Medical Imaging

Medical Imaging
Medical
Imaging
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Contents of this publication may be reproduced in whole or in part provided the
intended use is for non-commercial purposes and full acknowledgement is given
to the Canadian Institute for Health Information.
Canadian Institute for Health Information
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© 2003 Canadian Institute for Health Information
Cette publication est aussi disponible en français sous le titre :
L’imagerie médicale au Canada, 2003 ISBN 1-55392-268-9
About the Canadian
Institute for Health Information
As of July 2003, the following individuals are on CIHI’s Board of Directors:
• Mr. Michael Decter (Chair), Lawrence Decter Investment Counsel Inc.
• Mr. Tom Closson (Vice-Chair), President and Chief Executive Officer,
University Health Network
• Mr. Richard Alvarez (Ex-officio), President and Chief Executive Officer, CIHI
• Dr. Penny Ballem, Deputy Minister, British Columbia Ministries of Health
Planning and Health Services
• Dr. Laurent Boisvert, Director of Clinical-Administrative Affairs,
Association des hôpitaux du Québec
• Dr. Ivan Fellegi, Chief Statistician of Canada, Statistics Canada
• Mr. Rory Francis, Deputy Minister, Prince Edward Island Ministry of Health
and Social Sevices
• Mr. Ian Green, Deputy Minister of Health, Health Canada
• Dr. Michael Guerriere, Managing Partner, Courtyard Group Limited
• Mr. Phil Hassen, Deputy Minister, Ontario Ministry of Health and
Long-Term Care
• Mr. David Levine (observer status), President and Director-General,
Régie régionale de la santé et des services sociaux de Montréal-Centre
• Dr. Cameron Mustard, President and Scientific Director,
Institute for Work & Health
• Dr. Brian Postl, Chief Executive Officer, Winnipeg Regional Health Authority
• Mr. Rick Roger, Chief Executive Officer, Vancouver Island Health Authority
• Dr. Thomas F. Ward, Deputy Minister, Nova Scotia Department of Health
• Ms. Sheila Weatherill, President and Chief Executive Officer,
Capital Health Authority, Edmonton
About the Canadian Institute for Health Information
Since 1994, the Canadian Institute for Health Information (CIHI), a pan-Canadian,
independent, not-for profit organization, has been working to improve the health of
the health system and the health of Canadians by providing reliable and timely health
information. The Institute’s mandate, as established by Canada’s health ministers, is to
develop and maintain a common approach for health information in this country. To this
end, CIHI provides information to advance Canada’s health policies, improve the health
of the population, strengthen our health system, and assist leaders in the health sector
to make informed decisions.
Acknowledgments
The Canadian Institute for Health Information wishes to acknowledge and thank the
many individuals and organizations that contributed to the development of this report.
• Mr. Steven Lewis (Chair), President, Access Consulting Ltd., Saskatoon; Centre for
Health and Policy Studies, University of Calgary
• Dr. Nabil R. Bechai, Director and Chief, Department of Medical Imaging, Grand
River Hospital, Kitchener, Ontario; President, North York Diagnostic Imaging Inc.;
President, Quality Medical Imaging Inc.
• Dr. Patrice Bret, Radiologist-in-Chief, Joint Department of Medical Imaging,
Mount Sinai Hospital and University Health Network
• Mr. Bill Brodie, Manager, Medical Imaging, Montreal General Hospital, McGill
University Health Centre
• Dr. David Elliott, Medical Advisor, Policy Planning and Legislation Branch,
Nova Scotia Department of Health; Adjunct Professor, Community Health and
Epidemiology, Dalhousie University
• Dr. Vicki Foerster, Director, Health Technology Assessment Directorate,
Canadian Coordinating Office for Health Technology Assessment (CCOHTA)
• Mr. Todd Herron, Assistant Deputy Minister/CIO, Health Accountability, Alberta
Health and Wellness
• Ms. Elaine Kilby, Manager, Diagnostic Imaging Department, British Columbia
Cancer Agency–Vancouver Centre
• Mr. Normand Laberge, CEO, Canadian Association of Radiologists
• Dr. Andreas Laupacis, President and CEO, Institute for Clinical Evaluative
Sciences; Professor, Departments of Medicine and Health Policy, Management
and Evaluation, University of Toronto
• Ms. Diane Lugsdin, Manager, Acute Care and Technology, Health Care Policy
Directorate, Health Canada
• Mr. Ronald J. Wood, President and CEO, ProMed Associates Ltd.
• Ms. Jennifer Zelmer (Ex-officio), Vice President, Research and Analysis, CIHI
It should be noted that the analyses and conclusions in this report do not necessarily
reflect those of the individual members of the Expert Group or the organizations with
which they are affiliated.
Acknowledgments
We would particularly like to express our thanks to members of the Expert Group who
provided invaluable advice throughout the development process, including reviewing a
draft of the report. Members included:
Medical Imaging in Canada
The editorial committee were Jennifer Zelmer, Kira Leeb, Jeanie Lacroix, Steven Lewis, and
Patricia Finlay. Other members of the core report team include Sharon Gushue,
Joe Lai, Tina LeMay, Juliann Ju Yang, and Peter Driezen. Other contributing members include:
Lindsay Arscott, Geoff Ballinger, Jack Bingham, Brent Barber, Sue Beardall, Gary Bellamy,
Steve Buick, Zeerak Chaudhary, Nadia Ciampa, Bob Côté, Lorry Deng, Junell D’Souza, Lynne
Duncan, Gilles Fortin, Paula Freedman, Luisa Frescura, Glenda Gagnon, Lise Gagnon, Anyk
Glussich, Cheryl Gula, Leona Hollingsworth, Karen Holmes, Sandra Kopmann, Robert Kyte,
Anne Lauzon, Anick Losier, Cindy Major, Caroline Morrissette, Louise Ogilvie, Bruce Petrie,
Cyril Pires, Lise Poirier, Marie Pratte, Francine Anne Roy, Vanita Sahni, Steve Slade, Elizabeth
St. Aubin, Jill Strachan, Serge Taillon, Marie-Josée Tassé, Tammie Turner, Chrissy Willemse,
Scott Young, and Greg Zinck.
CIHI would also like to thank members of ProMed and Associates Consultants (particularly
Brian Lentle and Ronald Wood) and Peggy Edwards of Alder Group Consulting for their
contributions to Chapter 1, Medical Imaging Technologies: The Past, Present, and Future.
We would also like to thank Statistics Canada (particularly Lorna Bailie, Collette Khun,
Mario Bédard, and Ingrid Ledrou) for providing access to data for this report and the
Canadian Coordinating Office for Health Technology Assessment (especially Jill Sanders and
Vicki Foerster) for providing guidance and understanding of the historical data collected in
previous surveys and the survey instrument. We would also like to thank several groups for
their participation in the data collection phase for this report. Specifically, Promed and CIHI
staff were involved in updating the survey instrument (National Survey of Selected Imaging
Technologies) and administering it. A number of organizations including the Canadian Association
of Radiologists (CAR), Association des radiologistes du Québec (ARQ), Canadian Association
of Nuclear Medicine (CANM), General Electric (GE), Seimens, Kodak, and Toshiba assisted
with the survey process. The Federal/Provincial/Territorial Advisory Group on Information
and Emerging Technologies provided support in obtaining and validating aspects of the data
contained in the report.
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This report could not have been completed without the generous support and assistance of
many other individuals and organizations—including the many hospitals and other facilities
who completed the survey about medical imaging technology in Canada and the federal,
provincial, and territorial Ministries of Health—who compiled data, undertook research
discussed in the report, and/or provided financial support.
Highlights
The Services
• Many different kinds of imaging are used in clinical practice today, from new
equipment that is still in development to well-established technologies. Each has its
strengths and weaknesses, although capabilities sometimes overlap. Common tests
account for the bulk of operating expenditures on diagnostic imaging. For instance,
X-ray and ultrasound services accounted for more than half (56%) of total spending
on diagnostic imaging by Ontario hospitals in 2000–2001.
• In Canada and elsewhere, the use of several types of medical imaging has increased
in the last decade. In 2001, about 7% of Canadians aged 15 or older—about the
same proportion as were hospitalized overnight—reported having a non-emergency
CT, MRI, or angiography in the past 12 months. In total, over 787,000 had a CT;
647,000 an MRI; and 220,400 an angiography.
• Some types of imaging are even more common. For example, 70% of Canadian
women aged 50 to 69 reported having had a mammogram in the last two years in
2000-2001, up from 61% in 1996–1997.
• Like many technologies, the value of medical imaging depends on how it is used and
its ability to improve the lives of patients and/or the practice of health care. In areas
where evidence-based clinical practice guidelines exist, Canadian and international
researchers have documented both underuse and overuse of medical imaging
relative to the guidelines. Several recent federal and provincial reports on health care
have called for action to address access to diagnostic services and to better
understand the appropriate use of these technologies, now and in the future.
• A variety of public and private sources fund medical imaging services in Canada.
Most funding comes through provincial/territorial governments, but the mix varies by
technology and by jurisdiction. A 2003 survey found that provincial/territorial
governments were the primary source of operating funds for 98% of hospital-based
angiography suites; MRI, CT, and PET scanners; catheterization labs; and nuclear
medicine cameras. They were also the main funder for about one-third of the
machines housed in free-standing imaging facilities. Equipment in both settings may
also have a variety of secondary sources of funding.
• Total spending on medical imaging in Canada has risen in recent years. For example,
hospitals in British Columbia, Alberta, Ontario, and New Brunswick collectively spent
about $1.3 billion on diagnostic imaging services in 2000, up 44% from 1996.
Highlights
What We Know
Medical Imaging in Canada
• Waiting for care remains an important issue for Canadians. For example, respondents to a
November 2002 poll said that reducing wait times for diagnostic services, such as MRI and
CT scans, should be the number one priority for new health care spending. Over half (55%)
of Canadians aged 15 and over who had a non-emergency MRI, CT, or angiography in 2001
said that they waited less than a month for their test, but the 5% with the longest waits waited
26 weeks or more*. Sixteen percent of test recipients said that waiting affected their lives.
Worry, anxiety, and stress were the most frequently reported effects.
What We Don’t Know
• How many Canadians receive different types of medical imaging services each year? To what
extent does the current use pattern of medical imaging match with evidence-based best
practice? What combination of tests and rates of service would best meet the health care
needs of different patient groups and communities?
• How much is spent, in total, on medical imaging services? How do services provided by
free-standing and hospital-based imaging facilities differ? How do levels of public and private
spending on imaging affect access, patient and provider satisfaction, patient outcomes, and
overall health care costs?
• How do medical imaging services affect patient care, outcomes, and costs in particular
circumstances compared to other types of imaging or to assessing/managing patients’
conditions without imaging technology? What are the relative costs and benefits of using
various types of imaging?
The Technologies
What We Know
• All provinces now have nuclear medicine cameras, angiography suites, CT scanners,
and MRI machines, as well as other imaging technologies, such as X-ray and ultrasound
services. Numbers of some imaging machines are increasing. For instance, between 1997
and 2003, the total number of MRI machines in Canada (including those in hospitals and
free-standing imaging facilities) grew by 167%. The number of CTs grew by a third (33%)
over the same period.
• The supply of medical imaging equipment varies across Canada. For example, as of January
2003, Ontario had the most CT scanners (95) in the country, but the fewest machines per
million population (7.8). In contrast, the Yukon Territory’s one CT gave it the highest number
per capita (33.5). Variations also exist internationally. For instance, the per capita ratio of CT
machines for Japan (data for 1999) was triple that of Korea (2001), the country with the next
highest ratio; almost 9 times that of Canada (2001); and fifteen times that of England (2001).
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• Nationally and internationally, data show that regions with more machines per person do not
necessarily have higher scan rates. The supply of machines needs to be considered in the
context of many other factors, including how imaging machines are used to provide care,
their hours of operation and staffing, and the mix of other imaging services available.
*
Interpret with caution due to high sampling variability.
Highlights
• The extent to which imaging services are available outside of hospitals varies by imaging
modality. For example, free-standing facilities in some parts of the country have provided
X-ray and ultrasound services for many years. In some cases, the number of machines in
free-standing imaging facilities is growing. As of January 2003, 9 CTs (about 3% of the total)
and 27 MRIs (18%) were in this type of facility, up from an estimated 7 (about 2%) and 20
(15%) machines respectively in July 2001. In 2001, 98% of Canadians aged 15 and over who
had a non-emergency angiography in the past year said that they received their test in a
hospital or public clinic. That compares to 96% for CT scans and 92% for MRIs.
What We Don’t Know
• What number and mix of imaging technologies at regional, provincial, and national levels
would best meet current and future health care needs?
• At what point do imaging technologies require upgrading or replacement based on patient
safety, quality of care, cost-effectiveness, cost implications, and/or other considerations?
Based on this assessment, what proportion of today’s machines will require significant capital
investment in the next 1, 2, 5, 10 years, and beyond?
• How much in total is spent to purchase various types of medical imaging equipment? How
does the public/private funding mix for capital and operating costs differ among technologies
and across the country? Do these differences affect the mix of imaging services that
Canadians receive, their access to care, overall spending, and the cost-effectiveness of
imaging services?
The People
What We Know
• A diverse mix of health professionals is involved in medical imaging. For instance, there were
over 14,700 medical radiation technologists (MRTs), 2,500 sonographers, 1,900 diagnostic
radiology physicians, and 200 nuclear medicine physicians across Canada in 2001.
• Each profession tends to specialize in certain areas, although skills and roles are evolving
over time and sometimes overlap. For instance, as imaging technologies progress and new
applications are developed, radiologists are taking on a wider range of services (e.g.
interventional radiology). At the same time, other physicians sometimes perform services also
provided by radiologists. The roles of radiology technologists are also evolving. Just as there
is no agreed national or international standard for how many MRI or CT machines we should
have, deciding on the best number and mix of medical imaging professionals to serve a
particular community is challenging.
• As baby boomers move towards retirement, the average age of Canadians is rising. That
trend also holds for health professionals in general and imaging professionals in particular.
For example, the average age of MRTs increased from 34 years in 1991 to 40 years in 2001.
As well, the proportion of younger MRTs (under the age of 35) in the workforce is decreasing,
from 47% in 1991 to 31% in 2001.
• The level of education required to work in medical imaging varies from profession to
profession and has changed over time. For example, sonographers have traditionally taken
one-year post-diploma programs, but some institutions now offer three-year entry-level
diploma programs and four-year degree programs.
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Medical Imaging in Canada
x
What We Don’t Know
• How many and what mix of health professionals will be required in the future to meet the
medical imaging needs of Canadians regionally, provincially, and nationally? How will
changes to training requirements, scope of practice, and regulatory status for imaging
professionals affect their supply, access to care, and patient and provider satisfaction?
• What impact will recently announced plans for spending on medical equipment have on
training opportunities for imaging professionals and on the demand for their services?
• How will teleradiology and other digital imaging technologies affect the traditional dynamics of
the medical imaging team, productivity, access to care, and patient satisfaction and outcomes?
Table of Contents
About This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1
Chapter 1: Medical Imaging Technologies: The Past, Present and Future . . . . . . . . . . . . . . . 5
From the Beginning: X-rays and Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Radiography Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
A Different Approach: Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Harnessing Computer Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Positron Emission Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Single-Photon Emission Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2
Chapter 2: Medical Imaging in Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Mammography: Looking for Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Coronary Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CT Scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
MRI Scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
PET Scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Cost of Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Where the Money Comes From . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Where the Dollars Go . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3
Chapter 3: Imaging Technologies—Supply and Capital Costs . . . . . . . . . . . . . . . . . . . . . . . 29
How Many Are There? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
The Supply of Imaging Technologies in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
The International Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Where Imaging Technologies are Located . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Aging and Renewal of Medical Imaging Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Buying and Replacing Equipment: Capital Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Where The Money Comes From . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Table of Contents
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Medical Imaging in Canada
4
Chapter 4: Medical Imaging Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Who’s Who in Medical Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Medical Radiation Technologists (MRTs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Sonographers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Physician Specialists/Consultants in Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Medical Physicists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Trends in Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Age and Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
The Male/Female Mix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Learning to Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Regulating and Certifying Imaging Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Life at Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5
Chapter 5: Current Issues in Medical Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
The Right Tool for the Right Job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Effects on Care, Outcomes, and Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Complementary or Competing Technologies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Changing Roles and Evolving Scopes of Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
The Many Ways of Delivering Imaging Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Waiting for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6
Chapter 6: Medical Imaging in Canada: An Incomplete Picture . . . . . . . . . . . . . . . . . . . . . . 69
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
A: Fast Facts
B: Glossary of Terms
Index
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It’s Your Turn
About This Report
Timely access to medical imaging technologies has become a key area of concern for
Canadians. Respondents to a November 2002 Ipsos-Reid poll said that reducing wait
times for diagnostic services such as MRI and CT scans should be the priority for new
health care spending.* Within the last few years, two federal and several provincial
health commission report reviews have also stressed that the availability of appropriate
medical imaging services is of major importance.
Nevertheless, little is known about the actual use of these technologies in Canada.
This report aims to start to fill this gap. It is meant to serve as a consolidated reference
of what we know and don’t know about medical imaging across Canada, helping to
inform decisions as we move forward. We look in particular at the historical
development of imaging technologies; the numbers of different kinds of machines in
Canada and how they are used; and the skilled health professionals who operate the
equipment and interpret results. In general, we tend to focus on a selection of more
recent imaging technologies where the information base is strongest. Many of the
issues that we highlight, however, apply across the spectrum of imaging technologies.
The report is divided into six chapters:
Chapter 1: Medical Imaging Technologies: The Past, Present, and Future provides
a brief history of the development of medical imaging technologies and describes
selected types of technologies and their applications.
Chapter 2: Medical Imaging in Practice provides an overview of the available
information on the use of imaging technologies in Canada today. Included in
this chapter is information about scan rates and the costs of using these technologies.
*
Mickleburgh R. (November 25, 2002). Faster Care Tops Wish List in Health Care Poll. News Release. www.globeandmail.com.
About This Report
In the past century, we have witnessed dramatic technological changes in the field of
medicine, including in medical imaging. For example, X-rays were just starting to be used
for medical purposes in the late 1890s. Today, radiologists can read X-rays and other
diagnostic images produced thousands of miles away in a matter of minutes. Surgeries
that once required several days of hospitalization are now being performed on an outpatient basis. And more sophisticated forms of medical imaging—such as the ability to
generate functional images of almost any structure within the body—are becoming
essential to the provision of general and specialized medical care and treatment.
Medical Imaging in Canada
Chapter 3: Imaging Technologies—Supply and Capital Costs provides an overview
of the available information on supply of imaging equipment and where in the
country machines are located. It also provides information on factors affecting how
much imaging technology we have, including the capital costs associated with purchasing
these technologies.
Chapter 4: Medical Imaging Professionals profiles the women and men who make imaging
services possible. This chapter includes information about the training, availability, and worklife
of these medical professionals.
Chapter 5: Current Issues in Medical Imaging touches on some of the major issues related
to how medical imaging technologies are used. It addresses topics such as our current
understanding of when to use different technologies, how effective they are, and factors
that affect Canadians’ access to imaging services.
Chapter 6: Medical Imaging in Canada: An Incomplete Picture concludes the report with
a discussion about the existing gaps of information surrounding these topics.
Where possible, the report includes national and international comparisons. It also includes
a Fast Facts section. Fast Facts provides an expanded range of comparative data on medical
imaging technologies across the country. Whenever the icon to the right appears beside
the text, it indicates that related data can be found in the Fast Facts section at the back of
the report.
FF
What’s New in This Report
Medical Imaging in Canada draws on new data and analysis from CIHI, as well as research produced at provincial,
national, and international levels to explore what we know and don’t know about medical imaging in Canada. Examples
of the kinds of new information contained in this report are listed below.
2
• The number, age, and distribution of selected medical imaging technologies located
in hospitals and free-standing imaging facilities across Canada in 2003 and how
these characteristics have changed over time.
• How MRIs, CTs, and other selected imaging services are funded.
• How many people have non-emergency MRI, CT, and angiography tests, the reason
for their tests, and how scan rates in selected jurisdictions are changing.
• How selected imaging technologies are being used in various settings.
• The proportion of hospital spending on medical imaging services in selected provinces.
• The latest information on the age and distribution of medical imaging professionals in Canada.
Highlights and the full text of Medical Imaging in Canada are available free of charge in both
official languages on the CIHI Web site at www.cihi.ca. To order additional print copies of the
report (a nominal charge applies to cover printing, shipping, and handling costs), please contact:
About This Report
For More Information
Canadian Institute for Health Information Order Desk
377 Dalhousie Street, Suite 200
Ottawa, Ontario K1N 9N8
Tel: (613) 241-7860
Fax: (613) 241-8120
We welcome comments and
suggestions about this report
and about how to make future
reports more useful and informative.
For your convenience a feedback
sheet, It’s Your Turn, is provided
at the end of this report. You can
also email your comments to
[email protected]
There’s More on the Web!
The print version of this report is only part of what you can
find at our Web site (www.cihi.ca). On the day that Medical
Imaging in Canada is released and in the weeks and months
following, we will be adding much more information to what
is already available electronically. For example, it will be
possible to:
• Download free copies of the report in English or French.
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report’s contents.
• Sign up to receive regular updates via email.
• Look at CIHI’s annual reports; other special reports, such
as Canada’s Health Care Providers; and the regular series
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resources, health services, and population health.
• Learn about upcoming reports, including Improving the
Health of Canadians (check out the Canadian Population
Health Initiative at our Web address), and other special
reports on topics such as maternal and infant health and
health care.
3
Medical Imaging Technologies:
The Past, Present, and Future
Lending a Hand
1 From the Beginning: X-rays
The first human radiograph
(of Frau Roentgen’s hand).
