore, this paper analysed the effect of a web-based teleradiology system that was developed and deployed to evaluate its effect on patient waiting time and service satisfaction in public hospitals of the Amhara Regional State.

METHODS

A pre-post study design was employed to evaluate the effect of a web-based teleradiology system on patient waiting time and service satisfaction. The study included a total of 836 participants, out of which 417 participated during the pre-intervention and 419 in the post-intervention periods. Data were collected from October 2021 to February 2022 and from May 2022 to January 2023 for the pre-and post-implementation periods, respectively. Supportive measures, including user guides, onsite training, and onsite/virtual assistance, were given during the teleradiology implementation period. The effects of the teleradiology on waiting time and service satisfaction were evaluated with the Mann-Whitney U-test and the Generalized Linear Model. Waiting time was measured as the duration between image consultation and report completion. Furthermore, satisfaction was assessed using a 31-item, 5-point Likert scale. The statistical analysis was done using Stata version 17 software.

RESULTS

After the implementation of the web-based teleradiology system, a significant decrease in the median waiting time was observed from 43.5 h (IQR: 22.88-71.63) to 4.62 h (IQR: 2.52-10.53) (p-value < 0.01). The effect size for this improvement was found to be 0.84. Furthermore, the median patient satisfaction score was significantly improved from 96 (IQR: 89-103) to 113 (IQR: 105-124) (p-value < 0.01) and an effect size of 0.65. Similarly, the percentage of the scale mean score (%SM) showed an increase in patient satisfaction levels from 52.6% (pre-implementation) [95% CI: 51.8-53.5] to 65.7% (post-implementation) [95% CI: 64.5 -66.9%]. The GLM analysis demonstrated a 71% decrease in patient waiting time and an 11% increase in radiography service satisfaction (p-value < 0.01).

CONCLUSION

Implementing the web-based teleradiology system improved the patient's waiting time and service satisfaction remarkably. The notable reduction in waiting time and the significant improvement in patient satisfaction scores highlighted the benefits of teleradiology in enhancing timely diagnosis and treatment. Deploying a web-based teleradiology system in public hospitals is recommended to enhance efficiency and improve patient satisfaction in radiology consultations.

TRIAL REGISTRATION NUMBER

PACTR202401789144564.

TRIAL REGISTRATION DATE

09 January 2024.

Development of an online authentic radiology viewing and reporting platform to test the skills of radiology trainees in Low- and Middle-Income Countries

BACKGROUND

Diagnostic radiology residents in low- and middle-income countries (LMICs) may have to provide significant contributions to the clinical workload before the completion of their residency training. Because of time constraints inherent to the delivery of acute care, some of the most clinically impactful diagnostic radiology errors arise from the use of Computed Tomography (CT) in the management of acutely ill patients. As a result, it is paramount to ensure that radiology trainees reach adequate skill levels prior to assuming independent on-call responsibilities. We partnered with the radiology residency program at the Aga Khan University Hospital in Nairobi (Kenya) to evaluate a novel cloud-based testing method that provides an authentic radiology viewing and interpretation environment. It is based on Lifetrack, a unique Google Chrome-based Picture Archiving and Communication System, that enables a complete viewing environment for any scan, and provides a novel report generation tool based on Active Templates which are a patented structured reporting method. We applied it to evaluate the skills of AKUHN trainees on entire CT scans representing the spectrum of acute non-trauma abdominal pathology encountered in a typical on-call setting. We aimed to demonstrate the feasibility of remotely testing the authentic practice of radiology and to show that important observations can be made from such a Lifetrack-based testing approach regarding the radiology skills of an individual practitioner or of a cohort of trainees.

METHODS

A total of 13 anonymized trainees with experience from 12 months to over 4 years took part in the study. Individually accessing the Lifetrack tool they were tested on 37 abdominal CT scans (including one normal scan) over six 2-hour sessions on consecutive days. All cases carried the same clinical history of acute abdominal pain. During each session the trainees accessed the corresponding Lifetrack test set using clinical workstations, reviewed the CT scans, and formulated an opinion for the acute diagnosis, any secondary pathology, and incidental findings on the scan. Their scan interpretations were composed using the Lifetrack report generation system based on active templates in which segments of text can be selected to assemble a detailed report. All reports generated by the trainees were scored on four different interpretive components: (a) acute diagnosis, (b) unrelated secondary diagnosis, (c) number of missed incidental findings, and (d) number of overcalls. A 3-score aggregate was defined from the first three interpretive elements. A cumulative score modified the 3-score aggregate for the negative effect of interpretive overcalls.