Source: Images courtesy of Dr. D. Worseley, UBC and VHHSC
and Nuclear Medicine
On November 8, 1895, Wilhelm Conrad Roentgen
was experimenting with a cathode-ray tube in a dark
laboratory when he noticed a nearby screen begin to
glow. He realized that the glow could only have been
produced by more penetrating radiation than cathode
rays.1–5 By December, he released a preliminary
report, accompanied by experimental radiographs
and the first X-ray image—of his wife’s hand.
In February 1896, a Montreal physician used X-rays
to make a diagnosis for the first time in Canada. A
young man had been shot in a brawl on Christmas
Eve and several surgical explorations had failed to
find the bullet. After a radiograph showed the bullet
lodged between the tibia and fibula, it was
successfully removed.6,7 The film was subsequently
used in court, perhaps the first use of radiography
in jurisprudence.6
DID YOU KNOW?
Within weeks of Roentgen’s announcement, newspapers,
magazines, and professional journals around the world
were providing explanations of the mysterious rays, along
with detailed instructions on their production and use.
News of the X-ray caused a public fervour, including fears
about its use. In London, a firm began selling X-ray-proof
underwear. In New York state, officials tried to pass
legislation banning the use of X-rays in opera glasses.8
Radiology continued to progress rapidly
throughout the century. For example, Pierre
and Marie Curie made numerous discoveries,
including isolating radium, and became double
Nobel laureates. Their daughter, Irene Curie,
and her husband Frederick Joliot went on to
discover artificial radioactivity and to gain
Nobel prizes. Another laureate, Ernest (later
Lord) Rutherford, working at McGill University,
discovered alpha and beta particles and
1 Medical Imaging Technologies: The Past, Present, and Future
1
Just as microwaves have changed the way that we cook and telephones the way that
we communicate, medical imaging has changed the practice of medicine. From their
origins just over a century ago, a wide range of technologies can now be found in
clinicians’ toolboxes and more are being developed. Each has its strengths and
weaknesses, although capabilities often overlap. A variety of factors may be considered
when deciding which tool is best in a particular situation (for further details, see
Chapter 5). This Chapter provides a brief overview of the development and application
of some of the major imaging technologies, as well as glimpses into the future.
Medical Imaging in Canada
advanced our understanding of atomic structure as mostly space with tiny units of mass-energy in
the nucleus and orbiting electrons.
The use of orally administered pharmaceutical contrast agents in the early 1900s allowed
physicians to examine the alimentary tract for the first time. After much experimentation, an
intravenous contrast agent was developed. These discoveries and others—such as Georg Von
Hevesy’s tracer principle which is fundamental to the use of radionuclides in medicine—facilitated
the emergence of another clinical specialty after the Second World War: nuclear medicine.9
In 1946, a landmark event in the development of nuclear medicine took place—a patient suffering
from cancer of the thyroid was treated with radioactive iodine. The treatment prevented the
spread of the patient’s cancer.10 Subsequently, radioactive iodine was used to measure both the
function of the thyroid and to diagnose thyroid disease.
2
Milestones in Radiology
Since the discovery of radiology technology in the late 1800s, there have been numerous developments both in
Canada and in the world. A selection of events is shown below.
World Events
Year
Professor Roentgen discovers X-rays
1895
Canadian Events
1896
First clinical radiograph in Canada
Alexander Graham Bell experiments with X-rays in Baddeck, Nova Scotia
First tracer work by Georg Von Hevesy
1911
Ernest Rutherford determines nuclear structure of atoms
First X-ray film (cellulose nitrate base)
1913
Coolidge tube discovered
Walter Dandy develops pneumo-encephalography
1918
Egas Moniz performs first angiography
1927
Catheterization done for first time by Forssmann in Germany
1929
The first usable contrast media
1930
1937
Tc-99m discovered
1942
Nuclear Magnetic Resonance (NMR) phenomenon
discovered by Bloch and Purcell
1946
First image intensifier
1948
Canadian Association of Medical Radiation Technologists founded
1950
Canadian Association of Radiologists’ Journal first published
First scintillation scanner developed by Benedict Cassen
1951
World’s first cobalt-60 unit developed in Saskatoon
First clinical ultrasound of soft tissue
1952
First automatic film processor manufactured
1956
Gamma camera invented by Hal Anger
1958
1960
Emission reconstruction tomography developed by David Kuhl
1962
Hounsfield and Cormack develop computed tomography (CT)
1972
Rare earth screens available
1973
First Human Positron Emission Tomography (PET) scan
1974
1975
First clinical Magnetic Resonance Imaging (MRI) scans produced
First clinical Echo Planar MR Imaging (EPI) (of the brain)
6
Canadian Association of Radiologists formed
1938
Shoe-fitting fluoroscopes abandoned in 1960s
First CT scanner at Montreal Neurological Institute (MNI)
MNI developed and installed Canada’s first PET scanner
1980
1982
First MRI installed in Canada
1985
First clinical uses of MRI in Canada
1993
Source: Compiled by ProMed Associates.
Because bones absorb (attenuate) more of the X-rays passing through them than do the
surrounding tissues, they are clearly visible on an X-ray film. It is not surprising, therefore, that
X-rays were initially used to examine bones. The ability of other tissues in the body to absorb
X-rays varies only slightly, making it difficult to distinguish between organs or to detect
abnormalities within them.
Contrast material that is swallowed or injected enhances the visibility of certain tissues and organs
by outlining them clearly on the film. For example, swallowed contrast material can be used to see
the outline of the stomach or bowel.11 Injected contrast material can show the outline of arteries or
of the kidneys as it is excreted.
Fluoroscopy is used to examine the body using X-rays in real time. The image is projected on
a screen, allowing the radiologist to see the tissues and to move the patient as needed to obtain
different views. If the patient swallows a contrast material, for example, the way in which the
esophagus moves the material down into the stomach will be visible. In the same way,
angiography can reveal the arteries of the brain or the coronary arteries of a beating heart.
With these and other developments, today’s applications of radiography go far beyond the
standard X-ray machine. Examples include:
1 Medical Imaging Technologies: The Past, Present, and Future
Radiography Today
• Mammography uses low dose X-rays with high contrast, high-resolution film to create detailed
images of the breast. While breast X-rays have been performed since the 1920s, modern
mammography used to detect breast cancer emerged in the early 1970s.
• Bone Mineral Densitometry is a diagnostic test that measures the density of bones. The most
commonly used test is dual energy X-ray absorptiometry (DXA), a low dose X-ray beam that
scans the spine, hip, or both. This test is used in the diagnosis of osteoporosis and risk
fracture assessment.
7
• Angiography is used to find and treat abnormalities in the blood vessels. Using fluoroscopy
images to guide placement, a fine hollow catheter may be inserted into small blood vessels
deep in the body. A contrast agent is injected to outline the blood vessel and reveal
blockages or abnormalities in the blood supply to organs,
Beyond Diagnosis
such as may occur with cancer. The same catheter may then
be used to introduce drugs or other treatments, such as
In medicine, imaging technologies are
balloons to expand the artery wall (angioplasty).
most often used to diagnose health
• Cardiac Catheterization is a form of angiography used in the
problems. But, in interventional
cath lab to image the blood vessels in the heart, to examine
radiology, physicians use imaging
the function of the heart, and often to dilate narrowed blood
technologies (such as X-rays, CT and
MRI scans, and ultrasound) to guide
vessels that are not supplying adequate amounts of blood to
small instruments such as catheters or
heart muscles.
needles through blood vessels to treat
disease. In general, interventional
Although modern X-ray machines produce significantly less
radiology procedures are designed to
radiation than those of years ago, X-rays must still be used in a
replace open surgical procedures, with
prudent manner because over-exposure can cause unnatural
a view to making them less risky and/or
painful for patients. The American
chemical reactions inside the body’s cells. Experts recommend
Medical Association officially
that women who are pregnant or breastfeeding, for example,
recognized interventional radiology as a
should carefully weigh the benefits of radiography against the
medical specialty in the mid-1990s.13
potential risk of exposing the fetus or infant to radiation.12
Medical Imaging in Canada
A Different Approach: Ultrasound
Around the time that nuclear medicine was born, another important technology was
developing. Pierre Curie discovered the piezo-electric effect in crystals, a phenomenon
that forms the basis for creating and measuring sound waves in ultrasounds.
Ultrasound technology—like echolocation by bats, dolphins, and whales—works by measuring
the echoes of high-frequency sound waves. Ultrasound waves bounce off tissue in much the
same way as marine sonar detects fish or explores the sea bottom. As a sound wave
reaches a patient’s tissues, part of the wave is reflected back and part continues. Waves that
travel further into the body take longer to return; the intensity of a returning echo depends on
the properties of the tissues encountered. Doppler ultrasound measures changes in echo
frequency to calculate how fast an object is moving, thus permitting measurement of the
velocity and direction of blood flow.
Ultrasound was first used experimentally as a possible diagnostic tool in medicine in the early
1940s. Karl Theodore Dussik, a neurologist/psychiatrist at the University of Vienna, located
brain tumors and the cerebral ventricles by measuring the transmission of ultrasound waves
through the skull, using a transducer on either side. George Ludwig, a physician at the Naval
Research Institute in Bethesda, Maryland, was a pioneer in the late 1940s in using pulse-echo
ultrasound for animal tissue diagnosis. He discovered that gallstones embedded in the muscles
of animals could be detected using ultrasound.14 (This followed a much earlier experiment by
Sir William Osler, perhaps the most notable physician of his time, which failed to detect
gallstones using X-rays.)
Today, ultrasound is well established. It is used in many fields of medicine, including obstetrics
and gynecology, cardiology, urology, oncology, interventional radiology, and many others.
Common applications include the diagnosis of gallstones, tumors of the liver or kidney, and the
sex, position, and size of babies in the uterus. Emergency departments may also turn to
ultrasound as a rapid imaging tool for diagnosis, particularly in trauma.
Until recently, ultrasound could only provide three-dimensional images. However, a fourth
dimension—time—was recently added. This allows clinicians to see fetal motion, behaviour,
and surface anatomy. Proponents suggest that 4D ultrasound may also have applications
related to gynecology, breast cancer, prostate cancer, and other conditions.15
Harnessing Computer Power
8
Computers have revolutionized many aspects of our lives. Medical imaging is no exception.
New digital technologies can substitute bits and bytes for traditional imaging films. In some
cases, digital images may allow more latitude in exposure and some potential for image
processing (e.g. edge enhancement).16 Nevertheless, technology assessments do not
always find a significant advantage over conventional approaches.17
In a country as vast as Canada, providing access to quality care for everyone
is a challenge. New technologies, collectively known as telehealth, are beginning
to offer innovative ways of delivering health care services and information over
small and large distances.
Conceived by Alexander Graham Bell who experimented with the telephone
transmission of X-ray signals, teleradiology can now facilitate a range of imaging
services.18 For instance, X-rays and other diagnostic imaging can be transmitted
electronically for interpretation by radiologists who live many kilometers from
where the image was produced. These services (as well as regular radiology
services) often make use of a new set of technologies—called Picture Archiving
and Communication Systems or PACS—to store and exchange digital images.
Across the country, a number of small and large teleradiology projects are
underway. Some connect health facilities across provincial, territorial, and even
international boundaries, but not all telehealth connections cover large distances.
Many teleradiology technologies and projects are relatively new, but evaluations
of early initiatives are emerging. Some results suggest significant promise.
Others identify a number of technological, legal, organizational, clinical, and
other challenges.
An international systematic review of studies of patient satisfaction with telemedicine
indicated that under ideal circumstances, patients accept and are generally satisfied
with the care that they received.19 Likewise, a 2001 review found relatively
convincing evidence for effectiveness of teleradiology, although the authors
argued that evidence regarding the effectiveness of telemedicine is still limited.20
Closer to home, an evaluation was conducted of a teleradiology project in Nova
Scotia. Over 24,500 routine and about 200 emergency cases were transmitted as
part of this project as of May 1998. In a review of 87 emergency cases, referring
physicians indicated that teleradiology changed patient management in 68 of those
cases (78%). For example, for two in five cases, physicians were able to begin
treatment sooner and one-quarter avoided patient transfer. In 12% of cases,
admission to hospital was avoided.21
Computers have also
made possible an
alphabet soup of new
imaging technologies—
CT, MRI, SPECT, and PET
to name just a few. These
devices use high capacity
computers to reconstruct
sectional or other images
from complex data sets.
Most consist of a patient
bed (couch) that slides
into the central hole of a
donut-shaped device (the
gantry). The central hole
may admit the head (smallaperture) or whole body
(large-aperture). The
gantry contains the
imaging hardware. A
console in the technologist
area houses the computer
and controls, and a
physician console allows
for the interpretation of
images without disrupting
ongoing tests.
1 Medical Imaging Technologies: The Past, Present, and Future
The World of Digital Imaging
Computed Tomography
Computed Tomography or CT, also known as Computer Assisted Tomography or CAT, was
developed in the late 1960s and introduced in the early 1970s by Godfrey Hounsfield and
Allan Cormack. It was the first imaging technology to allow for three-dimensional images of
the structures within the body. CT scans use X-ray images processed by a computer to create
virtual slices of the part of the body being examined. A computer then processes the data to
create images that show a cross-section of body tissues and organs.
9
In present (third and fourth generation) machines, a fan beam of radiation sweeps through 360
degrees while detectors provide a digital readout of the amount of radiation and the degree to
which it has been attenuated. From the linear attenuation in multiple projections, it is possible
to reconstruct a sectional display of body structure according to electron density. Contrast
material may be used with CT to outline certain tissues, as in conventional radiography.
Medical Imaging in Canada
There are far more electrons in bone than in organs such as the liver, which in turn are more
electron-dense than fat. Because CT imaging can detect subtle variations in density—for
example between that of liver tumors and liver tissue—radiologists can construct sectional
structural maps that facilitate diagnosis of some health problems. CT examinations can also
be used to plan and properly administer radiation treatments for tumors and to guide biopsies
and other invasive procedures.
CT scanning technology continues to evolve. For example, the development of multi-detector,
multi-slice helical scanning CTs makes it possible to obtain images over a broader area with
good spatial resolution and in shorter times.16,22
Magnetic Resonance Imaging
Magnetic Resonance Imaging (MRI) uses three components to create detailed images of the
inside of the body—hydrogen atoms in the tissues, a strong external magnet, and intermittent
radio waves. In a strong magnetic field, atoms tend to line up like iron filings around a bar
magnet. A pulse of radio-frequency radiation (like that used in a microwave oven) disturbs that
alignment. When the atoms return to their former state, they emit the energy from the radiation
that reveals their molecular environment and spatial location. For example, the nucleus of a
hydrogen atom in a molecule of fat will emit a different signal than a hydrogen atom in the
protein of muscle.
10
MRI can provide detailed images of all tissues except bone (where the protons are tightly
bound and less susceptible to magnetic influence). Images are created using algorithms similar
to those used in CT.23 MRI techniques can be enhanced by injected agents such as gadolinium
chelates, analogous to the contrast materials used in radiography.
3
Visualizing the Way We Think
The bright areas in this MRI image show activity in the inferior
frontal region of the brain of a subject who had been asked to
think of words starting with a given letter of the alphabet.
Sagittal
Coronal
3
Z value
MRI scans can be used to diagnose
conditions such as multiple sclerosis
and infections in the brain or spine;
to visualize injuries; and to evaluate
tumors, herniated discs, and masses
in soft tissues. As with ultrasound,
MRI does not use ionizing radiation.
Drawbacks to the technology include
the high cost of MRI equipment and
the noise produced during a scan.
Some patients cannot have an MRI,
including those with pacemakers,
those who have difficulty holding still
for extended periods of time, and
those susceptible to claustrophobia.
For others, such as those who are
larger, pregnant, or young, the gantry
configuration may be hard to use.
To accommodate these and other
patient issues, some MRI machines
are built in an open configuration (i.e.
patients don’t need to enter a gantry).
2
1
0
Transverse
Source: Image courtesy of Dr. Bruce Forster, UBC and VHHSC
Another type of MRI, called magnetic resonance spectroscopy (MRS), measures concentrations
of metabolites to produce images of chemical processes, such as the adenosine phosphate
pathway responsible for releasing much of the energy the body expends.24 Likewise, magnetic
resonance angiography (MRA) uses magnetic resonance technology to image arteries and
veins. MRA techniques have improved over the last several years and in some cases MRA is
now being used to detect and diagnose disorders of the blood vessels instead of conventional
catheter angiography.
Positron Emission Tomography
Positron Emission Tomography (PET) scanners create images by detecting subatomic particles
emitted from a tracer radioactive substance injected into a patient. When the radionuclide
decays, it emits positrons (positively charged electrons also called ß+ particles), which, when
they collide with an electron, generate energy in the form of two gamma rays emitted at 180
degrees to each other. The detection of these gamma rays permits the creation of an image
of the distribution of the radionuclide, slice by slice, within certain organs of the body. The
sectional images that are created can be used to evaluate some functions in the body.
Brain Function and Parkinson’s Disease
4
The top PET image shows the brain of a patient with Parkinson’s
disease: the first (using a fluorodopa tracer) reveals evidence of
damage to pre-synaptic neurons while the second (using raclopride)
shows compensatory up-regulation. The lower image is of serial scans
with flurodopa in a patient with Parkinson’s disease who had
undergone fetal cell transplant.
Parkinsonian
F-Fluorodopa
C-Raclopride
18
11
Fetal Cell Transplant
Baseline
6 months
12 months
In Canada, PET has primarily been
used as a research tool. However,
the technology is emerging as a
clinical tool. For example, PET scans
have been used to detect cancer,
stage its extent, examine the effects
of therapy, and study myocardial
viability.25 Evaluations of clinical
applications are underway in some
parts of the country.
The logistics of a PET scan can be
complex. For example, a cyclotron is
needed to produce the radionuclides
used in PET scans. As the tracers
have very short half-lives (from a few
minutes to well over an hour), this
usually means that PET scanners
must be located in close proximity to
a cyclotron.
A recent development involves
combining anatomical and functional
imaging (sometimes called fusion
imaging) from CT and PET in the
11
Source: Images courtesy of Dr. D. Worseley, UBC and VHHSC
1 Medical Imaging Technologies: The Past, Present, and Future
A functional MRI (fMRI) has the potential to image chemical processes in the body. For
example, the iron in the hemoglobin of blood cells influences the protons in the oxygenated
hemoglobin of arterial blood differently than hemoglobin in venous blood. As a result, the
relative blood flow to parts of the brain can be imaged in response to different perceptual
or motor tasks.
Medical Imaging in Canada
same display. Early evaluations of the combined imaging system in certain clinical settings,
such as non-small-cell cancer, suggest that the images created by the integrated technology
may provide better diagnostic information for some clinical conditions than either of the
technologies on its own.26
Single-Photon Emission Computed Tomography
Single-Photon Emission Computed Tomography (SPECT) measures the concentration of
radionuclides introduced into a patient’s body. One or more gamma camera
heads are mounted on a gantry
Comparing CT and SPECT Visuals
that circles the patient. Using
Image (a) shows a SPECT image of a lung mass demonstrating the
computed algorithms, an image
hypermetabolism of F-18 fluorodeoxyglucose. Image (b) shows a
of tracer distribution in multiple
CT scan of the same site showing the 3 cm diameter mass. Image (c)
shows composite anatomical (CT) and functional (SPECT) images of
organ sections can be created.
5
the mass (a lung carcinoma).
SPECT is an older technology than
PET and tends to have more limited
resolution and sensitivity than PET.
Different radionuclides are used that
emit a single photon, rather than a
positron, as in PET. Nevertheless,
some suggest that the availability of
SPECT, particularly for imaging the
brain and head, and other practical
aspects of SPECT instrumentation
can make this mode of emission
tomography attractive.24, 27
a
b
c
Source: Images courtesy of Dr. D. Worseley, UBC and VHHSC
6
How Imaging Modalities Compare
Robert Greenes and James Brinkley have compared selected imaging modalities with respect to several basic
characteristics. For more details, please refer to the reference below.
Characteristic
Nuclear
Medicine
Ultrasound
CT
MRI
Computed
Radiology
Spatial resolution
Low
Moderate
Contrast resolution
Low
Low
Moderate
Low
High
High
High
Low
Temporal resolution
High
30
High
Moderate
Low
Low
30
(plus dynamic series)
60
100
2
Radiation
Cost
Moderate
None
Moderate
None
Moderate
Moderate
Low
High
High
Moderate
Physiologic
function
Yes
No
No
Yes
No
Portability
Yes
Yes
No*
No*
Some
Typical number of
images per study
Spatial resolution: A measure of the ability to distinguish among points that are close to each other.
Contrast resolution: A measure of the ability to distinguish among different levels of intensity.
Temporal resolution: The time between acquisition of each of a series of images. Limited by the time needed to produce each image.
Some mobile MRIs and CTs exist.
12
*
Source: Adapted by CIHI from Greenes RA, Brinkley JF. (2001). Imaging Systems. In Medical Informatics: Computer Applications in Health Care
and Biomedicine 2nd Ed. Shortliffe EH, Perreault LE Wiederhold G, Fagan LM. Eds. New York: Springer.
There is no crystal ball to predict the future of medical imaging technologies. Given the rapid
changes in the last few decades, any projections must be made particularly cautiously.
That said, no one-size-fits-all technology appears to be on the horizon that would diagnose
all diseases and support all types of interventional radiology. Plain film radiography, particularly
of the chest, continues to be a large part of the work in radiological or imaging services, in both
hospital and ambulatory care facilities. Use of several other technologies has also increased in
recent years. A number—such as MRI, ultrasonography, and image-guided interventions,
among others—have also become core radiological technologies.
New applications also continue to be explored for both diagnosis and treatment. A few of
the many items in the research pipeline include:
• Electrical Impedance Imaging: This technique relies on the fact that different tissues
absorb weak electrical currents differently. Reviews suggest that it has been slow to find
clinical applications despite its relative simplicity and low cost.28 However, sectional
impedance imaging has now been proposed and a commercial device has been produced.29
It aims to detect small breast cancers with a high degree of sensitivity and specificity, as a
precursor to selecting patients for mammography or for diagnosis in younger women with
dense breasts.
1 Medical Imaging Technologies: The Past, Present, and Future
The Future
• Optical Imaging: Using light to image the interior of the body as distinct from its surface is
not a new idea. Intense light was used to trans-illuminate the breast and peripheries years
ago. Further development of trans-illuminate imaging has proven challenging because of
issues in signal analysis, but research continues.30
• Molecular Imaging: This technique allows for the characterization and measurement of
processes at the molecular and cellular level. It is being used experimentally to assess
specific molecular targets for gene- and cell-based therapies. In the future it might be
used to detect and characterize disease earlier as well as to assess treatment efficacy at
the molecular level.31
• Imaging Capsules: A capsule–sized camera that can take colour video images as they pass
through the digestive tract is now being tested. These M2A capsules are just one example of
the rapidly developing technologies that offer new ways of looking inside the human body.
Which of these technologies, if any, will prevail? How will they fit within the imaging toolbox,
within the parameters of our evolving health care system, and with changing provider and
consumer expectations? Only time will tell.
13
Medical Imaging in Canada
14
For More Information
1
Kevles BH. (1997). Naked to the Bone: Medical Imaging in the Twentieth Century.
New Brunswick: Rutgers University Press.
2
Eisenberg RL. (1992). Roentgen and the Discovery of X-rays. In Patterson AS, Gunter A, eds.
Radiology: An Illustrated History. St. Louis: Mosby Year Book.
3
Aldrich J. (1995). Röntgen and the discovery of X-rays. In Aldrich J, Lentle BC, eds. A New Kind of Ray:
The Radiological Sciences in Canada 1895-1995. Montreal: The Canadian Association of Radiologists.
4
Donizetti P. (1967). Shadow and Substance: The Story of Medical Radiography. Oxford: Pergamon Press.
5
Grigg ERN. (1965). The Trail of the Invisible Light. Illinois: Thomas.
6
Cohen M. (1995). Canada’s first clinical X-ray. In Aldrich JE, Lentle BC, eds. A New Kind of Ray: The Radiological
Sciences in Canada 1895-1995. Montreal: The Canadian Association of Radiologists.
7
Cox J, Kirkpatrick RC. (1896). The new photography with report of a case in which a bullet was
photographed in the leg. Montreal Medical Journal, 24, 661.
8
Karolevitz RF. (1967). Doctors of the Old West: A Pictoral History of Medicine on the Frontier. Seattle:
Superior Publishing Company.
9
Eisenberg RL. (1992). Nuclear medicine. In Patterson AS, Gunter A, eds. Radiology: An Illustrated History.
St. Louis: Mosby Year Book.
10
Society of Nuclear Medicine. (2003). The History of Nuclear Medicine. www.snm.org/nuclear/history.html.
11
Cannon WB. (1898). The movements of the stomach studied by means of the Roentgen ray.
American Journal of Physiology, 1, 359.
12
Health Canada. (2000). X-ray Equipment in Medical Diagnosis Part A: Recommended Safety Procedures
for Installation and Use. Ottawa: Health Canada.
13
Society of Interventional Radiology. (2003). Interventional Radiology is 21st Century Medicine. www.sirweb.org.
14
Woo J. (2003). A Short History of the Development of Ultrasound in Obstetrics and Gynecology.
www.ob-ultrasound.net/history.html.
15
Industry Canada. (2002). Life Sciences News Brief GE Medical Systems Unveils 4D Ultrasound Breakthrough
in Canada. http://strategis.ic.gc.ca/ssg/ph01536e.html.
16
Freeman MT, Artz DS. (1997). Image processing in digital radiography. Seminars in Roentgenology, 32, 25-37.
17
Ho C, Hailey D, Warburton R, MacGregor J, Pisano E, Joyce J. (2002). Digital Mammography Versus
Film-Screen Mammography: Technical, Clinical and Economic Assessments. Ottawa: Canadian Coordinating
Office for Health Technology Assessment.
18
Aldrich J. (1995). Alexander Graham Bell. In Aldrich J, Lentle BC, eds. A New Kind of Ray:
The Radiological Sciences in Canada 1895-1995. Montreal: The Canadian Association of Radiologists.
19
Mair F, Whitten P. (2000). Systematic review of studies of patient satisfaction with telemedicine.
British Medical Journal, 320, 1517-20.
20
Roine R, Ohinmaa A, Hailey D. (2001). Assessing telemedicine: A systematic review of the literature.
Canadian Medical Association Journal, 165(6), 765-771.
21
Canadian Institute for Health Information. (2001). Health Care in Canada 2001. Ottawa:
Canadian Institute for Health Information.
22
Tsuchiya K, Katase S, Aoki C, Hachiya J. (2003). Application of multi-detector row helical scanning
to postmyelographic CT. European Radiology, 13(6), 1438-1443.
23
Balfe DM, Ehman RL. (1998). Research in CT and MRI imaging: 2000 and beyond. Radiology, 207, 561-566.
24
Orrison WW Jr. (1996). 3M Mayneord Memorial Lecture: Functional Brain Imaging—An Overview.
British Journal of Radiology, 69(822), 493-501.
25
Coleman R, Wieler H. (2000). Current status of PET. In Wieler H, Coleman R, eds.
PET in Clinical Oncology. Germany: Dietrich Steinkopff.
26
Lardinois D, Weder W, Hany TF, Kamel EM, Korom S, Seifert B, von Schulthess GK, Steinert HC. (2003).
Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed
tomography. New England Journal of Medicine, 348(25), 2500-2507.
27
Kessler RM. (2003). Imaging methods for evaluating brain function in man. Neurobiology of Aging, 24 Suppl 1, S21-S35.
28
Kotre CJ. (1997). Electrical impedance tomography. British Journal of Radiology, 70 Spec No, S200-S205.
29
TransScan. (2002). T-ScanTM 2000 ED: Advancing the Frontiers of Early Detection.
www.tscan.org/home/home.html.
30
Hebden JC, Delpy DT. (1997). Diagnostic imaging with light. British Journal of Radiology, 70 Spec No,
S206-S214.
31
Allport JR, Weissleder R. (2001). In vivo imaging of gene and cell therapies.
Experimental Hematology, 29(11), 1237-1246.
2
Medical Imaging in Practice
Although millions of Canadians receive imaging services each year, relatively little is known
about how these technologies are used and how they affect patient care and outcomes.
Pockets of information do, however, exist. This chapter of the report focuses on what we
know about five of the many types of imaging used today–mammography, angiography,
CT, MRI, and PET–and about the costs of imaging services.
2 Medical Imaging in Practice
Throughout the ages, society’s healers have developed a variety of approaches to
diagnose and treat their patients’ ills. Imaging technologies became part of the arsenal
of tools used to find and fight disease in the last century. Today, clinicians use dozens
of types of imaging, often as early diagnostic steps that may precede or preclude other
health care services. Some technologies, such as X-ray machines, have been used for
more than a century. Others, including MRI and PET scanners, are more recent, part of
an increasingly sophisticated range of imaging technologies.
Medical Imaging in Canada
About the Data: The Fine Print
• Statistics Canada’s Health Services Access Survey (HSAS) is a supplement to the
Canadian Community Health Survey (CCHS) 2000-2001. It captures national information on
how Canadians 15 years of age and older use health care services and perceive barriers to
care. The survey includes information on the use of three diagnostic services (MRI, CT, and
angiography) in non-emergency situations. Overall, 17,616 CCHS participants were
included in the HSAS; 81% responded. All estimates from the HSAS presented in this
chapter reflect reported use and may be different from estimates of the number of scans
performed derived from administrative data.
• CIHI’s National Ambulatory Care Reporting System (NACRS) captures summary
information on ambulatory care. For 2001–2002, the database primarily captured
information on emergency department care in Ontario (approximately 4.8 million
emergency department visits). For this report, we examined the use of CT scans in this
environment. Slightly more than 94,000 CT scans were reported. The CT scans were
completed during the emergency department visit and could have been ordered for either
the patient’s main problem or other problem.
• CIHI’s National Physician Database (NPDB) provides information about the sociodemographic characteristics of Canadian physicians and their fee-for-service activity levels.
Since fee codes and payment methods for imaging services vary across the country, billing
data on the use of medical imaging services are only directly comparable for selected
jurisdictions. Imaging services paid for entirely through hospital global budgets or by
individuals/third-party payers (e.g. Workers Compensation Boards) are not captured.
• CIHI’s National Survey of Selected Medical Imaging Equipment provides information on
the number, distribution, and key characteristics of selected imaging technologies
(angiography suites, catheterization labs, CT scanners, MRI scanners, nuclear medicine
cameras, and PET scanners)* in Canadian hospitals and those in free-standing imaging
facilities (sometimes also called ‘non-hospital’, ‘community-based’, and/or ‘private’
facilities) as of January 1, 2003. For more detailed information about this survey, please
refer to Chapter 3.
• CIHI’s Management Information Systems Database (CMDB) provides financial and
statistical information (e.g. expenditures by functional area, workload measurements,
outpatient visits) primarily on hospitals with some limited data on regional health authorities
across Canada. Information is primarily obtained from provincial/territorial ministry of health
databases. For some jurisdictions, however, data are collected from individual
facilities/regional health authorities via survey. For this report we examined hospital
operating expenses for selected types of medical imaging equipment.
16
For a more detailed description of these and other data sources, please visit CIHI’s Web site
at www.cihi.ca or Statistics Canada’s Web site at www.statcan.ca.
* The survey also included lithotriptors, but results will be reported elsewhere.
The National Cancer Institute of Canada estimates that there will be about 21,100 new cases of
breast cancer and about 5,300 breast cancer deaths among Canadian women in 2003. This
makes breast cancer the most commonly diagnosed form of cancer among women, although
lung cancer is the leading cause of cancer deaths.1
In an effort to reduce the toll of breast cancer, thousands of women receive clinical breast
exams, perform breast self-exams, and have screening mammograms each year. The body of
knowledge about what works best for which women continues to evolve. Several groups have
weighed this evidence and made recommendations about what women should do to prevent
the disease.
2 Medical Imaging in Practice
Mammography: Looking for Breast Cancer
7
Recommendations for Breast Cancer Screening
Recommendations for different types of breast cancer screening made by the American Cancer Society, the Canadian
Cancer Society, the Canadian Task Force on Preventive Health Care, and the US Preventive Services Task Force.
Organization and Date
Last Reviewed
Screening Mammography
Clinical Breast Exam
Breast Self-Exam
American Cancer Society
(2002)
Yearly starting at age 40
Every 3 years, ages 20–39;
yearly starting at age 40
Optional regular
self-monitoring
beginning at age 20
Canadian Cancer Society
(2002)
Every 2 years, ages 50–69
Every 2 years for all women
Regular selfmonitoring for all
women
Canadian Task Force on
Preventive Health Care
(1994–2001)
Good evidence for screening
every 1 to 2 years, ages 50–69
(1998)
Good evidence for screening
every 1 to 2 years, ages 50–69
(1998)
Evidence insufficient to
recommend for or against for
inclusion in the periodic health
examination for women aged
40-49 at average risk of breast
cancer (2001)
The value of adding clinical
breast examination to
mammography is unclear for
women aged 40-49 at average
risk of breast cancer (2001)
Fair evidence to
exclude from
periodic health
examination (2001)
Every 1 to 2 years starting at
age 40 with or without clinical
breast exam
Evidence insufficient to
recommend for or against
routine clinical breast exam
alone
US Preventive Services
Task Force (2002)
Evidence insufficient
to recommend for
or against
Source: Compiled by CIHI
17
Medical Imaging in Canada
Experts agree about what should
be done in many—but not all—areas.
For example, the Canadian and
American Cancer Societies and the
Canadian Task Force on Preventive
Health Care all recommend a
screening mammogram and a clinical
breast exam at least every two years
for women aged 50 to 69. However,
experts disagree in a few areas, as
table 7 shows. (For more information
surrounding the on-going debate
about mammography screening,
please refer to CIHI’s Health Care in
Canada 2002 report.)
8
Mammography Across Canada
Percentage of women aged 50 to 69 who reported having had a
mammogram for routine screening or for any reason in the past
two years in 2000-2001.
52%
70%
* 37%
* 58%
50%
65%
n/a
n/a
36%
* 51%
51%
67%
47%
68%
53%
74%
50%
68%
42%
64%
53%
72%
54%
71%
45%
47%
71%
71%
Most women aged 50 to 69 do have
regular mammograms, although some
Routine Screening
Any Reason
groups are more likely to have the test
than others. In the 2000–2001
Note: (1) Any reason includes routine screening, family history of breast cancer, age,
Canadian Community Health Survey,
previously detected lump, follow-up of breast cancer treatment, on hormone replacement
therapy, breast problem, or other reasons. (2) Data for Nunavut are suppressed due to
70% of women aged 50 to 69
extreme sampling variability.
reported having a mammogram in
* Interpret with caution due to sampling variability.
the last two years; 52% of all women
Source: Canadian Community Health Survey, Statistics Canada
in this age group said that their
mammogram was specifically for
routine screening. Women were more likely to have had a recent mammogram if they had a
regular doctor, higher incomes, and higher levels of education. The percentage of women who
reported having a recent mammogram also varied across the country.
Coronary Angiography
Coronary angiography (or arteriography) provides images of blood vessels or chambers of
the heart. It can be an important tool in detecting obstructions in coronary arteries and is
often performed to determine the necessity of further interventions, such as angioplasty or
bypass surgery.
18
Angiography is just one of many tests used to diagnose heart disease. As with other health
conditions, a variety of tests may be used alone or in combination. The choice of which test(s) to
use—and when—may depend on factors such as the patient’s risk factors, health history, and
current symptoms and situation; the availability of different tests and skilled professionals to
conduct them and to interpret the results; and options for proceeding after test results are known.2
Groups such as the American College of Radiology’s Expert Panel on Cardiovascular Imaging
have weighed the evidence and developed consensus-based ratings of the appropriateness of
different tests for different clinical conditions (see Figure 9 for an example).3
Appropriateness ratings (1=least appropriate; 9=most appropriate) and related comments for radiological
exam procedures that may be used for a patient with acute chest pain and suspected myocardial ischemia, as
assigned by the American College of Radiology’s Expert Panel on Cardiovascular Imaging in 1999.
Radiologic Exam
Procedure
Appropriateness
Rating
Comments
Chest film (X-ray)
9
Plain films are needed to exclude other causes for chest pain.
Coronary angiography
8
Necessary to define extent of stenosis. Usually done late in
the work-up.
Transthoracic
echocardiography (TTE)
7
Indicated as a screening test to evaluate cardiac function.
Inexpensive and portable.
Left ventricular (LV)
angiography
7
Indicated to define ventricular function as part of the
ischemia evaluation.
Radionuclide myocardial
perfusion scan
6
May be indicated to evaluate extent of ischemia. Usually
done after initial screening tests suggest ischemia.
Radionuclide ventriculogram
6
May be indicated to evaluate cardiac function.
Infarct avid imaging
5
May be indicated in questionable cases to confirm infarction.
Transesophageal
echocardiography (TEE)
4
May be indicated to evaluate cardiac function or to rule out
aortic dissection.
Electron beam CT/multihead
ultrafast CT with contrast
4
Probably not indicated except for quantitating ventricular
function. Noncontrast images may be useful in screening
for coronary calcification.
Magnetic resonance
angiography (MRA)
4
Conventional computed
tomography (CT) with contrast
3
Little indication except for documenting other sources of
chest pain.
Magnetic resonance imaging
(MRI)
3
Little indication except for screening for possible aortic
dissection. May have some applicability in evaluating
cardiac function.
MR perfusion studies
2
Research studies show promise in evaluating infarction.
Not extensively used clinically.
Positron emission tomography
(PET)
2
See comments on MR perfusion studies.
2 Medical Imaging in Practice
9
Which Test?
Note: Reproduced with permission from the Canadian Chapter of the American College of Radiology.
Source: American College of Radiology Expert Panel on Cardiovascular Imaging. (1999). Acute Chest Pain—Suspected Myocardial Ischemia.
www.acr.org/dyna/?id=appcrit&pdf=0007-14_acute_chest_pain_susp_myocard_ischemia_ac.
10
Growth in the Number of CT Scans
The percentage change in publicly funded CT scans performed
based on fee-for-service billings paid by selected provinces
between 1994 and 2000.
Percentage change in CT scans
160%
140%
120%
100%
80%
60%
40%
20%
0%
Ont.
Que.
N.B.
P.E.I.
N.L.
Sources: National Physician Database, CIHI (Ontario and PEI)
Eco-Santé, Ministère de la Santé et des Services sociaux
(Québec)
Department of Health and Wellness, Government of New
Brunswick
Department of Health and Community Services, Government of
Newfoundland & Labrador
19
Province
Notes: (1) Comparing scan rates between provinces and/or
countries is challenging for a variety of reasons. For example,
where fee-for-service data exist, the billing codes used to
designate a CT scan—and how scans are counted—sometimes
differ, limiting the ability to compare between jurisdictions.
Accordingly, only data on the percent change in the number of
scans–rather than an actual scan rate per population–is
presented here. (2) Data from Ontario, PEI, New Brunswick, and
Newfoundland and Labrador are by fiscal year; Quebec data are
by calendar year. (3) Data from Ontario, PEI, and Newfoundland
and Labrador exclude scans performed for hospital inpatients
(4) Interprovincial billings and scans done on hospital inpatients
are included in New Brunswick data.
Medical Imaging in Canada
In the 2001 Health Services Access Survey (HSAS) by Statistics Canada, about 1%* of
respondents aged 15 and older reported that they had had a non-emergency angiography within
the last year. These respondents tended to be between the ages of 40-64; 52%* were women.
Most (98%) said that their procedure was done in a hospital or public clinic.
FF
CT Scans
Physicians use CT scans for diagnosing a wide and changing range of conditions, such as
head injury, chest trauma, or musculoskeletal fractures. According to Statistics Canada data,
about 787,300 Canadians aged 15 and older (3%) reported that they had had a non-emergency
CT scan in 2001. The leading reason for these tests, accounting for almost 30% of scans, was
neurological or brain disorders. About 33%* reported a mix of other reasons for their CT scans,
and 37% did not specify the reason for their test. Most respondents (96%) stated that their CT
scan was done in a hospital or public clinic.
FF
Performing CTs In Ontario Emergency Departments
Radiology plays an important role in the emergency department (ED). Used appropriately, imaging can, for
example, aid in identifying patients who may benefit from immediate intervention, monitoring, or
early discharge.
Depending on a patient’s condition and circumstances and other factors, different types of imaging (or, of
course, no imaging) may be used. Some types of tests are relatively common–1.4 million X-rays were
performed for patients in Ontario’s EDs in 2001–2002. Others are used less often. For example, just over
94,000 CT scans were performed in the same period. Two-thirds of these tests (66%) were head scans;
another 20% were of the abdomen. The number of women receiving CT scans was higher than the number of
men for all age groups, except those aged 10 to 29. Patients 70 years of age or older received 28% of scans,
although they accounted for only 13% of all ED visits.
20
In Canada, researchers expect that use of
this rule would stabilize or decrease CT use
for patients with minor head injury.10 A
recent study suggested that Canadian CT
use could fall by 17.8% (with the ‘mediumrisk’ criteria designed to detect important
brain injury) or by 44.5% (with the ‘highrisk’ criteria designed to detect patients who
need neurological intervention). Researchers
estimate that this could result in annual
savings of about $3.5-$5.5 million to the
Canadian health care system.11 Researchers
in other countries however, have questioned
the generalizability of these Canadian rules.12
* Interpret with caution due to sampling variability.
Number of CT scans
The decision about whether to use a CT is not always clear. For example, there is some debate about which
patients with minor head injury should be scanned.7,8 Canadian researchers recently developed a decision rule
to assist physicians with these choices.7
They found that when the rule was used,
CT Scans in Ontario’s Emergency Departments
physicians were significantly better able to
The number of CT scans by body site in Ontario’s emergency
predict whether a CT scan would find an
departments, 2001–2002.
important brain injury and whether patients
70,000
needed neurosurgery than they could when
9,10
relying on judgement alone.
60,000
11
50,000
40,000
30,000
20,000
10,000
0
Head
Abdomen
Thorax
Other
Body Site
Note: (1) Some emergency departments did not submit data to the National Ambulatory
Care Reporting System for the 2001-2002 fiscal year and are therefore excluded from
these counts. (2) “Other” includes CT scans not otherwise specified.
Source: National Ambulatory Care Reporting System, CIHI
2 Medical Imaging in Practice
In Canada and elsewhere, both the number of CT machines and the number of CT scans has
increased in recent years. For example, the number of publicly funded CT scans in Newfoundland
and Labrador more than doubled between 1994 and 2000 and almost doubled in Ontario and
New Brunswick. Other provinces, such as Quebec and PEI, also saw a growth in the number of
CT scans during this period. Scan rates have also been rising in other parts of the world. Many
other countries, including Australia,4 the United States,5 and England,6 have also seen significant
growth in CT scans in recent years.
12
Decision Rules for CT Scans
Key parameters from recent multicentre studies comparing the results of applying Canadian and US
decision-rules for CT scans in patients with minor head injuries in a Canadian context.