RESULTS

A total of 436 scan interpretations and scores were available from 13 trainees tested on 37 cases. The acute diagnosis score ranged from 0 to 1 with a mean of 0.68 ± 0.36 and median of 0.78 (IQR: 0.5-1), and there were 436 scores. An unrelated secondary diagnosis was present in 11 cases, resulting in 130 secondary diagnosis scores. The unrelated secondary diagnosis score ranged from 0 to 1, with mean score of 0.48 ± 0.46 and median of 0.5 (IQR: 0-1). There were 32 cases with incidental findings, yielding 390 scores for incidental findings. The number of missed incidental findings ranged from 0 to 5 with a median at 1 (IQR: 1-2). The incidental findings score ranged from 0 to 1 with a mean of 0.4 ± 0.38 and median of 0.33 (IQR: 0- 0.66). The number of overcalls ranged from 0 to 3 with a median at 0 (IQR: 0-1) and a mean of 0.36 ± 0.63. The 3-score aggregate ranged from 0 to 100 with a mean of 65.5 ± 32.5 and median of 77.3 (IQR: 45.0, 92.5). The cumulative score ranged from - 30 to 100 with a mean of 61.9 ± 35.5 and median of 71.4 (IQR: 37.4, 92.0). The mean acute diagnosis scores and SD by training period were 0.62 ± 0.03, 0.80 ± 0.05, 0.71 ± 0.05, 0.58 ± 0.07, and 0.66 ± 0.05 for trainees with ≤ 12 months, 12-24 months, 24-36 months, 36-48 months and > 48 months respectively. The mean acute diagnosis score of 12-24 months training was the only statistically significant greater score when compared to ≤ 12 months by the ANOVA with Tukey testing (p = 0.0002). We found a similar trend with distribution of 3-score aggregates and cumulative scores. There were no significant associations when the training period was categorized as less than and more than 2 years. We looked at the distribution of the 3-score aggregate versus the number of overcalls by trainee, and we found that the 3-score aggregate was inversely related to the number of overcalls. Heatmaps and raincloud plots provided an illustrative means to visualize the relative performance of trainees across cases.

CONCLUSION

We demonstrated the feasibility of remotely testing the authentic practice of radiology and showed that important observations can be made from our Lifetrack-based testing approach regarding radiology skills of an individual or a cohort. From observed weaknesses areas for targeted teaching can be implemented, and retesting could reveal their impact. This methodology can be customized to different LMIC environments and expanded to board certification examinations.

Global survey on point-of-care ultrasound (pocus) use in child surgery

PURPOSE

To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery.

METHODS

An electronic survey was disseminated via the GICS (Global Initiative of Children's Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery.

RESULTS

Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available.

CONCLUSIONS

Ultrasound is critically important in children's surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance.

A pilot program evaluating WhatsApp as an interactive educational tool for pediatric radiology in Eastern Africa

The widespread use of WhatsApp as a communication tool makes it a candidate platform to facilitate the delivery of educational materials to radiology trainees in Eastern Africa. The aim of this pilot program is to assess the novel approach of using WhatsApp as a learning tool in pediatric radiology for residents in Kenya, Rwanda, Tanzania and Uganda. We recruited radiology residents to participate in a 3-month case-based pediatric radiology learning module that was delivered through WhatsApp to personal cell phones. Residents were presented with a multiple choice question once a week. Once they submitted their answer, the correct answer and explanations for each choice were provided. Questionnaires investigated comfort with reading pediatric radiology imaging, perception of the module content and convenience of the approach. Of the 72  participants, 40 (56%) responded to all 12 questions and both questionnaires, of whom 22 (55%) reported little to no comfort before the module and feeling very comfortable after. Confidence decreased with the number of incorrect answers. There was no correlation between the number of correct answers and the year level of the resident. Participants reported that the module was useful for learning pediatric radiology, found the material moderately difficult and found the application convenient for learning. Pediatric radiology educational content delivered over WhatsApp to residents in Eastern Africa is perceived as beneficial and convenient. This interactive learning platform provides opportunities for mentorship and enhanced learning of pediatric radiology.

Exploring the perceptions of radiographers pertaining to the provision of quality radiological services in Zimbabwe

INTRODUCTION

Radiology is part of the service industry; therefore, there is a need to understand quality and its associated factors. The cost of poor service quality is a loss of competitive advantage, increased litigation, misdiagnosis, unnecessary radiation exposure, and patient mortality. There has been little research into the factors influencing the quality of radiological services in Zimbabwe. This work, therefore, aimed to explore the radiographer's perceptions of the factors that affect the quality of radiological services at central hospitals in the Harare Metropolitan Province.