Study Parameters
Canadian CT Head Rule
New Orleans Criteria
Population
Adult minor head injury patients with
witnessed loss of consciousness,
amnesia, or confusion and a Glasgow
Coma Score of 13–15.
Adult minor head injury patients with
witnessed loss of consciousness,
amnesia, or confusion and a Glasgow
Coma Score of 15.
# patients included in population
2,588
1,733
% patients requiring a CT scan
using head rule
36% (‘high risk’ criteria)
62% (‘medium risk’ criteria)
88%
% patients requiring neurological
intervention identified using
head rule
100% (‘high risk’ criteria)
100%
% patients with important brain
injuries identified using head rule
100% (‘medium risk’ criteria)
100%
% cases MDs underestimated
the risk
7.1%
5.4%
% cases MDs uncomfortable in
applying the rule
7.7%
11.5%
Notes: The Canadian CT head rule stratifies minor head injury patients into high-, medium- and low-risk categories based upon seven clinical
criteria. The Glasgow Coma Score is a trauma scoring index ranging from 3 to 15 (3 being severe, 15 being minor) based on observation of
patient eye, verbal, and motor responses.
Sources: Stiell IG, Clement C, Wells GA, Brison R, McKnight RD, Schull M, Rowe BH, Dreyer JA, Bandiera G, Lee J, MacPhail I,
Lesiuk H. (2003). Multicenter prospective validation of the Canadian CT head rule. Academic Emergency Medicine, 10(5), 539.;
Stiell IG, Clement C, Rowe BH, Brison R, Schull M, Wells GA, Greenberg G, Cass D, Holroyd B, Worthington JR, Reardon M,
Eisenhauer M. (2003). Multicenter prospective validation of the New Orleans criteria for CT in minor head injury.
Academic Emergency Medicine, 10(5), 477.
MRI Scans
The first MRI machine came to Canada in 1982,13 but most scanners have been installed within
the last five years. The number of tests performed and the range of health conditions for which
MRI tests are used have also increased in recent years.
Across the country, about 647,000 Canadians aged 15 and over (3%) reported having had a nonemergency MRI scan in 2001. About 18%† were scans of joints and/or fractures, followed by tests
for neurological or brain disorders (12%).**† As for CT scans, most patients (92%) received their
MRI tests in hospitals or public clinics.
†
The reason for the MRI was unspecified in 37% of all cases.
Interpret with caution due to sampling variability.
21
**
FF
13
MRIs for What?
Thousands of outpatient MRI scans by body site per year in Ontario,
1992–2001.
70
Thousands of MRI Scans
Medical Imaging in Canada
As in other parts of the world,
available provincial administrative
data suggest that scan rates have
increased in recent years and
applications of the technology have
changed.4,6 For example, researchers
from Ontario’s Institute for Clinical
Evaluative Sciences (ICES) showed
that the number of outpatient MRI
scans in the province increased
between 1992 and 2001. Throughout
this period, MRIs of the head were
the most common type of test (they
accounted for 39% of MRIs in 2001),
but some rarer scans rose rapidly
(eg: abdominal scans were up more
than 1,100%).14
60
50
40
30
20
10
0
1992
1993
1994
1995
1996
1997
1998
Extremities
Head
Spine
Other
1999
2000
Note: Other includes MRI scans for abdomen, pelvis, thorax, and neck.
Source: Iron K, Przybysz R, Laupacis A. (2003). Access to MRI in Ontario: Addressing the
Information Gap. Toronto: Institute for Clinical Evaluative Sciences.
Data from other parts of the country are not directly comparable, partly because of differences
in how MRI services are offered and reimbursed. Cautious comparisons do suggest that scan
rates vary considerably across the country. But regions with higher rates don’t necessarily have
more MRI machines, and vice versa. For example, Ontario had more hospital-based machines
per capita in 2001 than Manitoba, but reported fewer outpatient scans per capita. (Inpatient
scan rate comparisons are not available)
Internationally, the same is true. For instance, England had more MRI machines per person in
2001 than Manitoba, but seems to have performed fewer scans per capita. Nationally and
internationally, many factors may explain observed differences in scan rates including what
types of scans are being performed, how many hours machines are operating (see Chapter 5),
and how services are organized and delivered.
PET Scans
Positron emission tomography (PET) was introduced shortly after computed tomography (CT)
in the early 1970s.15 Unlike CT, which produces images of the patient’s anatomy, PET is a type
of nuclear medicine that measures biochemical processes in the body.
Across Canada, there were 14 PET scanners in January 2003, up from six in 1997. Most were
located in hospitals or affiliated research centres, but one has recently been installed in a freestanding imaging facility in British Columbia and Ontario. Eleven of the 14 scanners installed
as of January 2003 can accommodate full-body scanning; the others can only accommodate
head scans.
22
2001
While many imaging modalities are regularly used in clinical practice, PET remains largely a
research tool in Canada.16 In part, the high cost of equipment and the complexity of its use may
have slowed its adoption in clinical settings, according to the literature.17 For example, PET
imaging studies use short-lived radioactive molecules (positron emitting tracers) to produce
images, requiring access to a nearby cyclotron to generate the radioisotopes. Cyclotrons are
particle accelerators that cost about $3-4 million plus annual maintenance and other costs.17-19
• Oncology: PET scanning may be useful in the diagnosis and staging of lung cancer.19-21
• Neurology: A Quebec study found evidence to support the use of PET for identifying regions
in the brain responsible for inducing epileptic seizures and in evaluating lesions following
treatment of a recurrent brain tumor (mainly gliomas).21 In contrast, an Ontario study did not
find evidence to support the use of PET for diagnosing or for the symptomatic management
of dementia.19
2 Medical Imaging in Practice
Will PET scans become part of the diagnostic toolbox in Canada? Several recent studies have
assessed the appropriateness of its use for specific clinical applications.19-21 All pointed to the
need for further research (e.g. larger studies comparing PET with other imaging technologies
and research on the cost-effectiveness of PET use in Canada). Nevertheless, the authors did
suggest that:
• Cardiology: A Quebec study found PET to have clinical utility in studying myocardial
viability.21 However, a study from Ontario found in that there was no convincing evidence of
the clinical utility of PET for cardiac indications.19
Total operating costs vary
widely depending on the
type of imaging, the
complexity of the images
required, salary and fee
levels, and other factors.
Although medical imaging
technologies have become
essential tools in health care,
there is little comparable
information on the costs of
providing these services
across the country.
The number of fee-for-service outpatient MRI scans and fees paid
(in millions of dollars) by the Ontario Health Insurance Plan, 1992-2001.
160
$25
140
$20
120
100
$15
80
$10
60
40
$5
Fees paid by OHIP ($ millions)
Canadians spend billions of
dollars each year on imaging
services. The professionals
who operate and maintain
the equipment must be paid;
related parts and supplies
must be purchased;‡ and
overhead costs add up. In
addition, physicians receive
professional fees for
performing and/or
interpreting tests. There
are also other costs.
14
The Growing Use and Cost of MRIs in Ontario
Thousands of MRI Scans
The Cost of Imaging
20
0
$0
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
# of scans in thousands
Fees paid by OHIP ($ millions)
Source: Iron K, Przybysz R, Laupacis A. (2003). Access to MRI in Ontario: Addressing the
Information Gap. Toronto: Institute for Clinical Evaluative Sciences.
15
Spending on Medical Imaging in Hospitals
Total hospital operating expenses for selected types of medical
imaging equipment, Ontario, 1999–2000 and 2000–2001.
X-ray (including
Mammography)
CT
Nuclear Medicine
Ultrasound
Cardiac Catheterization
MRI
$0
$50
$100
$150
$200
$250
$300
$350
Spending in millions of dollars
2000–2001
1999–2000
‡
Capital costs associated with medical imaging equipment are examined in Chapter 3.
23
Source: Canadian MIS Database, CIHI
Medical Imaging in Canada
Available snapshots include:
• Total spending on medical imaging in Canada has risen in recent years. For example,
hospitals in British Columbia, Alberta, Ontario, and New Brunswick collectively spent about
$1.3 billion (7%) on diagnostic imaging services in 2000.!
• A recent Quebec Auditor General’s report indicated that the province spent about $358
million on diagnostic imaging services in 1999-2000.22
• A recent Ontario study showed an eight-fold increase in the overall amount that the provincial
health insurance plan paid for outpatient MRI scans between 1992 and 2001.14
• The Saskatchewan government estimates that MRI services alone cost more than $3.9 million
in 1998-1999 or about $365 per scan, excluding maintenance contracts on new units.23
• In 2001, the British Columbia government estimated costs of about $20 million to operate its
MRI scanners.24
Where the Money Comes From
FF
A variety of public and private sources fund Canada’s medical imaging operating costs. Most
funding comes through provincial/territorial governments, but funding approaches vary by
technology and by jurisdiction. In some cases, there are also differences between how
physicians’ professional fees are funded and payments for hospital or other facility operating
costs. For example, physicians may receive fee-for-service payments for their professional
services, while other operating costs may be included in hospital/health region global budgets.
Alternatively, the fee-for-service payment may include both a ‘professional’ and ‘technical’
component, covering all operating costs.
The 2003 National Survey of Selected Medical Imaging Equipment provides insight into the
extent to which different payers fund medical imaging operating costs for MRI, CT, and PET
scanners, nuclear medicine, catheterization labs, and angiography. For the vast majority of
hospital-based equipment captured in the survey, funding for operating costs comes primarily
from provincial/territorial governments
16
(98%). This was also the primary
Paying to Operate Health Technologies
Percentage of equipment in hospital facilities by primary funding source
funding source for about a third
of operating dollars for selected imaging technologies, 2002–2003.
(32%) of the machines housed in
free-standing imaging facilities.
CT
Equipment in both settings may also
have a variety of secondary sources
of funding, not all of which were
identified by every survey respondent.
Examples include the federal
government, Workers’ Compensation
Boards, research grants, private
insurance companies, and out-ofpocket payments. See Chapter 5 for
more information about issues related
to funding for imaging services.
Nuclear Medicine
Angiography
MRI
Cardiac Catheterization
PET
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% equipment by primary funding source
Provincial Govt.
Other
Note: Other category includes funding not otherwise specified and Worker’s
Compensation Board payments
24
Source: National Survey of Selected Medical Imaging Equipment, CIHI
!
Hospital spending in total dollars based on data from the following provinces: British Columbia, Alberta,
Ontario, and New Brunswick. Comparable data from other provinces were not available.
Medical imaging tests vary greatly in their complexity and the resources required to carry them
out. In most hospitals, common tests account for the bulk of overall operating expenditures on
diagnostic imaging. According to CIHI’s Management Information Systems Database (CMDB), in
2000-2001 hospitals in Ontario spent about $309 million on X-rays— approximately three times as
much as to other imaging technologies such as CT, ultrasound, cardiac catheterization, or nuclear
medicine. Other services—such as
17 MRIs—cost more per test, but fewer
Where the Dollars Are Spent
The distribution of hospital operating expenses for selected types
people receive them. Ontario hospitals,
of medical imaging equipment, Ontario, 2000–2001.
for example, spent about $46 million
X-ray (including
for MRI scans in 2000-2001.
mammography)
Nuclear Medicine
CT
Ultrasound
Cardiac Catheterization
MRI
0%
20%
Compensation
40%
60%
Percentage of total operating costs
Equipment Expenses
80%
Supplies
100%
Other
Note: Other category includes sundries, referred out services, and building
and grounds expenses.
Source: Canadian MIS Database, CIHI
2 Medical Imaging in Practice
Where the Dollars Go
Types of operating expenses also vary
according to imaging modalities. For
some services (e.g. MRI, CT, and
ultrasound), salaries paid to health
professionals account for more than
half (57%, 66%, and 80% respectively)
of total operating costs. For others,
such as cardiac catheterizations,
medical supplies used to perform the
procedure make up the majority of
spending (59%).
25
Medical Imaging in Canada
Information Gaps:
What We Know
• Proportion of Canadians who reported receiving selected non-emergency medical imaging
services in 2001.
• Number of selected medical imaging services provided over time for various jurisdictions.
• Number of medical imaging services in Ontario emergency departments and the demographic
characteristics of those who received them.
• What hospitals in selected provinces spend to operate certain types of medical imaging equipment.
• How much physicians bill in fee-for-service payments for certain types of medical imaging
procedures for selected provinces.
• The primary sources of operating funding used for selected types of imaging technology.
What We Don’t Know
• Exactly how many Canadians receive different types of medical imaging services each year?
How many scans are performed? What combination and rate of medical imaging services would
best meet the health care needs of different patient groups and communities and what would the
implications be for access to care, health care costs, and patient outcomes?
• How many Canadians receive medical imaging services that are not publicly funded? Where do
they receive these services and for what purpose? What effect does this have on their health and
health care, as well as on publicly funded services and costs?
• How much is spent in total to provide medical imaging services? How do levels of spending on
imaging affect access to imaging and other types of care, patient and provider satisfaction, patient
outcomes, and overall health care costs?
• What types of imaging services are payers other than provincial/territorial Ministries of Health
purchasing? What are the motivations for these purchases? What effect do they have on patient
and provider satisfaction, patient outcomes, and overall health care costs?
What’s Happening
• In February 2003, Canada’s First Ministers agreed to report to their citizens annually on
enhancements to diagnostic and medical equipment and services using comparable indicators and
to develop the necessary data infrastructure for these reports. Ministers were directed to consider a
number of indicators, including volumes and wait time measures for MRIs and CTs.
26
• CIHI recently revised the diagnostic imaging workload measurement system in the Canadian MIS
Guidelines to better capture the volumes and costs of medical imaging activities in hospitals and
health regions.
1
National Cancer Institute of Canada. (2003). Canadian Cancer Statistics 2003. Toronto: National Cancer Institute
of Canada.
2
American Heart Association. (2002). Tests to Diagnose Heart Disease.
www.americanheart.org/presenter.jhtml?identifier=4739.
3
American College of Radiology. (1999). Acute Chest Pain-Suspected Myocardial Ischemia.
www.acr.org/dyna?/id=appcrit&pdf=0007-14_acute_chest_pain_susp_myocard_ischemia_ac.
4
Australian Health Insurance Commission. (2003). Health Statistics: Diagnostic Imaging Services
(Magnetic Resonance Imaging). www.hic.gov.au.
5
International Marketing Ventures. (2002). CT Sites Moving Quickly to Adopt Latest CT Multi-slice Technology
and Applications. www.imvlimited.com/mid/news_ctpr.html.
6
Department of Health. (2002). Total Number of Imaging and Radiodiagnostic Examinations or Tests, by Imaging
Modality, England, 1995-96 to 2001-02.
www.doh.gov.uk/hospitalactivity/data_requests/imaging_and_radiodiagnostics/ts_imag.xls.
7
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McNight RD, Verbeek R, Brison R, Cass D,
Eisenhauer ME, Greenberg G, Worthington J. (2001). The Canadian CT head rule for patients with minor head
injury. Lancet, 357(9266), 1391-1396.
8
Oguz KK, Yousem DM, Deluca T, Herskovits EH, Beauchamp NJ. (2002). Effect of emergency department CT on
neuroimaging case volume and positive scan rates. Academic Radiology, 9(9), 1018-1024.
9
Stiell IG, Worthington J, Dreyer J, Vandemheen K, Clement C, De Maio V, Schull M, Reardon M, Morrison L,
McKnight D, MacPhail I, Greenberg G, Eisenhauer M, Cass D, Brison R, Wells G. (2003). Comparison of the
Canadian CT head rule to physician judgement. Canadian Journal of Emergency Medicine, 2(3), 49.
10
Stiell IG, Clement C, Wells GA, Brison R, McKnight RD, Schull M, Rowe BH, Dreyer JA, Bandiera G, Lee J,
MacPhail I, Lesiuk H. (2003). Multicenter prospective validation of the Canadian CT head rule. Academic
Emergency Medicine, 10(5), 539.
11
Coyle D, Stiell IG, Wells GA, Clement C. (2003). Economic evaluation of the potential impact of the Canadian CT
head rule. Academic Emergency Medicine, 10(5), 554.
12
Needham G, Currie DG. (2002). Canadian CT head rule for patients with minor head injury. Clinical Radiology,
57(2), 152-153.
13
Rankin RN. (1999). Magnetic resonance imaging in Canada: Dissemination and funding. Canadian Association
of Radiologists Journal, 50(2), 89-92.
14
Iron K, Przybysz R, Laupacis A. (2003). Access to MRI in Ontario: Addressing the Information Gap. Toronto:
Institute for Clinical Evaluative Sciences.
15
Robert G, Milne R. (1999). Positron emission tomography: Establishing priorities for health technology
assessment. Health Technology Assessment, 3(16), 1-54.
16
Zeidenberg J. (2003). Ontario’s First Private-Sector PET Imaging Clinic Open for Business.
www.canhealth.com/may03.html#anchor58697.
17
Adams EJ, Asua J, Conde Olasagasti JG, Erlichman M, Flynn K, Hurtado-Saracho I. (1999). Positron Emission
Tomography: Experience With PET and Synthesis of the Evidence. Stockholm: International Network of Agencies
for Health Technology Assessment.
18
Minnesota Department of Health. (1999). Positron Emission Tomography for Oncologic Applications.
www.health.state.mn.us/htac/pet.htm.
19
Laupacis A. (2001). Health Technology Assessment of Positron Emission Tomography: Executive Summary.
Toronto: Institute for Clinical Evaluative Sciences. www.ices.on.ca/PDFs/TechnicalReports/PET-ExSum.pdf.
20
Benk V, Laupacis A, Paszat L, Hodgson D. (2003). Health Technology Assessment of Positron Emission
Tomography (PET) in Oncology: A Systematic Review. Toronto: Institute for Clinical Evaluative Sciences.
www.ices.on.ca/PDFs/TechnicalReports/PET_report_May2003.pdf.
21
Dussault FP, Nguyen VH, Rachet F. (2001). Positron Emission Tomography in Quebec. Montreal: Agence
d’évaluation des technologies et des modes d’intervention et santé (AÉTMIS).
22
Auditor General of Quebec. (2001). Report to the National Assembly for 2000–2001, Volume 1. Quebec:
Government of Quebec.
23
Legislative Assembly of Saskatchewan. (2000). No. 50 Votes and Proceedings: First Session - Twenty-Fourth
Legislature. www.legassembly.sk.ca/journals/Votes/24L1S/2401vp50.htm.
24
Legislative Assembly of British Columbia. (2001). Select Standing Committee on Health: Minutes and Hansard.
www.legis.gov.bc.ca/cmt/37thparl/session-2/aaf/hansard/a11024p.htm.
2 Medical Imaging in Practice
For More Information
27
Imaging Technologies—
Supply and Capital Costs
This chapter addresses these and related questions, but it’s only part of the picture.
The supply of machines needs to be considered in the context of many of the factors
covered in this and other chapters of this report. For example, an important factor is
how imaging machines are used to provide care (see Chapter 2). So is the number and
mix of medical imaging professionals (see Chapter 4) and the context in which imaging
technologies are used (see Chapter 5).
How Many are There?
Many different kinds of imaging machines are used in clinical practice today, from
new equipment that is still in development to well-established technologies. Overall,
we know more about the numbers and distribution of some newer technologies than
about several of the more common, such as X-ray and ultrasound.
CIHI’s recent National Survey of Selected Medical Imaging Equipment tracked six
types of imaging equipment.! As of January 1, 2003, it counted:
• 594 nuclear medicine cameras,
• 147 MRI scanners,
• 326 CT scanners,
• 94 catheterization laboratories, and
• 165 angiography suites,
• 14 PET scanners.
These imaging technologies have been introduced into clinical practice at different
times, and their diffusion rates vary. For example, the number of CT and MRI scanners
has grown significantly since they were introduced (in 1973 and 1985 respectively).
Since 1990, the number of CT scanners has grown by 65% whereas MRIs have grown
by 674%. Overall, growth in the number of MRI scanners has outpaced that for CT
machines since 1997.
What accounts for the variations in the speed with which different innovative technologies
are adopted and diffused? A number of factors may be involved, including the functional
capability of the innovation; usefulness and cost of the new equipment; practice patterns;
health policies; funding mechanisms; and attitudes toward new technologies.1–3
!
The survey also counted lithotriptors, but results will be reported elsewhere.
3 Imaging Technologies—Supply and Capital Costs
3
In Chapter 2, we looked at the changing utilization of medical imaging technologies in
health care. Often, however, the focus seems to be more narrow—how many machines
we have, as well as how that quantity compares over time and with other countries.
Medical Imaging in Canada
About the National Survey of Selected
Medical Imaging Equipment
Over a period of many years, the Canadian Coordinating Office for Health Technology
Assessment (CCOHTA) conducted a survey on the number, distribution, and key
characteristics of selected imaging technologies in Canadian hospitals. Following
discussions with CCOHTA, CIHI undertook a similar survey in 2003. Basic information
on the survey is provided below. For more information, see CIHI’s Web site: www.cihi.ca.
What’s Included: The CIHI survey tracked data on machines installed in Canadian
hospitals and those in free-standing imaging facilities (sometimes also called
“non-hospital”, “community-based”, and/or “private” facilities) as of January 1, 2003.
The imaging machines covered by the survey (angiography suites, catheterization labs,
CT scanners, MRI scanners, nuclear medicine cameras, and PET scanners) were the
same as those surveyed by CCOHTA in 2001.
The Survey Process: CIHI retained the services of ProMed Associates Ltd. to coordinate
data collection. They contacted health regions and hospitals and relevant free-standing
imaging facilities across Canada. Various medical and technical organizations and
provincial/territorial ministries of health were asked to encourage participation in the survey.
Most respondents completed the survey using a bilingual Web site. To maximize response
rates, ProMed Associates Ltd. completed several rounds of follow-up with respondents.
18
Trends in MRI and CT Scanners in Canada
Numbers of magnetic resonance imaging (MRI) and computed
tomography (CT) scanners in Canada between 1983 and 2003,
including units in hospitals and in free-standing imaging facilities.
350
Number of Scanners
300
250
200
150
100
50
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
Year
CT
MRI
Notes: 1) The numbers of MRI and CT scanners in free-standing imaging facilities were
imputed for years prior to 2003 based on data collected in the 2003 National Survey of
Selected Medical Imaging Equipment. 2) CCOHTA inventories were not conducted
annually. A dotted line is drawn between data points spanning two years or more.
30
Sources: OECD Health Data 2002, OECD (1983–1990)
National Inventory of Selected Imaging Equipment, Canadian Coordinating
Office for HealthTechnology Assessment (1991–2001)
National Survey of Selected Medical Imaging Equipment, CIHI (2003)
Validating the Results: To ensure that
the coverage was as complete as possible,
responses were cross-checked against
results from CCOHTA’s 2001 survey, lists
provided by medical imaging technology
manufacturers, published lists of
equipment (e.g. research reports and
health directories), and data reported
by hospitals and health regions to
CIHI’s Canadian MIS Database.
Provincial/territorial ministries of
health were also asked to validate
overall equipment counts. In addition,
ProMed Associates reviewed information
submitted and contacted participants for
follow-up where required. All equipment
captured in the 2001 survey was captured
in 2003. An additional 317 machines (31%
more than in the 2001 survey) were also
identified, including those located in freestanding imaging facilities (not captured
in previous surveys).
Most Canadians receive imaging services in the province or territory where they live, although
some travel within their jurisdiction or to other parts of the country for care. All provinces now
have nuclear medicine cameras,
19
Imaging Technologies in Canada in 2003
angiography suites, CT scanners,
Number of units per million population of selected imaging
and MRI machines,! as well as other
technologies in Canadian hospitals and free-standing imaging
imaging technologies, such as X-ray
facilities as of January 1, 2003.
and ultrasound services.
20
Number of Units Per Million Population
18.9
18
16
14
12
10.3
10
8
5.2
6
4.7
4
3.0
2
0.4
PET Scanners
Catheterization
Labs
MRI Scanners
Angiography
Suites
CT Scanners
Nuclear
Medicine
Cameras
0
Note: Of the 14 PET scanners in Canada, eleven can accommodate full body
scans; three can only accommodate head scans.
Rates of equipment per population
do, however, vary across the country.
For example, as of January 2003,
Ontario, with the largest population
in Canada, had the largest numbers
of CT scanners (95). However, it had
the fewest CT machines per million
population (7.8). In contrast, with one
CT scanner, the Yukon Territory has
the largest per capita ratio (33.5).
That said, more machines do not
FF
necessarily mean more scans
(see Chapter 2).
3 Imaging Technologies—Supply and Capital Costs
The Supply of Imaging Technologies in Canada
Source: National Survey of Selected Medical Imaging Equipment, CIHI
20
Distribution of Imaging Technologies Across Canada in 2003
Numbers (#) and numbers of units per million population (rate) of selected imaging technologies in hospitals and
free-standing imaging facilities by jurisdiction as of January 1, 2003.
Jurisdiction
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Nun.
N.W.T.
Y.T.
Canada
Nuclear
Medicine Cameras
#
Rate
CT Scanners
#
Rate
Angiography MRI Scanners Catheterization PET Scanners
Labs
Suites
#
Rate
#
Rate
Rate
#
Rate #
61
14.7
44
10.6
20
54
17.2
30
9.6
14
13.9
10
9.9
16
13.9
14
244
20.1
151
18
20.2
23.8
23
2
10
2.6
2
0.5
11
3.5
2
0.6
4
4.0
2.6
4
3.5
–
–
–
–
50
4.1
36
3.0
6
0.5
40
5
5.5
6.6
21
2
2.8
2.6
4
–
0.5
–
5.3
4
4.2
3
3.2
–
–
7.1
–
–
–
–
–
–
20.7
4
7.5
1
1.9
2
3.8
–
–
4.3
11
23
7.3
3
3.0
2.6
3
66
5.5
38
9
5.1
11.9
15.9
5
14.2
1
4.8
18
15
4.8
4
4.0
12.2
3
95
7.8
94
9
12.6
11.9
24.4
15
14.2
2
18.8
11
–
–
–
–
–
–
–
–
–
–
–
–
1
24.2
1
24.2
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
5.2
147
4.7
94
3.0
14
0.4
–
–
1
33.5
–
594
18.9
326
10.3
165
Note: Of the 14 PET scanners in Canada, eleven can accommodate full body scans, and three can only accommodate head scans.
Source: National Survey of Selected Medical Imaging Equipment, CIHI
Prince Edward Island’s new MRI machine was not counted in the national survey since it was installed in the spring of 2003.
31
!
Medical Imaging in Canada
In some cases, it is also helpful to consider the mix of
equipment available in a jurisdiction. For example, although
the capabilities of MRIs and CTs differ for specific applications,
there are areas where the modalities overlap. As a result, some
suggest that a high availability of CT services might reduce
acquisition of MRIs.4 Interestingly, Newfoundland and Labrador,
the province with the highest per capita rate of CTs (20.7 per
million population), also has the lowest rate of MRIs (1.9). On
the other hand, Alberta has the most MRIs per capita (7.3 per
million) but fewer CTs (9.6) than most jurisdictions.
Technology At Our Fingertips
With digital imaging comes the potential to acquire, review, distribute,
and archive image information electronically. Picture Archiving and
Communications Systems (PACS) are designed to undertake several
of these functions. Evaluating the impact of these systems
on cost, quality, and other outcomes is challenging, partly because
the technology continues to evolve and has been implemented in
different ways in different places.5
Canadian hospitals began implementing PACS systems many years
ago, but comprehensive information about who is using what types of
systems and how is not currently available. Implementation is,
however, continuing. For example, six projects with PACS
components have been moving forward under the Canada Health
Infostructure Partnerships Program, including ones with Central BC
and the Yukon, Manitoba Telehealth, Saskatchewan Telehealth, NORad
(which includes nine Northeastern Ontario hospitals), NORTH
Network, and Health Infostructure Atlantic (which includes New
Brunswick, Newfoundland, Nova Scotia, and Prince Edward Island).6
Ratios of MRIs to CTs
Ratios of MRIs to CTs in hospitals and
free-standing imaging facilities by
jurisdiction as of January 1, 2003.
Jurisdiction
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Nun.
N.W.T.
Y.T.
Canada
MRI:CT Ratio
1:2.5
1:1.3
1:3.3
1:4.7
1:1.9
1:2.3
1:1.8
1:3.8
–
1:10.9
–
–
–
1:2.2
Source: National Survey of Selected
Medical Imaging Equipment, CIHI
The International Context
Internationally, the Organization for Economic Cooperation and Development (OECD) has
reported large variations in the supply of medical imaging technologies among member
countries. For instance, the per capita ratio of CT machines for Japan (data for 1999) was triple
that of Korea (2001), the country with the next highest ratio; almost 9 times that of Canada
(2001); and fifteen times that of England (2001).
All OECD countries where data are available report more CTs and MRIs over time, but some
have acquired the technologies at a faster rate than others. For example, throughout the 1990s,
the number of MRIs per capita in Canada grew less quickly than Spain’s and Australia’s, but
more quickly than those of the Czech Republic and Greece.
As is true in Canada, having more machines does not necessarily mean that more people
receive imaging services. A wide range of factors may explain the variations in the international
supply pattern of medical imaging services and technologies. In the case of Japan, for
example, the high per capita ratio of MRIs has been partly attributed to the market situation of
the medical engineering industry, as well as sociocultural factors such as a bias towards new
32
21
22
MRIs in OECD Countries
Number of magnetic resonance imaging (MRI) scanners
per million population in selected OECD countries with a
population of a million or more and the year for which
rates were reported.
Number of computed tomography (CT) scanners per
million population in selected OECD countries with a
population of a million or more and the year for which
rates were reported.
Number of MRIs Per Million Population
0
10
5
15
20
Japan (1999)
Number of CTs Per Million Population
25
23.2
United States (2001)
17.4
Switzerland (1999)
13.0
Finland (2001)
Austria (2001)
Sweden (1999)
7.9
23
CTs in OECD Countries
10 20 30 40 50 60 70 80 90
0
Japan (1999)
84.4
Korea (2001)
27.3
Austria (2001)
11.7
Italy (1999)
11.6
Switzerland (1999)
26.3
19.6
18.5
Sweden (1999)
14.2
Korea (2001)
6.8
Finland (2001)
13.7
Italy (1999)
6.7
Denmark (2001)
13.2
Denmark (2000)
6.6
England (2001)
5.4
Median
5.4
Spain (2000)
4.9
Australia (2000)
4.7
Canada (2001)
4.2
France (1999)
2.8
Czech Republic (2001)
1.9
Spain (2000)
12.2
Czech Republic (2001)
11.4
Median
11.4
New Zealand (2001)
10.6
Turkey (2001)
10
Canada (2001)
9.7
France (1999)
9.6
Slovak Republic (2001)
8.6
Greece (1999)
1.5
Greece (1999)
Hungary (2000)
1.5
England (2001)
1.3
Hungary (2000)
Slovak Republic (2001)
Mexico (2000)
0.3
Mexico (2000)
3 Imaging Technologies—Supply and Capital Costs
technologies.7 Furthermore, decisions by individual countries about which types of imaging
technology to invest in, and how many machines to acquire, may depend on a variety of
domestic factors, including the state of the assessment of the appropriateness of a particular
technology’s use in different clinical situations and environments (see Chapter 5).
7.8
5.8
5.4
2
General Notes: 1) Countries for which only data prior to 1999 were available are not shown.
2) Mexico only counts scanners located in public institutions.
3) Units located both in hospitals and in free-standing imaging facilities are included for Canada. The number of MRI and CT scanners in free-standing
imaging facilities was imputed for 2001 based on data collected in the 2003 National Survey of Selected Medical Imaging Equipment.
MRI Notes: 4) Australian numbers include only units approved for billing to Medicare.
5) Only units located in hospitals are counted in Japan.
6) Units located both in hospitals and non-hospital sites are included for the United States. “Mobile” MRI units are not included. IMV was used as the data source
because it counts the number of MRIs, whereas OECD figures count the number of hospitals that report having at least one scanner.
CT Notes: 7) Greece and Hungary do not include CT scanners from military hospitals.
8) Japan only counts CT scanners in hospitals and general clinics.
9) CT scanners installed in the private sector are not counted in England.
10) OECD estimates for the United States refer to the number of hospitals that report having at least one scanner, rather than the total number of machines.
Accordingly, they were not included.
Sources: OECD Health Data 2002, OECD
National Inventory of Selected Imaging Equipment
Canadian Coordinating Office for Health Technology Assessment (2001 data for Canada)
Information Services for the Health Care and Scientific Markets (IMV) (data for the United States)
33
Trends in the number of magnetic resonance imaging (MRI) scanners per million population between
1983 and 2003 in selected OECD countries (Canada and the five countries whose most recent rates of
scanners per million population were closest to Canada’s in 2001).
6
Number of MRIs Per Million Population
Medical Imaging in Canada
24
MRI Trends
5
4
3
2
1
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
Year
Canada
Czech Republic
Greece
France
Australia
Spain
25
CT Trends
Trends in the number of computed tomography (CT) scanners per million population between 1983 and
2003 in selected OECD countries (Canada and the five countries whose most recent rates of scanners per
million population were closest to Canada’s in 2001).
Number of CTs Per Million Population
14
12
10
8
6
4
2
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
Year
Canada
Greece
New Zealand
Czech Republic
France
Spain
Notes: 1) Yearly data on the number of machines are not available for every country.
A dotted line is drawn between data points spanning two years or more.
2) Australian MRI numbers include only units approved for billing to Medicare.
3) England was not included because prior to 2000 data were collected for all of United Kingdom;
therefore, data prior to 2000 are not comparable to 2001 data.
4) Units located both in hospitals and in free-standing imaging facilities are included for Canada for all years.
The number of MRI and CT scanners in free-standing imaging facilities was imputed for years prior to 2003 based on data
collected in the 2003 National Survey of Selected Medical Imaging Equipment.
34
Sources: OECD Health Data 2002, OECD
National Inventory of Selected Imaging Equipment
Canadian Coordinating Office for Health Technology Assessment (1991–2001 data for Canada)
National Survey of Selected Medical Imaging Equipment, CIHI (2003 data for Canada)
Hospitals typically offer a range of medical imaging services, but some types of imaging are
also available elsewhere. For example, there is a well-established practice of free-standing
facilities offering X-ray and ultrasound services.
Number of MRI Scanners
The extent to which imaging services are available outside of hospitals varies by imaging
modality. Services such as CT and MRI, for example, tend to be located in densely populated
areas and are often found in teaching
26
and large community hospitals.
MRI Scanners Outside of Hospital
Approximate number of magnetic resonance imaging (MRI) scanners in
However, the number in free-standing
free-standing imaging facilities in Canada between 1997 and January 2003.
(or non-hospital) imaging facilities is
30
growing. As of January 2003, about
25
3% of CTs and 18% of MRIs were
20
in this type of facility, up from an
estimated 2% and 15%, respectively,
15
in July 2001. This transition has not
10
been without controversy, as Chapter
5
5 describes. (For locations of
0
selected imaging modalities across
1997
1998
1999
2000
2001
2002
2003
Canada, please see Appendix A—
Year
Fast Facts).
3 Imaging Technologies—Supply and Capital Costs
Where Imaging Technologies are Located
FF
Note: The numbers of MRI scanners were imputed for years prior to
2003 based on data on year of installation reported in the 2003 survey.
Source: National Survey of Selected Medical Imaging Equipment, CIHI
Aging and Renewal of Medical
Imaging Technologies
The age of Canada’s imaging technologies varies by modality and across the country. For
example, while about 38% of catheterization labs were under five years old at the beginning
of 2003, 73% of MRIs were in
27
this category.
Age of Imaging Technologies in Canada in 2003
Percentage of units by years since installation for selected medical
imaging technologies located in Canadian hospitals and free-standing
imaging facilities as of January 1, 2003 (some machines were upgraded
since installation).
Angiography
Suite
Catheterization
Lab
CT
MRI
Canada’s MRI and CT machines
also tend to be somewhat newer than
those in many European countries.
In 2001, the proportion of scanners
that were installed in Canadian
hospitals under five years old was
higher than that in hospitals in
selected European countries.
Nuclear
Medicine
PET
0%
10%
20%
30%
0–5 years
40%
50%
6–10 years
60%
70%
80%
90%
100%
Greater than 10 years
Source: National Survey of Selected Medical Imaging Equipment, CIHI
35
Medical Imaging in Canada
Like other equipment, medical
imaging technologies do not last
indefinitely, but there is no universally
agreed standard about when
equipment should be replaced or
updated. For example, both the
Canadian Association of Radiologists
and the British Royal College of
Radiologists estimate that an imaging
machine’s useful life varies between
6 years (e.g. for MRIs) and 10 years
(e.g. for X-ray machines).8, 9 On the
other hand, the Quebec Ministry
of Health and Social Services
recently advised the Quebec Auditor
General that maximum life spans of
between 9 and 18 years respectively,
were appropriate.10
28
Age of CTs and MRIs in Canadian and European
Hospitals in 2001
Percentage of units by years since installation of CTs and MRIs located
in Canadian and European hospitals in 2001.
Belgium
Canada
Finland
France
Germany
Italy
The Netherlands
Spain
Sweden
United Kingdom
0%
10%
20%
30%
0–5 years
40%
50%
60%
6–10 years
70%
80%
90%
100%
Greater than 10 years
Notes: Data for European countries represent data from four major companies which
supply diagnostic imaging equipment to European hospitals. The study relies on data
that do not cover 100% of the installed equipment, but the companies involved in the
study represent a high share of the total installed base. The companies are:
General Electric Systems Europe, France; Philips Medical Systems, The Netherlands;
Siemens Medical Solutions, Germany; Toshiba Medical Systems, The Netherlands.
Sources: European Coordination Committee of the Radiological and Electromedical
Industries. (2003). Age Profile Medical Devices, Third Edition: The Need for Sustained
Investment. Frankfurt: COCIR; National Inventory of Selected Imaging Equipment,
Canadian Coordinating Office for Health Technology Assessment (data for Canada)
The age of equipment may matter for
a number of reasons. According to the
Canadian Association of Radiologists,
outdated equipment may carry a higher
risk of failure or breakdown, which may disrupt imaging services.8 Furthermore, they suggest
that it may be more difficult to obtain spare parts for older equipment; that there may be cost
implications (i.e. maintenance fees) involved when updating older equipment; and that older
machines may produce poorer quality images. At the same time, upgrading or replacing
equipment can be costly, both in terms of capital costs and for other reasons, such as
retraining staff.
Buying and Replacing Equipment:
Capital Costs
36
29
Capital Spending Across Canada
Total capital spending in health care (expenditures on construction,
machinery, and equipment of hospitals, clinics, first-aid stations, and
residential care facilities) by public and private sector payers in Canada
between 1990 and 2002 (forecast).
6
Total spending on capital ($ billions)
In 2002, Canada spent $4.8 billion
on construction, machinery, and major
equipment in the health sector.11
Capital costs represented about
4.3% of total health spending
(forecast). Most (89%) came through
provincial/territorial governments;
about 11% came from the private
sector. Both sources of funds and
levels of capital spending have
fluctuated over time. After a
comparatively lean period in the
early to mid 1990s, spending has
risen steadily in recent years.
5
4
3
2
1
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Public sector
Private sector
Total
Note: Open symbols represent forecast figures.
Source: National Health Expenditure Database, CIHI
30
Medical imaging equipment
accounts for an important, but
unknown, share of total capital
spending. “Big ticket” technologies
120
such as MRI and CT scanners have
100
high initial costs compared to
80
common technologies such as
60
X-rays and ultrasounds. An MRI
40
costs over $2 million (Cdn),
whereas the average cost of a CT
20
scanner is about $1 million according
1998
1999
2000
2001
2002
to the UK Audit Commission.12
Apparatus based on the use of X-rays—for medical, surgical, or veterinary uses NES
Viewed in another way, for the cost
Apparatus based on the use of X-rays—for radiography, radiotherapy
of one MRI, it would be possible to
Ultrasonic scanning apparatus
CT apparatus
buy about five X-ray machines at about
MRI apparatus
$340,000 each or 12 ultrasound
X-ray tubes
Apparatus based on the use of X-rays—for dental uses NES
machines at about $160,000 each.
Of course, making these choices
Source: Trade Data Online, Industry Canada based on data from Statistics Canada
would affect which types of patients
would benefit, operating costs, and many other factors. PET scanners are much more
expensive: about $2.5 million to $4.6 million depending on whether a cyclotron is present.13
Trade deficit ($ millions)
Canada’s trade deficit (total imports minus total exports) for selected
imaging equipment and supplies in millions of Canadian dollars (not
adjusted for inflation) between 1998 and 2002.
3 Imaging Technologies—Supply and Capital Costs
Net Imports of Imaging Equipment
Canada’s total spending on medical imaging equipment is a fraction of worldwide sales,
which are estimated at $14.5 billion in 2002.14 The majority of the devices used in Canada,
as well as the parts to maintain them, come from outside the country. The bulk of our
imports come from the United States, Germany, and Japan. The United States alone
accounted for 57% of MRI, 50% of radiography and radiotherapy X-ray, 66% of ultrasound,
and 53% of CT apparatus imports in 2002.15
Domestically, there were about 15 companies in the medical imaging/radio-therapy sector
(including expenditures for equipment such as X-ray, ultrasound, MRI, nuclear medicine, etc.)
in 2000, according to Statistics Canada’s Medical Devices Industry Survey. Together, this
sector had just over $115 million in net medical devices sales in 1999. Firms forecast that
sales would grow to $194 million by 2002.16
Where the Money Comes From
37
Funding to buy medical imaging equipment comes from many sources. Many
provincial/territorial governments fund the purchase and replacement of non-major equipment
through regular health region/hospital operating funds.17 Funds for specific larger projects, on
the other hand, may be allocated directly by the ministry of health or through regional health
authorities. Such purchases are often also funded at least partly through non-governmental
sources such as hospital foundations and private funding agencies, among others. Some are
also partly or wholly paid for by research grants. For example, a study of funding sources for
MRI equipment in Canada in 1997 reported that about 23% of the capital spending for the then
national inventory of MRI machines was provided by direct government grants.18 Free-standing
imaging facilities may also invest in or lease the equipment that they use. Part of what they
charge for their services goes towards recovering capital costs.
Medical Imaging in Canada
In recent years, the federal government has also played a role in funding imaging and other
equipment. In September 2000, it created a $1 billion Medical Equipment Fund to assist
provinces and territories with purchasing and installing equipment. There has been some
controversy regarding how and how
quickly these funds were spent,19 but
Medical Equipment Fund Spending in Ontario
Selected diagnostic equipment purchases made by Ontario health
the Romanow Commission and Kirby
care facilities using the funds from the Federal Medical Equipment
Committee both called for expanded
Trust Fund for 2000/2001 and 2001/2002.
investment in this area. Following the
X-ray
2003 First Ministers Accord, the
Cancer
federal government announced a
Equipment
new $1.5 billion Diagnostic/Medical
Ultrasound
Equipment Fund. This fund is
CT
intended to support specialized staff
Nuclear
Medicine
training and equipment, and to
Other
improve access to publicly funded
20
diagnostic services.
Mammography
31
MRI
$0
$10
$20
$30
$40
$50
$60
$70
Expenditure ($ millions)
Notes: 1) Expenditure on the above medical equipment also includes
dollars spent on accessories and upgrades.