METHODS

A qualitative, explorative study applying the SERVQUAL model was carried out. One-on-one interviews with 10 purposively sampled radiographers employed at central hospitals in the Harare Metropolitan Province were conducted. The data were managed by Nvivo 12 (QSR International) and analyzed by framework analysis.

RESULTS

Radiographer's perceptions of the factors that affect the quality of radiological services were categorized by five themes namely; i. Tangibles - the physical appearance of the radiology department and facilities, ii. Reliability and dependability - the ability to perform the promised service dependably and accurately, iii. Responsiveness - the willingness to help patients and provide prompt service, iv. Assurance - the knowledge and courtesy of radiology staff and their ability to inspire trust and confidence, and v. Empathy - caring, the individualized attention the radiology department provides to its patients.

CONCLUSION

Economically viable, well-designed national strategies are needed to prioritize and fund radiology in Zimbabwe and other resource-constrained settings. Recognition of acquired specialist skills by radiographers to halt the exodus and training of radiologists, radiology nurses, medical physicists, and biomedical engineers by local institutions will go a long way in improving the quality of radiological services.

How does the model make predictions? A systematic literature review on the explainability power of machine learning in healthcare

BACKGROUND

Medical use cases for machine learning (ML) are growing exponentially. The first hospitals are already using ML systems as decision support systems in their daily routine. At the same time, most ML systems are still opaque and it is not clear how these systems arrive at their predictions.

METHODS

In this paper, we provide a brief overview of the taxonomy of explainability methods and review popular methods. In addition, we conduct a systematic literature search on PubMed to investigate which explainable artificial intelligence (XAI) methods are used in 450 specific medical supervised ML use cases, how the use of XAI methods has emerged recently, and how the precision of describing ML pipelines has evolved over the past 20 years.

RESULTS

A large fraction of publications with ML use cases do not use XAI methods at all to explain ML predictions. However, when XAI methods are used, open-source and model-agnostic explanation methods are more commonly used, with SHapley Additive exPlanations (SHAP) and Gradient Class Activation Mapping (Grad-CAM) for tabular and image data leading the way. ML pipelines have been described in increasing detail and uniformity in recent years. However, the willingness to share data and code has stagnated at about one-quarter.

CONCLUSIONS

XAI methods are mainly used when their application requires little effort. The homogenization of reports in ML use cases facilitates the comparability of work and should be advanced in the coming years. Experts who can mediate between the worlds of informatics and medicine will become more and more in demand when using ML systems due to the high complexity of the domain.

CT without borders: Comparison of diagnoses for abdominal pain from a teaching hospital in rural Kenya and a US academic medical center

PURPOSE

Radiology global health opportunities are expanding as more hospitals in low- and middle-income countries utilize CT. This creates opportunities for global health program building, education, service, and research. This study determines the diagnostic yield and variety of abdominopelvic CT diagnoses for abdominal pain in a US academic medical center (UW) compared to a rural Kenyan teaching hospital (Tenwek).

METHODS

A retrospective, cross-sectional sequential sample of 750 adults from both hospitals who underwent abdominopelvic CT for abdominal pain from February 2019 through July 2020 was obtained. Exclusion criteria were trauma, cancer staging, and recent hospitalization or surgery. Patient age, sex, comparison studies, use of contrast, known cancer diagnosis, and CT diagnoses were compared. Negative exam rate, acute abdomen diagnosis, and new cancer diagnosis were recorded. Statistical analysis was performed using R.

RESULTS

750 UW patients met inclusion criteria (mean age 53.3 ± 20 years; 442 women) and 750 Tenwek patients met inclusion criteria (mean age 52.5 ± 18 years; 394 women). 72% of UW patients had comparison imaging compared to 6% of Tenwek patients. 11% (83/750) of UW patients had a known cancer diagnosis compared to 1% (10/750) of Tenwek patients. 39% of UW patients had a negative exam compared to 23% of Tenwek patients (p < 0.001). 58% of UW patients had an acute abdomen diagnosis compared to 38% of Tenwek patients (p < 0.001). 10 of the 15 top acute abdomen diagnoses were shared, but in different order of frequency. Diagnoses unique to UW were diverticulitis, constipation, stercoral colitis, and epiploic appendagitis. Diagnoses unique to Tenwek were tuberculosis and hydatidosis. 3% of UW patients received a new cancer diagnosis (7/19 metastatic), compared to 40% of Tenwek patients (153/303 metastatic) (p < 0.001).