2) The “Other” category includes other diagnostics and therapeutics
such as bone densitometry, echocardiography, and ECG systems.
38
Source: Federal Medical Trust Fund—Ontario’s Share Report For The 2000–01 and
2001–02 Fiscal Years, Ontario Ministry of Health and Long-Term Care, March 2003,
www.health.gov.on.ca/english/public/pub/ministry_reports/med_equip/med_equip.pdf.
What We Know
• How many MRIs, CTs, and other selected imaging technologies are installed in hospitals
and free-standing imaging facilities across Canada and where they are located.
• How selected technology-to-population ratios in Canada compare with those in other
•
•
•
•
OECD countries.
Patterns of diffusion of MRI and CT scanners in Canada and in other OECD countries
over time.
The age range of different technologies in Canada and in some European countries.
Total capital expenditures by the public and private sector for each province/territory
and Canada.
Total imports and exports of selected medical imaging equipment for Canada
over time.
3 Imaging Technologies—Supply and Capital Costs
Information Gaps:
What We Don’t Know
• What number and mix of imaging technologies at regional, provincial,
and national levels would best meet health care needs?
• What factors should be taken into account in life-cycle planning for equipment?
At what point do imaging technologies require upgrading or replacement based
on patient safety, quality of care, cost-effectiveness, and other considerations?
• How much in total is spent to purchase various types of medical imaging equipment?
How does the public/private funding mix for capital and operating costs differ among
imaging technologies and across the country? Are there resulting implications
concerning the mix of imaging services that Canadians receive, access to care, overall
spending, and the cost effectiveness of imaging services?
What’s Happening
• In September 2000, first ministers agreed on a vision, principles, and action plan for
health system renewal; the First Ministers’ Accord on Health Care Renewal followed in
2003. This accord sets out an action plan for reform, which includes establishing new
investments to improve access to publicly funded diagnostic services.
• Commencing in 2004, first ministers agreed to report to their citizens on an annual basis
on enhancements to diagnostic and medical equipment and services. This reporting is
intended to inform Canadians on progress achieved and key outcomes.
• To track the nature, distribution, and use of medical imaging equipment, CIHI conducted
a pan-Canadian survey of selected technologies in hospitals and in free-standing imaging
facilities in 2003.
• The Canadian Association of Radiologists is conducting a survey about the distribution
and implementation of PACS in Canada. The survey will examine the number of
diagnostic imaging departments and clinics that have PACS, the percentage of work
that is filmless, the provincial distribution of PACS, the number of diagnostic imaging
departments and clinics that have plans to implement PACS within the next 3–5 years,
and the level of support for PACS.
39
Medical Imaging in Canada
40
For More Information
1
Amendola M, Gafford J. (1988). The Innovative Choice: An Economic Analysis of the Dynamics of Technology. Oxford:
Basil Blackwell Limited.
2
Dodgson M, Bessant J. (1996). Effective Innovation Policy: A New Approach. London: International Thompson
Business Press.
3
Battista RN, Jacob R, Hedge MS. (1995). Health Care Technology in Canada (with special reference to Quebec).
Washington, DC: U.S. Government Printing Office.
www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk1/1995/9562/956205.PDF.
4
Australian Health Technology Advisory Committee. (1997). Review of Magnetic Resonance Imaging.
www.health.gov.au/haf/mri/mriahtac.pdf.
5
VA Research and Development. (1997). Picture Archiving and Communication Systems: A Systematic Review of
Published Studies of Diagnostic Accuracy, Radiology Work Processes, Outcomes of Care, and Cost.
www.va.gov/resdev/ps/pshsrd/pacs.pdf.
6
Personal communication. (2003). Office of Health and the Information Highway, Health Canada.
7
Hisashige A. (1994). The introduction and evaluation of MRI in Japan. International Journal of Technology
Assessment in Health Care, 103, 392-405.
8
Canadian Association of Radiologists. (2000). Special Ministerial Briefing - Outdated Radiology Equipment: A
Diagnostic Crisis. Montreal: Canadian Association of Radiologists.
9
European Coordination Committee of the Radiological and Electromedical Industries. (2003). Age Profile Medical
Devices, Third Edition: The Need for Sustained Investment. Frankfurt: COCIR.
10
Le Vérificateur Général du Québec. (2001). Rapport à l’Assemblée nationale pour l’année 2000-2001 (1) - Services
d’imagerie médicale. Québec : Gouvernement du Québec.
11
Canadian Institute for Health Information. (2002). National Health Expenditures Trends 1975-2002. Ottawa: CIHI.
12
The Audit Commission. (2002). Radiology: Acute Hospital Portfolio. Review of National Findings. London,
United Kingdom: The Audit Commission.
www.audit-commission.gov.uk/Products/AC-REPORT/AB95E11A-A6C1-4335-9482-618441DB347/Radiology_Full.pdf.
13
Agency for Health Services and Technology Assessment (AETMIS). (2001). Positron Emission Tomography Fact
Sheet. www.aetmis.gouv.qc.ca/fr/publications/scientifiques/ imagerie_medicale/2001_03_ann_en.pdf.
14
Medtech Insight. (2002). The World Wide Market for Diagnostic Imaging Equipment.
www.medtechinsight.com/Report1491.html.
15
Industry Canada. (2003). Trade Data Online. http://strategis.ic.gc.ca/sc_mrkti/tdst/engdoc/tr_homep.html.
16
Statistics Canada. (2001). Medical Devices Industry Survey 2000. Ottawa: Statistics Canada.
17
McKillop I, Pink GH, Johnson LM. (2001). The Financial Management of Acute Care in Canada: A Review of Funding,
Performance Monitoring, and Reporting Practices. Ottawa: CIHI.
18
Rankin RN. (1999). Magnetic resonance imaging in Canada: Dissemination and funding. Canadian Association of
Radiologists Journal, 50(2), 89-92.
19
Canadian Medical Association. (2002). Wither the Medical Equipment Fund? Background Paper and Technical Notes.
www.cma.ca/cma/staticContent/HTML/N0/l2/advocacy/ news/2002/MedicalEquipmentFund.pdf.
20
Federal/Provincial/Territorial First Ministers. (2003). First Minister’s Accord on Health Renewal.
www.scics.gc.ca/pdf/800039004_e.pdf.
4
Medical Imaging Professionals
Who’s Who In Medical Imaging
Medical imaging professionals are a diverse group.! A growing and changing array of
trained imaging professionals work together across the country. The size, composition,
distribution, and inter-relationships among these professionals can vary depending on
the imaging facility, in which part of the country the facility is located, and on the
procedure being performed. In addition to the patients themselves, imaging services
often involve referring physicians who order imaging tests and inform patients of their
results; technologists who operate the equipment and ensure patient safety;
radiologists or nuclear medicine specialists who supervise tests, read and interpret
test results, and consult with referring physicians; nurses who assist with any clinical
requirements, such as sedation, breast examination, or injections; clerical staff who
book appointments; medical physicists who ensure optimum performance of
equipment; and service engineers who maintain and service equipment. Other
professionals—such as dentists, chiropractors, and obstetrician/gynaecologists—may
also use medical imaging equipment as part of the services that they offer to patients.
Medical Radiation Technologists (MRTs)
Canada’s 14,700-plus medical radiation technologists (MRTs) make up the bulk of the
medical imaging workforce. They include radiological, nuclear medicine, radiation
therapy,! and magnetic resonance technologists.
FF
Radiological technologists, also called radiographers, comprise about 80%
(about 11,650) of all active MRTs. They often work in hospitals, or free-standing imaging
facilities to produce diagnostic X-ray images of specified parts of the body, as well as
conduct some therapeutic procedures. Radiological technologists may operate X-ray
equipment including plain film radiography, mammography, angiography, fluoroscopy, and
!
Detailed role descriptions of physician specialists in imaging (www.rcpsc.medical.org), MRTs (www.camrt.ca), sonographers
(www.csdms.com/pdf/scope.pdf), and medical physicists (www.medphys.ca) can be found at their respective websites.
!
For the purpose of this report we focus on diagnostic technologists (radiological, MRI, and nuclear medicine technologists)
rather than therapeutic sub-disciplines (radiation therapy).
4 Medical Imaging Professionals
In the world of science fiction, many machines think for themselves, although like
the superhuman android “Data” on Star Trek, they rarely have human feelings. In practice,
even today’s most sophisticated imaging technologies are relatively inert machines.
They require skilled professionals to guide patients through the testing process; design,
install, operate, and maintain the equipment; interpret imaging results; and perform the
many other functions that are essential to providing effective imaging services. This
chapter focuses on what we know and don’t know about the many professionals who
work with X-rays, ultrasounds, MRIs, CTs, and other types of medical imaging equipment.
The number of selected medical imaging professionals in
Canada, 2001.
16,000
14,749
14,000
12,000
10,000
8,000
6,000
1,903
214
277
Medical
physicists
2,505
2,000
Nuclear
medicine
physicians
4,000
Diagnostic
radiology
physicians
Sonographers
0
MRTs
Nuclear medicine technologists
(NMTs) comprise about 11% of all
MRTs. These professionals also
work primarily in hospitals and
in free-standing imaging facilities.
The approximately 1,600 NMTs
across Canada administer
radioactive materials (tracers) and
operate special detectors (gamma
cameras) and computers to
produce diagnostic images of
body function.1 Nuclear medicine
technologists may also assist with
some treatment procedures, and
some are trained to operate
positron emission tomography
(PET). Like radiological
technicians, NMTs can also
further specialize in the field
of magnetic resonance.
32
Imaging Professionals
Number of professionals
Medical Imaging in Canada
computed tomography (CT). A
radiographer can further specialize
in the area of magnetic resonance
imaging (MRI).1
Notes: MRT category includes radiological technologists, nuclear medicine
technologists, and radiation therapists.
Physician data are as of December 31 of given year and include physicians in clinical
and/or non-clinical practice. Data exclude residents and physicians who are not
licensed to provide clinical practice and those who have requested to the Business
Information Group (formerly Southam Medical Group) that their data not be published.
Specialty is based on most recent certified specialty, and data may differ from other
sources of provincial/territorial physician data that categorize physicians on some
other basis (e.g. functional specialty, payment specialty, or provisional licenses).
Data for medical physicists include only those registered with the
Canadian Organization of Medical Physicists.
Sources: 2001 Census of Canada, Statistics Canada (sonographer data). Southam
Medical Database, CIHI (physician data).
Health Personnel in Canada, CIHI (medical physicists and MRT data).
Sonographers
There were about 2,500 sonographers (also known as ultrasonographers) practicing across
Canada in 2001. They perform ultrasounds in various health care settings and report the initial
technical findings to supervising clinicians.1 They can be registered in one or more areas or
specialties, including general sonography, vascular sonography, and cardiac sonography. In
Quebec, they are grouped with MRTs and are regulated accordingly. In the rest of Canada,
sonographers are considered a separate professional group.
Physician Specialists/Consultants in Imaging
Many types of physicians order and use the results of medical imaging in their practices. A
smaller group provide imaging services. The Royal College of Physicians and Surgeons of
Canada (RCPSC) recognizes two specialties in medical imaging: diagnostic radiology and
nuclear medicine.
FF
42
Physicians in other specialties may also supervise, perform, and interpret images in some
situations. For example, cardiologists are often responsible for performing procedures with
cardiac catheters; obstetricians and gynecologists may perform ultrasound examinations in
emergency situations in the labour room and/or their private offices; emergency physicians are
sometimes the first to read an X-ray; and other specialists, such as neurologists, oncologists,
and orthopedic surgeons, may use imaging equipment in their practice and/or refer patients for
imaging tests.
4 Medical Imaging Professionals
Who Orders Tests
In Canada, many types of medical imaging require a referral by a physician. Who orders
the test may vary depending on the type of test, policies/protocols in specific health
regions or facilities, the reason the test is being ordered, the available range of medical
specialties, the geographical location of the ordering physician and other factors. For
example, a recent report 2 by the Institute for Clinical Evaluative Sciences (ICES) showed
that neurologists, family physicians, orthopedic surgeons, and neurosurgeons order
most outpatient MRI scans in Ontario. They accounted for 24%, 20%, 17%, and 8% of
scans respectively.
The distribution of MRI referrals varied depending on the kind of physician making
the referral, the body site for which the MRI test was ordered, and where the physician
worked. For example, neurologists were more likely to order an MRI scan of the head
(41.5% of scans), compared to GPs/FPs (14.8%). Likewise, referrals for scans in
northern Ontario were more likely to come from GP/FPs (42% of scans) than those
in southern Ontario (17%).
33
Who Refers Patients for Tests?
Types of medical professionals who can refer patients for MRI or CT scans in each jurisdiction.
Jurisdiction
MRI
CT
B.C.
Specialist or GP
Specialist or GP
Alta.
Specialist usually, but may vary by regional
health authority
Specialist or GP
Sask.
Specialist
Specialist usually, but in some areas GP
Man.
Specialist
Specialist or GP with level of urgency indicated
Ont.
Specialist or GP
Specialist or GP
Que.
Specialist or GP
Specialist or GP
N.B.
Specialist but in some circumstances GP upon
radiologist consultation
Specialist usually; GP request with radiologist
consultation
N.S.
Specialist
Specialist or, where absent or scarce, GP
P.E.I.
Referred out of province by attending physician*
Specialist or GP
N.L.
Specialist usually
Specialist except in rural board where GPs may refer
N.W.T.
Referred out of territory by specialist or GP
Specialist or GP
Nun.
Specialist or GP
Specialist or GP
Y.T.
GP in consultation with specialist
GP in consultation with specialist
*Newly installed MRI now means not all patients travel out of province.
Source: Information obtained from the Provincial/Territorial Ministries of Health as of 2001; updated 2003.
Diagnostic radiology physicians supervise and interpret X-rays, CT scans, mammography, and other
imaging modalities in the study, diagnosis, and treatment of disease and injury. They may also be
responsible for determining the appropriateness of a test, quality control, and a number of clinical
procedures. Canada’s 1,900 diagnostic radiologists work both independently, as well as with other
physicians and health care professionals.3 In some cases, using interventional radiology, radiologists
and other specialists also use imaging to guide surgery or to provide less invasive alternatives to surgery
(e.g. angioplasty).4
43
The Royal College recognizes two subspecialties in diagnostic radiology: neuroradiology (diagnostic
radiology of the central nervous system, brain, head, neck, and spine using X-ray, MRI, CT, and
angiography) and paediatric radiology. These subspecialties are accredited but not certified. That is,
there is no certification examination.
Medical Imaging in Canada
Nuclear medicine physicians # (about 200 in Canada in 2001) are primarily concerned with the
use of radioactive materials in the study, diagnosis, and treatment of disease.5 Nuclear medicine
physicians are usually based in a hospital and/or a university. In general, they are responsible for
consulting with referring physicians on diagnoses and treatments, advising them on appropriate
imaging procedures, and deciding if further investigations are needed. Other responsibilities
might include supervising or administering procedures, overseeing daily operations, and
teaching junior colleagues and students.
Medical Physicists
Like many health care professionals, medical physicists fulfill a variety of roles and can work in
clinical settings, regulatory agencies, industry, research and development, academia, and other
areas. In a clinical setting, medical physicists are principally active in radiation therapy and
diagnostic imaging. For example, their responsibilities may include quality assurance of imaging
systems, radiation safety, technical specification and acceptance of new equipment, and
development of specialized protocols to use the equipment in ways tailored to clinical need.
Medical physicists also work in academic and research institutions. Research efforts in medical
imaging concentrate primarily on developing new and improved methods of imaging body
structure and function, with the ultimate goal of advancing the ability to diagnose and treat
disease.6 In addition, as a result of their expertise with
DID YOU KNOW?
ionizing radiation, they are often appointed Radiation
Safety Officers within the settings where they work.
Questions about whether the
available supply of imaging
professionals does (or will) meet
Just as there is no agreed national or international
demand are not unique to Canada.
standard for how many MRI or CT machines we should
For example, authors of an
have, deciding on the best number and mix of medical
Australian study (2002)7 reported
imaging professionals to serve a particular community is
a shortfall in the number of
challenging. Many factors come into play. Some relate to
radiologists and projected that,
the characteristics of the area and the people who live
based on the status quo, future
there. Others relate to how health services are organized
demands for radiology services
and delivered; how clinical knowledge, practice patterns,
would outweigh supply. Likewise,
and technology evolve; health professionals’ characteristics
a report by the United Kingdom’s
and how they work, both individually and together; and
Royal College of Radiologists
much more.
revealed that over 150 positions
had remained unfilled for more than
Nevertheless, tracking the supply and characteristics of
2 years in 2000.8 Similar data about
health care providers can provide important insights for
vacancy rates are not available
planning. For example, for every one diagnostic radiologist,
across Canada, but pockets of
there are 8 MRTs.
FF
information e.g. 9 do exist.
Trends in Supply
44
While numbers of professionals fluctuate from year to
year, they have been relatively stable for MRTs, diagnostic radiologists, and medical physicists
since 1997. As Chapter 3 showed, this period saw growth in some types of imaging equipment
(e.g. MRI and CT). However, we do not know whether the use of more common imaging
technologies, such as X-ray, rose or fell during this period.
#
Some radiologists also work in nuclear medicine.
Trends in the supply of selected medical imaging professionals per
100,000 Canadians.
55
Notes: The data for MRTs only reflect those who are
active members of the College of Medical Radiation
Technologists of Ontario (Ontario data), l’Ordre des
technologues en radiologie du Québec (Québec
data), and the Canadian Association of Medical
Radiation Technologists (data for other provinces).
# of medical imaging professionals per 100,000
50
The data for medical physicists represent those who
are registered members of the Canadian
Organization of Medical Physicists.
30
The data for diagnostic radiology physicians are
as of December 31 of given year and include
physicians in clinical and/or non-clinical practice.
Data exclude residents and physicians who are not
licensed to provide clinical practice and those who
have requested to the Business Information Group
(formerly Southam Medical Group) that their data
not be published. Specialty is based on most
recent certified specialty, and data may differ from
other sources of provincial/territorial physician data
that categorize physicians on some other basis
(e.g. functional specialty, payment specialty, or
provisional licenses).
25
20
15
10
5
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
4 Medical Imaging Professionals
34
The Supply of Imaging Professionals
Sources: Health Personnel in Canada, CIHI
(medical physicists and MRTs).
Southam Medical Database, CIHI
(diagnostic radiology physicians).
Medical radiation technologists
Medical physicists
Diagnostic radiologists
Moving Abroad
Overall, about 1% of active physician specialists in
diagnostic radiology left Canada between 1991 and
2001, although about half returned within this period. The
resulting total net loss of diagnostic radiology physicians
was three-fifths of a percent of the total supply. This loss
may have been offset by foreign-trained specialists who
migrated to Canada and became licensed to practice for
the first time, but the number of physician specialists in
imaging who did so is not known.
35
Physician Migration
The total number of diagnostic radiology physicians who moved
abroad between 1991 and 2001 and the number who returned
during this time. (Does not include immigration of foreign physicians
who have not previously practiced in Canada).
Number of diagnostic radiology physicians
250
200
150
100
50
0
1991
1992
1993
1994
1995
Moved abroad
1996
1997
1998
1999
Returned from abroad
2000* 2001
Total
Notes: Data are as of December 31 of given
year and include physicians in clinical and/or
non-clinical practice. Data exclude residents and
physicians who are not licensed to provide
clinical practice and those who have requested
to the Business Information Group (formerly
Southam Medical Group) that their data not be
published. Specialty is based on most recent
certified specialty, and data may differ from other
sources of provincial/territorial physician data that
categorize physicians on some other basis
(e.g. functional specialty, payment specialty, or
provisional license).
*Data from 2000 do not reflect annual updates
from the Government of the Yukon and the
College of Physicians and Surgeons of Alberta.
Source: Southam Medical Database, CIHI
45
Medical Imaging in Canada
Age and Aging
As baby boomers move towards retirement, the average age of Canadians is rising. That trend
also holds for health professionals in general and imaging professionals in particular. For
example, Census data show that the proportion of the MRT workforce younger than 35 was
31% in 2001, down from 47% a decade earlier.
36
The Age of Imaging Professionals
The average age of selected medical imaging professionals
in Canada, 2001.
Notes: Physician data are as of December 31 of given year
and include physicians in clinical and/or non-clinical practice.
Data exclude residents and physicians who are not licensed to
provide clinical practice and those who have requested to the
Business Information Group (formerly Southam Medical
Group) that their data not be published. Specialty is based on
most recent certified specialty, and data may differ from other
sources of provincial/territorial physician data that categorize
physicians on some other basis (e.g. functional specialty,
payment specialty, or provisional licenses).
Average age (years)
60
50
40
30
20
10
0
Medical radiation
technologists
Sources: Labour Force Survey, Statistics Canada
(MRT and sonography data);
Southam Medical Database, CIHI (physician data).
Medical
Diagnostic
Nuclear medicine
sonographers radiology physicians
physicians
The Male/Female Mix
Percentage of MRTs in Canada by age group
in 1991, 1996, and 2001.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
17%
46
0%
56.3%
47.3%
60.2%
38.4%
31.4%
1996
35–54
2001
55+
Source: 2001 Census of Canada, Statistics Canada.
20%
86%
22%
48.6%
8.4%
38
80%
Diagnostic
radiology
physicians
Nuclear medicine
physicians
5.3%
15–34
Percentage of selected medical imaging professionals by
gender in Canada, 2001.
Sonographers
4.1%
1991
The Gender Divide
Medical radiation
technologists
37
Fewer Young MRTs
Percentage of MRTs
Overall, about 8 in 10 health professionals
are female, but the mix differs from group
to group. In medical imaging, about 8 in 10
technologists were women, compared to
about 2 in 10 physician imaging specialists.