CONCLUSION

For adults undergoing CT for abdominal pain, there are differences in the prevalence of abdominal pain diagnoses, new cancer diagnosis, and negative exam rate between the rural Kenyan teaching hospital and the US academic medical center.

Factors Influencing the Choice of Radiology Subspecialty Among Radiology Trainees in Sudan

Background and objective There are numerous reasons why radiologists would be interested in seeking additional fellowship training, some of which are personal, such as the possibility of bettering their career prospects, while others are work-related. This study aimed to identify whether the Sudanese radiology trainees wanted to pursue fellowship and what were the motivating and restricting factors affecting their career choices. Methods This was a re-do research of a study from Saudi Arabia previously published in the Cureus journal in 2019. This was a descriptive cross-sectional study conducted among the radiology registrars training under Sudan Medical Specialization Board (SMSB) in 2022 (n=90). By using convenient sampling, 74 of the 90 registrars were contacted, and a response rate of 81% (n=60) was achieved. Data were collected using a pre-tested self-administered online questionnaire. Data were analyzed using IBM SPSS® Statistics version 25.0 (IBM Corp., Armonk, NY). A p-value ≤0.05 was considered statistically significant. Results The majority of the trainees in our study were females (61.7%, 37/60). More than 93% (n=56) of our participants were training in Khartoum, the capital of Sudan. The most commonly chosen subspecialties in our study were as follows: neuroradiology (33.3%, n=20) body imaging (26.7%, n=16), and interventional radiology (25%, n=15). In contrast, nuclear medicine (1.7%, n=1) and emergency radiology (3.3%, n=2) were among the least popular subspecialties. The top influencing factors among our trainees in choosing a subspecialty included "strong personal interest," "lifestyle," and "area of strong personal knowledge." The most common factors preventing trainees from opting for a fellowship were "financial restriction" (55%, n=33) and "family obligation" (28.3%, n=17). Of those with no plans to subspecialize, 75% (six out of eight) stated that the lack of a fellowship program in Sudan is a possible deterrent. A statistically significant association was found between gender and the choice of subspecialty in interventional radiology and women's/mammogram imaging. Our findings revealed that there are currently no trainees in the first year of radiology residency because the last selection exam had been conducted in 2019. Despite the current unavailability of subspecialty training in Sudan, 75% (n=45) of trainees in our study were interested in joining a local program for fellowship training in the future. Conclusion Radiology trainees in Sudan share similar interests and influencing and restricting factors when pursuing subspecialty training, as reported in the literature. Unlike other countries, females predominate in the field of radiology training in Sudan at the moment. Radiologists from Sudan who are interested in subspecializing usually travel abroad for training; and once they find better prospects, many of them may not return. Programs offering subspecialization locally could mitigate the attrition of radiologists in Sudan. When designing subspecialty training programs in Sudan, stakeholders should use knowledge of influential factors and understanding of subspecialty decision trends among radiology trainees as a reference point. To the best of our knowledge, this study is the first of its kind to be conducted in this field in Sudan.

To err is human; acute appendicitis a mistaken clinical identity for metastatic follicular thyroid carcinoma, a case report

INTRODUCTION AND IMPORTANCE

Thyroid cancer accounts for majority of endocrine cancers with follicular thyroid cancer the second most common. It tends to spread via hematogenous route with distant metastasis thus besides presenting as a neck mass it may also present with symptoms tallying to regions of metastasis which may misguide the diagnosis. We report a case of a 50-year-old man who presented with features of appendicitis only to discover metastatic right iliac bone follicular thyroid cancer. We describe our experience on diagnostic formulation, radiological work up, surgery, radioactive iodine therapy and follow up.

CASE PRESENTATION

50-year-old man presenting with acute abdomen and fevers with suspicion for appendicitis, worked up and found to have metastatic follicular carcinoma. Underwent total thyroidectomy and radioactive iodine therapy to achieve disease stability without progression with a 5 year follow up completed.

CLINICAL DISCUSSION

The tendency to jump to medical imaging to establish a diagnosis in a lab oriented rather than clinical oriented approach. The role of radiology to establish the underlying disease and identify the primary lesion. Successfully halting disease progression for metastatic follicular thyroid carcinoma with surgery and radioactive iodine therapy.

CONCLUSION

Right iliac fossa tenderness does not always equate to acute appendicitis hence the use of diagnostic imaging to diagnose the metastatic lesion thus simplifying the puzzle to identify the primary. We hope through sharing our experience, we encourage the use of interventional radiology in a region that tends to opt for open approach when percutaneous approaches have shown to be successful.