Why does this matter? Research suggests
that female physicians tend to have different
practice patterns from their male colleagues.
Likewise, it has been suggested that with
longer maternity leave benefits, additional
staff will need to be hired to replace those
on leave, possibly affecting the supply of
health professionals, such as MRTs.10
14%
78%
83%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of professionals
Female Male
Notes: Physician data are as of December 31 of given year
and include physicians in clinical and/or non-clinical practice.
Data exclude residents and physicians who are not licensed to
provide clinical practice and those who have requested to the
Business Information Group (formerly Southam Medical
Group) that their data not be published. Specialty is based on
most recent certified specialty, and data may differ from other
sources of provincial/territorial physician data that categorize
physicians on some other basis (e.g. functional specialty,
payment specialty, or provisional licenses).
Sources: 2001 Census of Canada, Statistics Canada
(MRT and sonographer data).
Southam Medical Database, CIHI (physician data).
The level of education required to work in medical imaging varies from profession to profession
and has changed over time. For example, while it may take less than five years to become an
MRT following high school graduation, physician specialists in nuclear medicine or diagnostic
radiology may spend 12 years or more in training.
39
Training The Experts
Minimum typical duration of training after high school graduation for entry into selected medical imaging
professions, Canada, 2003.
Diagnostic radiology physicians
Pediatric radiology
physicians
MRI technologists
Radiographers
5
Exiting
High 0
School
10
15
20
YEARS OF STUDY
Sonographers
Nuclear medicine
technologists
4 Medical Imaging Professionals
Learning to Image
Medical physicists
Neuroradiology physicians
Nuclear medicine
physicians
Sources: Certification Candidates Handbook, Canadian Association of Medical Radiation Technologists, 2002.
Royal College of Physicians and Surgeons, www.rcpsc.com.
Canadian Organization of Medical Physicists and Canadian College of Physicists in Medicine, www.medphys.ca.
Canadian Society of Diagnostic Medical Sonographers.
Questions continue to be raised about how training requirements should (or should not)
change in the future. Some point to the increasing complexity of medical radiation technology,
the changing roles of members working in multi-disciplinary teams, and the increased acuity
of patients seeking care as factors that are driving the demand for further education. Others
counter with concerns about the ability to attract and retain adequate numbers of personnel
whose training is well matched to the work they will be doing and about the costs of extended
training.10 Ensuring appropriate clinical training opportunities for students, whether in shorter
or longer programs, can also be an issue as they are dependent on the availability of programs
and instructors/preceptors.
Medical radiation technology is one area in which training requirements are changing.
Currently, MRTs require a college diploma from an accredited school to be eligible for
certification in Canada. There are also degree programs in MRT, such as those at the British
Columbia Institute of Technology and The Michener Institute (in affiliation with the University
of Toronto). Degrees are not yet required for entry-to-practice, but, as of 2005, the Canadian
Association of Medical Radiation Technologists has announced that it will no longer permit
diploma graduates to write the certification exam or to register as members of the association.
(Requirements for a university degree would not apply to those who graduated prior to 2005.)
Internationally, it has been reported that some countries—United States, the United Kingdom,
and Australia—all who have held reciprocity agreements with Canada, are becoming less
accepting of Canadian diploma graduates.1
47
1
1
1
1
1
1
2
1
1
6
3
1
2
1
1
5
4
1
1
1
1
1
1
2
3
Neuroradiology
4
1
1
1
2
1
1
7
4
3
1
2
1
23
Pediatric
radiology
1
1
Nuclear
medicine
1
1
Diagnostic
radiology
1
4
Medical physics
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Total
Physician
specialties
Radiological
technology*
Other medical
imaging professions
Nuclear medicine
technology*
• Sonographers have traditionally
taken one-year post diploma
programs. However, some entrylevel educational requirements
have changed, and a number
of three-year entry-level diploma
programs and some four-year
degree programs (e.g. in Nova
Scotia) have been developed.12
40
The distribution of training programs across Canada for selected
medical imaging professions, 2003.
Magnetic resonance
imaging technology*
• Some employers require that
medical imaging technologists be
cross-trained, especially in remote
and rural areas where it may not
be practical to have a technologist
in each sub-discipline. In response,
some provinces are developing
cross-training programs (e.g.
Newfoundland and Labrador).11
Medical Imaging Training Programs Across The Country
Diagnostic ultrasound
(sonography)*
Medical Imaging in Canada
Changes in training have also
occurred in other areas, including:
1
1
2
2
2
1
48
1
1
• Education for most medical
11
4
6
15
16
9
3
6
imaging professionals is a life-long
commitment, because they must
Notes: The above list covers most of the medical physics programs across Canada.
keep pace with the development
Some smaller graduate physics programs that involve graduate students working on
of new imaging equipment,
medical imaging projects may not be captured.
* Programs registered/accredited through the conjoint accreditation process
techniques, and knowledge
managed by the Canadian Medical Association as of June 26, 2003.
about best practices. For
example, physician specialists
Sources: Canadian Medical Association (list of medical imaging technology programs),
www.cma.ca/accredit.
are required to continue their
Royal College of Physicians and Surgeons of Canada, www.rcpsc.medical.org.
education post-residency.
Canadian Organization of Medical Physicists, www.medphys.ca.
The Royal College established
a Maintenance of Certification
program that
commenced in
Training Physicians
2001. Fellows
must participate
Each year, dozens of new residents begin their specialist training. According to the Canadian
Resident Matching Service, the number of training spaces for physician specialists in
in this program
imaging fluctuates slightly from year to year. Between 1997 and 2001, there were 39–44
to receive and
diagnostic radiology spaces and 2–5 nuclear medicine spaces annually. The former have
renew their
been increasingly sought after. Sixty-one Canadian residency applicants listed diagnostic
Fellowship and to
radiology as their first choice for specialty training in 2002, up from 44 in 1997. In contrast,
use the College’s
not all nuclear medicine training spaces have been filled in recent years.
designations.13
Each year, some international medical graduates (IMGs) also undertake residency training in
Canada. Some are permanent residents or Canadian citizens. They accounted for 1–8%
of total students exiting from diagnostic radiology programs each year between 1993 and
2002, according to the Canadian Post-MD Education Registry. In 2002, there were more
(37%) IMGs with visas that exited diagnostic radiology programs in Canada, up from
17% in 1993.
For many health professionals receiving a degree or diploma is only the first step. Graduates may
also need to pass a certification examination or meet other requirements. For example:
41
Who is Regulated Where?
$
%
#%
$
$
$
$
$
$
Nuclear medicine
physicians
$
%
#%
$
$
%
#%
Diagnostic radiology
physicians
#
$
$
#
$
$
$
$
#
#
$
$
$
Medical physicists
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Y.T.
N.W.T.
Nun.
Sonographers
Medical radiation
technologists*
Regulatory status for selected medical imaging
professions by province, Canada, 2003.
$%
$%
$
$
$
$%
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
* includes radiographers and nuclear
medicine technologists
$ Regulated
$ not regulated
# voluntary professional provincial associations
% profession seeking self-regulation
Sources: Canadian Association of Medical Radiation Technologists
(CAMRT) and Provincial Associations.
Canadian Association of Registered Diagnostic
Ultrasound Professionals (CARDUP).
Canadian Organization of Medical Physicists (COMP)/Canadian
College of Physicists in Medicine (CCPM).
Provincial/Territorial medical registration organizations.
• The Royal College of Physicians and Surgeons
is the national certifying body for specialty and
subspecialty physicians. They are also
responsible for setting and maintaining
standards for post-graduate medical education,
as well as for promoting continuing education.
4 Medical Imaging Professionals
Regulating and Certifying Imaging Professionals
• In order to practice in Canada, MRTs must pass
an examination set by the Canadian Association
of Medical Radiation Technologists or its
Quebec counterpart.
• Sonographers are only currently regulated in
Quebec, where the responsible regulatory body
is the Ordre des technologues en radiologie du
Québec. Nevertheless, many employers in other
jurisdictions may require that sonographers be
registered with (or eligible for registration with)
either the American Registry of Diagnostic
Sonographers or the Canadian Association of
Registered Diagnostic Ultrasound Professionals.
Several provinces, in collaboration with
professional associations, are in various stages
of exploring self-regulation for sonographers.14
• Medical physicists are not currently regulated
in Canada. However, medical physicists in a
few jurisdictions have started the complex
process of regulation under appropriate
provincial legislation.
What is Self-regulation?
49
With self-regulation, members of a profession
are accountable to the public through a
regulatory college or a professional
organization. This generally includes setting
standards of practice which describe various
professional tasks and what it means to
perform them at an acceptable level;
establishing entry-level qualifications to
practice; establishing a formal complaints and
discipline procedure; assuming accountability
for defining standards; ensuring appropriate
qualifications to practice and qualifications for
continuing competence in the profession; and
setting policy related to disciplinary
action for professional misconduct.15
New research is beginning to explore the relationship between the worklife of health
professionals and their recruitment and retention, job satisfaction, and health, as well
as patient satisfaction, outcomes of care, and health care costs. Relatively little is known,
however, about the working conditions, health, and worklife of Canada’s medical imaging
professionals. That said, some information does exist, including:
• According to the 2001 Census, full-time MRTs and sonographers who worked for the full
year earned, on average, just over $47,000 and $46,000 respectively. However, average
incomes vary across the country. A 2001 environmental scan report commissioned by
Health Canada11 looking at human resources issues facing medical technologists suggested
that wage disparities may cause
42
unbalanced distribution of medical
Income Comparisons
Average annual incomes of selected technical health professionals
imaging professionals across the
who worked full year, full-time, in 2000.
country, with higher income
potential attracting more medical
60,000
imaging professionals to provinces
$47,312
$46,125
50,000
$44,933
$37,774
able to afford them. Recent news
40,000
30,000
stories about MRT recruitment in
20,000
some parts of the country have
10,000
also led to questions about
0
differences in compensation and
Sonographers
MRTs
Medical laboratory
Cardiology
technologists
technologists
working conditions between some
hospitals and free-standing
Note: Medical laboratory technologist category includes pathologists’ assistants
imaging facilities.
Average annual income ($)
Medical Imaging in Canada
Life at Work
Source: 2001 Census of Canada, Statistics Canada.
• In 2002, about 8 in 10 MRTs and
sonographers worked full-time,
about the same as in recent years.
The Health Canada report11 noted
that some employers may find it
more attractive to hire casual and
part-time technologists because
they do not have to pay for benefits
for these workers. The authors also
suggested that evening and
weekend demands for diagnostic
imaging services might be more
easily alleviated with
part-time/casual positions.
43
Type of Work
The percentage of MRTs and sonographers working full-time/
part-time in Canada, 2002.
MRTs
82%
Sonographers
0%
18%
79%
10%
20%
30%
40%
21%
50%
60%
70%
80%
90%
100%
Percentage employed
Full-time
Part-time
50
Source: Labour Force Survey, Statistics Canada.
Risk at Work?
4 Medical Imaging Professionals
• Information on job satisfaction, absenteeism, and other similar indicators is scarce for
imaging professionals. Nevertheless, based on input received, the authors of the Health
Canada report 11 concluded that low morale in the workplace was common among medical
imaging technologists, possibly because of budget pressures and cutbacks, increased client
flow, limited career opportunities, and greater volume of work leading to increased workrelated stress and injury on the job. It was reported that these and other related issues may
contribute to absenteeism and burnout.
Radiologists and radiation technologists were among the first
occupational groups to use and be exposed to radiation. In 1902,
soon after X-rays were discovered, cases of skin cancer were prevalent
among radiologists.16 Concern about occupational exposure to radiation
prompted radiologists around the world to form the First International
Congress of Radiology in 1925. The first task was to develop a
standard method and unit by which to measure radiation. The second
was to set up a committee and program on protection against radiation.
In 1928, a new quantity and unit (named after Roentgen, inventor of the
X-ray) to measure X-ray radiation was developed, but no agreement
was reached about what level of exposure was reasonably safe. The
Roentgen remained in use until 1953 when two more units were
added—the rad and the rem.17
In the early 1950s, increasing leukemia mortality rates among
radiologists began to receive attention.16 It was at this time that regular
monitoring of radiation became routine.18 Since then, there have been
significant improvements in radiological protection and technology. At
the same time, however, new cutting-edge technologies create new
challenges in understanding and managing occupational hazards related
to radiation exposure.19
In Canada, a 2002 report 20 on occupational radiation exposure showed
that imaging professionals tend to be well below the allowable annual
dosage of occupational radiation (50 mSv).& Average annual doses
were 0.07mSv for radiological technologists, 1.47 mSv for nuclear
medicine technologists, 0.13 mSv for diagnostic radiologists, and
0.20 mSv for medical physicists.
&
Radiation dose equivalent is expressed in Sievert (Sv), or milliSieverts
(mSv; 1/1000 of a Sievert). These terms stand for the dose of radiation
to living tissue, and take into account both the absorbed dose and type
of radiation.
51
Medical Imaging in Canada
Information Gaps:
What We Know
• Which imaging professions are regulated in different jurisdictions.
• Typical minimum length of training and the distribution of educational
•
•
•
•
•
•
•
programs across Canada for physician specialists, MRTs, sonographers,
and medical physicists.
Changes in training requirements for MRTs, sonographers,
and physician specialists.
Number of post-MD training spaces offered in nuclear medicine and
diagnostic radiology.
How many active physician specialists in imaging, medical radiation
technologists (MRTs), sonographers, and medical physicists there
are in Canada and in each province and territory.
Selected demographic characteristics for medical imaging professionals.
Average earnings for MRTs and sonographers and how many work
full-time versus part-time.
Migration patterns of Canadian physician imaging specialists.
Pockets of information on the worklife of MRTs, sonographers,
and physician specialists.
What We Don’t Know
• How many and what mix of health professionals will be required to meet the
imaging needs of Canadians nationally, provincially, and regionally? How will
changes to training requirements, scope of practice, and regulatory status
for imaging professionals affect their supply, access to care, and patient
and provider satisfaction?
• What impact will recently announced plans for spending on medical equipment
have on the training opportunities for imaging professionals and on the demand
for their services?
• How many MRTs, sonographers, and medical physicists are leaving Canada
to practice abroad and/or returning to Canada? What impact does international
and inter-provincial migration of imaging professionals have on their supply,
training programs, and on Canadian’s access to care?
• How will teleradiology and other digital imaging technologies affect the
traditional dynamics of the medical imaging team, productivity, access
to care, and patient satisfaction and outcomes?
What’s Happening
• On March 31, 2003, the federal minister of health announced the scope and
52
parameters of the new $1.5 billion Diagnostic and Medical Equipment Fund.
The Fund is intended to support new investments in training staff as well as in
purchasing and installing new medical and diagnostic equipment and upgrading
older equipment. Also, commencing in 2004, first ministers have agreed to report
on enhancements to diagnostic and medical equipment and services.
• The Canadian Institute for Health Information will soon be releasing updated
health personnel data for years 1993 to 2002.
1
Health Human Resources Advisory Committee. (2001). Profile of Select Allied Health Professions:
Medical Imaging Workshop. www.healthplanning.gov.bc.ca/strategic/pdf/pharmprofile.pdf.
2
Iron K, Przybysz R, Laupacis A. (2003). Access to MRI in Ontario:
Addressing the Information Gap. Toronto: Institute for Clinical Evaluative Sciences.
3
Royal College of Physicians and Surgeons of Canada. (2003). Objectives of Training
and Special Training Requirements in Diagnostic Radiology.
http://www.rcpsc.medical.org/english/residency/certification/training/diarad_e.html.
4
Millward SF, Holley ML. (2001). The current status of interventional radiology in
Canada: Results of a survey by the Canadian Interventional Radiology Association.
Canadian Association of Radiologists Journal, 52(2), 87-91.
5
Royal College of Physicians and Surgeons of Canada. (2003). Objectives of Training
and Training Requirements in Nuclear Medicine.
www.rcpsc.medical.org/english/residency/certification/training/nucmed_e.html.
6
Canadian Organization of Medical Physicists and the Canadian College of Physicists in Medicine.
(2003). What is Medical Physics? www.medphys.ca/index.cfm.
7
Jones DN. (2002). 2002 Australian Radiology Workforce Report. Australasian Radiology, 46, 231–248
8
Royal College of Radiologists. (2002). Clinical Radiology: A Workforce in Crisis.
http://www.rcr.ac.uk/upload/workforce1.pdf.
9
Ontario Ministry of Health and Long-Term Care. (2003). List of Areas Designated as
Underserviced for Specialists July/August/September 2003.
http://www.health.gov.on.ca/english/providers/program/uap/listof_areas/specialist_ladau_7-9_03.pdf.
10
Noseworthy T. (2001). Diagnostic Supply Report: Newfoundland and Labrador 2000/2001.
www.nlhba.nf.ca/hr/documents/Diagnostic.pdf.
11
Assessment Strategies. (2002). An Environmental Scan of the Human Resource Issues
Affecting Medical Laboratory Technologists and Medical Radiation Technologists 2001.
Ottawa: Health Canada.
http://www.hcsc.gc.ca/hppb/healthcare/pdf/environment_scan.pdf.
12
Personal communication. (2003). Office of the Executive Director, Canadian Society
of Diagnostic Medical Sonographers.
13
Royal College of Physicians and Surgeons of Canada. (2003). Maintenance of Certification.
www.rcpsc.medical.org/english/maintenance/.
14
Canadian Society of Diagnostic Medical Sonographers (CSDMS). (2003). Provincial Regulation.
www.csdms.com/regulation.html.
15
Casey JT. (1999). Status Report and Analysis of Health Professional Regulations in Canada.
Prepared for the Federal/Provincial/Territorial Advisory Committee on Health Human Resources.
Edmonton: Field Atkinson Perraton.
16
Mabuchi K, and Yoshinaga S. (2002). Medical radiation exposure in occupational studies:
Overview of occupational medical exposure. Radiation Research, 158, 803-4.
17
Taylor LS. (1996) What you need to know about radiation.
http://www.physics.isu.edu/radinf/lstintro.htm.
18
National Radiological Protection Board. (2002). eBulletin No.2: Current Issues in Radiation and Health.
www.nrpb.org/publication/bulletin/no2/report1_print.htm.
19
Croft J, LeFaure C. (2003). Overview of Medical Occupational Exposure Issues
in the European Countries.
http://ean.cepn.asso.fr/pdf/program6/Session%20A/J_Croft.pdf.
20
Health Canada. (2002). 2002 Report on Occupational Radiation Exposures in Canada.
Ottawa: Health Canada.
4 Medical Imaging Professionals
For More Information
53
Current Issues in
Medical Imaging
• the appropriate use of imaging technologies;
• their impact on patient care, outcomes, and costs, as well as how they fit with other
types of technologies;
• the changing roles of medical imaging professionals;
• the settings in which imaging services are provided; and
• wait times for different kinds of imaging.
The Right Tool for the Right Job
To scan or not to scan (and what and how to scan)–these decisions can have farreaching consequences, both for patients and for the health care system. Medical
imaging may be done for many reasons: screening patients at risk for a disease;
reducing uncertainty about a diagnosis to reassure practitioners, patients, and
caregivers; assisting with decisions about care choices; monitoring the effect of
treatments and understanding prognoses; and/or guiding surgery or other interventions.1,2
Deciding the best tool (or tools) to use in each of these contexts for different patients is
challenging, particularly given the ongoing evolution of imaging technologies, research
evidence, and practice patterns. Often, a particular type of imaging is of obvious,
undisputed value for some groups of patients or types of research. Other cases are
less clear. Examples of factors that may influence decisions include:
• Technical efficacy: how well an imaging technique represents the physical structure
of the body site in question;
• Diagnostic accuracy: to what degree is test information likely to contribute to the
determination of a correct diagnosis;
• Comparative efficiency: how much better (or worse) is the diagnostic information
produced than that generated by other approaches;
• Therapeutic impact: to what extent is diagnostic information likely to affect care
decisions; and
• Health outcomes: what are the expected effects—positive, neutral, or negative—of both
diagnosis and treatment on morbidity and mortality outcomes.3
In addition, non-clinical and other factors may be considered.
5 Current Issues in Medical Imaging
5
So far, we’ve focused on the history, utilization, and supply of medical imaging
technologies, as well as the professionals involved in providing imaging services.
We’ve touched on a few of the major issues in the field, including the rapid evolution
of imaging technologies, but have not addressed many others. In an attempt to start
to fill this gap, this chapter focuses on additional issues related to the dynamic
development and application of the MITs and services, including:
Medical Imaging in Canada
Safety of Medical Imaging
Medical imaging tests, like other health care interventions, are rarely risk-free. For instance,
X-rays carry risks associated with radiation exposure. Technologies that do not use ionizing
radiation may pose other risks. Examples include potential mechanical, thermal, and
biological effects.4
44
Typical Radiation Dose
Effective radiation doses that patients in the United Kingdom typically received from various
medical imaging procedures during the 1990s, the number of chest X-rays required to generate a
similar dose, and the length of time required to receive a similar dose from background radiation in
the United Kingdom.
Diagnostic procedure
Typical effective
dose (mSv)
Equivalent # of
chest X-rays
Approx. equivalent period
of natural background
radiation in the UK
Limb & joint X-ray (except hip)
<0.01
<0.5
<1.5 days
Chest X-ray
0.02
1
3 days
Hip X-ray
0.3
15
7 weeks
Abdomen X-ray
1.0
50
6 months
Barium swallow
1.5
75
8 months
CT of the head
2.3
115
1 year
PET of the head (F-18 FDG)
5
250
2.3 years
Barium enema
7
350
3.2 years
CT of the chest
8
400
3.6 years
CT of the abdomen or pelvis
10
500
4.5 years
Source: European Commission Directorate-General for the Environment (Adapted by experts representing European radiology
and nuclear medicine in conjunction with the UK Royal College of Radiologists). (2001). Radiation Protection 118: Referral
Guidelines for Imaging. Luxembourg: Office for Official Publications of the European Communities.
For many patients, the potential benefits of the information obtained from tests clearly
outweigh foreseeable risks, including the consequences that may arise from false positive
or false negative findings.5 For others, careful consideration of potential benefits, costs,
and risks is required. In some cases, the best option may be to rely on approaches used
for centuries, such as careful observation or feeling a joint to check for a break. This
balance may vary from test to test, place to place, patient to patient, and over time.6
56
Many have called for technology assessments, clinical practice guidelines, and other tools to
summarize the latest evidence and assist clinicians, policy makers, and patients in making
decisions about medical imaging technologies.7,8 At the same time, some point out that this
process can be challenging given the rapid evolution of technology and practice in the field.9
Nevertheless, groups have begun to develop and apply tools to assist with decisions.
For example, Ottawa-based researchers have created a series of decision-rules for use
in the emergency department. They cover X-rays for ankle6 or knee10 injuries; cervical spine
radiography for alert and stable trauma patients;11 and CT scans in patients with minor head
injuries.2 The rules suggest imaging in some cases, observation or other clinical processes
in others. The researchers suggest that if Canadian hospitals were to apply these rules, they
would substantially reduce the number of tests ordered, while still accurately identifying
patients at higher risk who should be tested.2,10,12
“Recreational” Scanning?
Marketing imaging services to healthy people is controversial. Enchanted as some are with the fetal photo album or
keepsake videos, for example, many oppose the use of ultrasound for non-medical purposes. The Canadian Association
of Radiologists (CAR),14 Health Canada4, the US Food and Drug Administration (FDA),15 the American Institute of
Ultrasound in Medicine (AIUM),16 and others have all expressed concerns about the relative risks and benefits of this
practice. At the same time, these groups do support appropriate use of ultrasound as a clinical tool in the care of
expectant mothers and their babies. Obstetricians often use ultrasounds to check the size, location, and number of
fetuses in the womb, as well as other health-related factors such as birth defects, fetal movement, breathing, and
heartbeat; a number of clinical practice guidelines have been developed in this area.(e.g. 17)
5 Current Issues in Medical Imaging
The earliest decision-rules (the Ottawa Ankle Rules) are the best known. More than 69% of
emergency physicians in the US, Canada, the UK, and France (but not Spain) were aware of
them and more than 70% in Canada and the UK reported using the rules frequently. Awareness
and use of the later decision rules for the knee was lower in all countries.13
Similarly, “full-body” or “head-to-toe” CT scans for healthy individuals are being advertised in some parts of Canada.
While proponents argue that these types of scans can detect markers for diseases such as lung cancer and certain
types of heart disease in asymptomatic individuals, many experts dispute their merits.18-23 They point to the lack
of scientific evidence about the efficacy and risks of screening and the difficulties in providing full information to support
informed consumer choices. Risks may include radiation exposure and false positive screening results, which could
trigger significant follow-up care and its associated costs and risks.24-26
In March 2002, the Canadian Association of Radiologists concluded, “there is no conclusive evidence that CT scan
screening of asymptomatic healthy individuals is of benefit to their health.”27 Internationally, organizations such as
the U.S. Food and Drug Administration,28 the United Kingdom’s Department of Health29 and the American College
of Radiology30 share their view that currently there is insufficient evidence that the benefit of whole-body screening
outweighs its potential harm.
Effects on Care, Outcomes, and Costs
‘First do no harm’ is an enduring principle of medical care, but both ancient and modern texts
also focus on how patients’ lives can benefit from appropriate care. An understanding of the
probability that a test result will affect patients’ diagnoses, their care plans, and their outcomes
can aid in deciding whether or not to test (and in evaluating the cost-effectiveness of a test).
Yet establishing direct causal links between imaging results, care decisions, and outcomes
may not be easy as many other factors may be involved. In addition, in certain cases our
ability to diagnose health problems exceeds our ability to treat them.
Nevertheless, studies have begun to look at the effects of medical imaging. An early Manitoba
study (November 1991 to October 1992) explored the impact of MRI scans on patient management
and outcomes.31 Researchers found that test results changed the referring physicians’ provisional
diagnosis in 42% of cases. Two-thirds of the time, the provisional diagnosis was ruled out by
normal scan results; in the other cases, the consulting radiologist offered an alternative diagnosis.
Overall, physicians reported altering patient management plans in just over half (54%) of all
cases; in about a quarter (24%), they switched from lower to higher levels of intervention.
Whether these results would still hold today is not clear, given the changes that have occurred
in the number and use of MRIs over the last decade.
57
Medical Imaging in Canada
A number of other researchers have also studied what imaging technologies allow clinicians
and patients to know and do. Sometimes results are clear, but often results are mixed. For
example, while some studies have reported that CT scanning reduces unnecessary
appendectomy rates,32-35 others show no such effects.36-39
How and how often test results influence care plans and patient outcomes also affects the costeffectiveness of medical imaging. So do the costs of tests and associated follow-up care for
patients with positive and negative test results. As technology and operating costs, care
patterns, and patient outcomes change over time, the balance of costs and benefits also shifts.
Many cost-effectiveness studies in medical imaging have focused on specific applications in
particular care environments. Research results have been mixed, perhaps partly because the data
required for a full assessment of costs and benefits have often not been available. Some studies
suggest that new technologies save money overall, but many show that they increase costs.40-42
Complementary or Competing Technologies?
New breakthrough products get a lot of attention, but there are also ongoing changes in how both
new and older technologies are used.43 For example, X-rays are now used very differently than
when introduced. Sometimes new applications or adaptations, such as mammography screening,
are developed.44 In other cases, emerging evidence suggests alternatives to imaging tests.
In some cases (or at least for some specific applications), new technologies replace old ones, but
uses may also overlap. For example, imaging technologies, such as CTs and MRIs, have specific
applications but can also sometimes be substituted one for another.45 Imaging modalities may also
be complementary. For instance, patients being evaluated for possible disease often first receive
non-invasive tests (those that do not
involve inserting objects or fluids into
Common and Not-So-Common Tests
Number of imaging tests paid for by Saskatchewan Health
the body). If further information is
in 2002–2003, according to the department’s annual report
required, they may then undergo
(selected modalities).
more complex or invasive tests.
45
MRIs
58
New or expanded applications for
CT scans
existing imaging equipment, as well
Ultrasounds
as changes in field strength, speed
Radiology services
and clarity of imaging, patient
comfort and convenience, and
0
50
100
150
200
250
300
evidence about the effectiveness of
Thousands of tests performed
imaging modalities are examples of
Source: Saskatchewan Health. (2003). Annual Report 2002-2003. Regina:
the technological factors that may
Saskatchewan Health. www.health.gov.sk.ca/mc_dp_skhlth_2002-03_ar.pdf
play a role in changing the demand
for–and consequently the use
of–imaging technologies.46,47 Non-technical factors such as clinician and patient knowledge
about the capabilities and risks of different medical imaging technologies, patients’ preferences
regarding their health care, costs, and the availability of different technologies may also
influence use.3,48,49
Over the last century, several different types of health professionals have become involved in
medical imaging services. Some roles are distinct. Others are shared. “Scopes of practice”
define the services that members of an occupation may provide and the methods that they
use.50 Each profession tends to specialize in certain areas, although skills and roles are
evolving over time and sometimes overlap. For instance, as imaging technologies progress
and new applications are developed, radiologists are taking on a wider range of services,
such as the subspecialty of interventional radiology which is still relatively new.
At the same time, other physicians sometimes deliver services also provided by radiologists.
For example, a survey in 2001 found that some interventional radiology functions (e.g. biopsies)
were performed by other specialties.51 Likewise, in a separate national survey, emergency
physicians reported that they were usually the first to read radiographs during and after normal
business hours, although most hospitals said that a majority of their emergency physicians did
not have formal training in reading radiographs.52 (Emergency physicians were also less likely
than their radiologist colleagues to report that current emergency radiology services were
excellent–29% versus 46%).
5 Current Issues in Medical Imaging
Changing Roles and Evolving Scopes of Practice
The roles of radiology technicians and technologists are also evolving. In Canada, basic
education programs for medical radiation technologists (MRTs) are lengthening, as described
in Chapter 4. The merits of increasing entry-to-practice requirements continue to be debated.
Proponents point to new and more complex imaging technologies and techniques, changes in
roles of the imaging team, and other factors. Others note the cost of extended training and are
concerned about the ability to attract and retain personnel whose training is well matched with
the work that they will be doing.53
Changes in roles are also happening in other countries. For example, the UK has developed a
“red dot” system. Under this system, the radiological technologist studies each X-ray film or
image and indicates the potential presence of an abnormality with a red dot. This assists
radiologists by enabling them to focus on patients with abnormal findings, thus speeding the
throughput of patients. Also, some radiological technologists perform intravenous injections
and administer barium enemas.54
In the US, the American College of Radiologists (ACR) has defined the roles and
responsibilities of a new advanced-level ‘radiology assistant’ position.55 These professionals will
interpret radiological examinations and transmit observations to the supervising radiologist. As
well, radiology assistants will be responsible for obtaining consent for and injecting agents for
diagnostic imaging purposes; obtaining clinical history from patients or medical records;
assisting radiologists with invasive procedures; communicating reports of radiologists’ findings
to referring physicians; and other tasks.
59
Medical Imaging in Canada
The Many Ways of Delivering Imaging Services
The words “private health care” evoke strong feelings for many Canadians–both for and
against.56 But they also mean different things to different people. In the context of medical
imaging, the phrase may refer to:
• Who paid to purchase the equipment? Governments may pay for equipment publicly through
direct grants, hospital/health region global budgets, and/or public research grants. Alternatively,
its purchase may be funded privately through foundations, gifts, private capital, and private
research grants.57 For information on the purchase of capital equipment, see Chapter 3.
• Who owns and operates it? Many imaging facilities are located in not-for-profit hospitals,
but there is also a well-established tradition in Canada of free-standing imaging facilities
which may be for- or not-for-profit. In some cases, they are led by entrepreneurs (often the
health professionals delivering the services) who need not answer to shareholders; in
others, they are owned by corporate organizations that aim to provide returns on investment
to their shareholders.56,58
• Who pays for the delivery of imaging services? Whether the facility is for-profit or not-forprofit, provincial/territorial health insurance programs, other public payers (e.g. workers’
compensation boards or the federal government), and/or private individuals or their insurance
plans may pay for imaging services. Who pays may depend on why the scan is required,
what type of scan is needed, where the facility is located, and many other factors.
Free-standing imaging facilities range from specialized services such as dentistry, chiropractic,
or mammography to broad-based imaging centres offering a wide range of tests. The mix of
hospital-based and free-standing imaging facilities where patients receive services differs among
imaging modalities. For example, 98% of Canadians who reported having had a non-emergency
angiography in 2001 said that they received their test in a hospital or public clinic. The
proportion was slightly lower for CT scans (96%) and for MRIs (92%).
The first MRI in a free-standing imaging facility opened in Calgary in 1993. Within a decade
(by January 2003), there were 16 such facilities with MRIs across Canada and another nine with
both MRI and CT services. Overall, about 18% of the country’s MRI machines and about 3% of
CTs were installed in free-standing imaging facilities at the beginning of 2003. That’s up from
about 15% and 2% respectively in mid-2001. However, as of January 2003, fewer than 5% of
angiography, catheterization labs, and nuclear medicine cameras were located outside
of hospitals.
60
According to the National Survey of Selected Medical Imaging Equipment both hospital-based
and free-standing imaging services receive operating funding from various sources, but the mix
of funding differs. In the vast majority of cases, the primary source of operating funding for
hospital-based equipment was the provincial/territorial government. Additional secondary
funding sources also existed. For example, some hospitals provide CT and MRI services
funded by other payers in off-hours. In contrast, provincial/territorial governments were the
primary source of operating funding for about a third (32%) of imaging equipment located in
free-standing imaging facilities.
Percentage of selected types of medical imaging equipment installed in public hospitals and free-standing imaging
facilities across Canada by primary source of operating funds and the total number of machines installed in each setting
as of January 2003.
Hospital-Based Equipment
Primary source of
operating funds
CT
MRI
Provincial Government
98%
98%
Workers’ Compensation
Board
<1%
Private Health Insurance,
Other Private Insurance,
Out-Of-Pocket Payments
Free-Standing Facilities
Nuclear Medicine
CT
MRI
Nuclear Medicine
99%
-
15%
64%
-
-
-
-
-
-
-
-
22%
19%
28%
Other Types of Funding
2%
2%
1%
78%
63%
8%
Total # Machines
317
120
569
9
27
25
5 Current Issues in Medical Imaging
46
Who Pays?
Note: Figures may not add to 100% due to rounding error.
Source: National Survey of Selected Medical Imaging Equipment, CIHI
47 Waiting for Care
Waiting for Diagnostic Services
An example of the care path for patients waiting for
diagnostic radiology services.
Patient’s health problem
suggests test needed
P
A
T
I
E
N
T’
S
Clinician’s request for
examination received in hospital
radiology centre
P
R
O
G
R
E
S
S
Appointment received
by patient
Request checked by
radiology staff
‘Test waiting time’
Comparable data about who is waiting for what,
and for how long, are scarce but growing. One
of the challenges is deciding how to define wait
times, specifically, when waiting actually begins
and ends.61
Booking made
Examination carried
out and report prepared by
radiology staff
Report sent to
referring clinician
Waiting for care remains a key issue for
Canadians, both for diagnostic tests and for
other services.59 Respondents to a November
2002 Ipsos-Reid poll said that reducing wait
times for diagnostic services, such as MRI and
CT scans, should be the number one priority
for new health care spending.60
‘Reporting time’
Patient informed
of result
Adapted from: The Audit Commission. (2002). Radiology:
Acute Hospital Portfolio. Review of National Findings.
www.audit-commission.gov.uk/Products/AC-Report/
AB95E11A-A6C1-4335-9482-9618441DB347/Radiology_Full.pdf
61
* Interpret with caution due to high sampling variability.
A recent Statistics Canada survey62 describes
the experiences of Canadians aged 15 and
over who accessed non-emergency MRIs,
CTs, or angiographies in 2001. About 1.7 million
people (7% of those aged 15 and over) reported
getting at least one of these services in the
previous 12 months. Over half (55%) reported
waiting less than a month for their test, but the
5%* with the longest waits waited 26 weeks or
more for their test. Half waited longer than
3 weeks and half waited 3 weeks or less.
48
What Are the Difficulties?
Percent of Canadians aged 15 and over who had selected diagnostic
services (non-emergency MRI, CT, or angiography) in the last year in
2001 who reported difficulties in accessing the test.
20%
% reporting difficulty
Medical Imaging in Canada
A quarter of those who had any of
the three diagnostic tests felt that
their wait time was unacceptable.
These individuals were more likely to
have had longer waits (median wait
of 8.6* weeks instead of 2.0 weeks)
and 10 times more likely to have
reported that waiting had affected
their lives (51% vs. 5%*), than those
who said their wait time was
acceptable. The most common
consequences reported by the 16%
of patients who said that waiting
affected their lives were worry,
anxiety, or stress (68% of those who
said they were affected by waits).
15%
18%
13%
10%
5%
3%
2%
0%
Difficulty getting
an appointment
Waited too long
for service
Waited too long in
office or for
diagnostic test
Any access
difficulty
Source: Health Services Access Survey, Statistics Canada
Additional information from Canada and elsewhere are beginning to give us further insight into
factors that affect wait times. Examples include:
• What type of care you need: For example, data from Alberta suggest that wait times for
MRIs and CTs differ substantially.63,64 Likewise, waits at the University Health Network in
Toronto between January and March 2003 were shorter for elective angioplasty (median wait
of 15 days) than for outpatient cardiac catheterization (22 days).65
• Whose list you are on and where you are waiting: There is no single nation-wide or often
even province-wide wait list for medical imaging. Wait lists are typically managed at the
regional, hospital, or clinic level. Where comparable data are collected, they often show wait
time variations. For example, Alberta wait time data suggest that variations exist between the
various MRI and CT facilities in the province.63,64 Similarly, data from Quebec showed
differences in wait times for ultrasound and CT across health regions and sometimes even
within the same region.66
62
• How urgently you need care: The Western Canada Waiting List (WCWL) project67 was
launched to develop practical tools for prioritizing patients on scheduled waiting lists,
including those waiting for MRIs. The project developed scoring tools based on literature
reviews and input from clinical panels. Evaluations found that reliability was strongest for the
general surgery and hip and knee criteria and weakest for the diagnostic MRI criteria. In spite
of the challenges, some health regions are introducing prioritization tools. For example,
Calgary has established priority guidelines for MRI and CT in an effort to optimize utilization
of equipment and patient management. The guidelines suggest recommended maximum
wait times based on whether a patient’s condition is emergent, urgent, semi-urgent, or routine.68,69
* Interpret with caution due to high sampling variability.
49
Keeping Track of Waiting
There are many ongoing and new initiatives aimed at collecting data about wait times. The results of these studies are
not always comparable partly because of variations in the methods and data sources used. The table below outlines
some of the key differences between selected recent Canadian wait list studies.
Physician
survey
Patient survey
Health Regions/Facilities
Jurisdiction/Study
Data Source
What is Measured
5 Current Issues in Medical Imaging
• How many hours imaging facilities operate: Operating hours vary by type of imaging, by
location and/or facility, by time of year, and other factors, such as the availability of trained
professionals to operate the equipment and interpret results and maintenance/upgrading
schedules.70 A recent report by the Institute for Clinical Evaluative Sciences1 showed that two
of Ontario’s 25 MRI centres in 2002 operated 24/7, two were open less than 12 hours a day
and seven were not open on weekends (the hours of operation for the remaining centres
were not reported). Likewise, reports from Quebec in 2001 and Nova Scotia more recently
show variations in hours of operation between MRI centres.66,71
Time Period
Publicly funded scans
in Alberta published in
Alberta Health and
Wellness reports
Actual patient
experience reported
by Regional Health
Authorities & Alberta
Cancer Board
Volume and average
wait times for publicly
funded MRIs, CTs
Ongoing quarterly
reporting
Winnipeg Regional
Health Authority’s
regular report for
region and government
Actual patient
experience reported
by hospitals
Wait times (in weeks)
for publicly funded
scans; number of
patients waiting;
number of exams for
CT, MRI, ultrasound,
and bone densitometry
Ongoing monthly
reporting
Quebec Auditor
General Report
2000–2001
Health regions and
hospitals
Minimum and
maximum days
waiting for abdominal
ultrasound and head
CT (with infusion)
among health regions
in Quebec
20–24 November 2000
Nova Scotia Capital
Health Annual Report
for 2001–2002
Free-standing imaging
facilities and hospitals
Average wait times
(in days) for
mammography
screening for women
with no symptoms in a
free-standing imaging
facility; average wait
times (in days) for MRI
and bone densitometry
screenings
August 2002
Health Services Access
Survey, Statistics
Canada
Patient reports on
waits for nonemergency MRI, CT,
and angiography
received in the past
12 months.
From decision by
doctor and individual
to go ahead with a
test, to the test
(includes publicly and
privately funded scans)
November–December
2001
Fraser Institute
National Waiting List
Survey
Survey of physician
opinion on waits
across 12 specialties
and 10 provinces
Median of specialists’
responses
Ongoing annual survey
since 1995
Source: Compiled by CIHI
63
Medical Imaging in Canada
• How care is delivered: Practice patterns and patient preferences vary. Patients referred
for imaging in some settings may be managed differently in others. For example, clinicians
responding to proposed rules for CT scans for patients with minor head injuries felt that their
use would lead to fewer scans in Canada and the United States but more in parts of the
United Kingdom.72 Because there is little systematic data on these variations, it is difficult
to assess their effects on wait times (or on outcomes and costs).
• How a wait is measured: Inconsistencies in calculating wait times affect the ability to
compare and determine acceptable waits. Additionally, wait lists may be inaccurate. For
instance, audits of waiting lists in Canada and elsewhere often find that the same patient
is on multiple lists, that not all listed patients still require the service, and other issues.73
64
• Special factors related to individual patients or conditions: A range of factors may play a
role for different types of medical imaging. For example, critically ill patients may need to be
stabilized before they have tests. In the case of elective tests, patients may wish to schedule
the procedure to take work or family events into account.
What We Know
• Recommendations on the appropriate use of selected medical imaging technologies in
certain clinical situations made by different groups.
• Number of free-standing imaging and hospital-based facilities for selected types of
imaging technologies.
• Number of Canadians aged 15 and over who reported receiving selected non-emergency
medical imaging services and whether or not they had difficulties in accessing these
services.
• Some information on wait times for various imaging services and problems patients
report experiencing while waiting for care.
5 Current Issues in Medical Imaging
Information Gaps:
What We Don’t Know
• How do medical imaging services affect patient care, outcomes, and costs in particular
circumstances, compared to other types of imaging or to assessing/managing patients’
conditions without imaging technology? What are the relative costs and benefits of using
various types of imaging?
• To what extent does the current pattern of use of medical imaging services match with
evidence-based best practice? What factors contribute to any observed deviations? What
impact do deviations have on patients and on the health care system?
• How does the private/public funding mix for capital and operating costs vary among
technologies across the country? How do services provided by free-standing and
hospital-based imaging facilities differ? What effect do these differences have on
access to care, costs, wait times, and patient satisfaction and outcomes?
What’s Happening
• In February 2003, Canada’s first ministers pledged to report to their citizens annually
on enhancements to diagnostic medical equipment and services, using comparable
indicators, and to develop the necessary data infrastructure for these reports. In addition,
wait times for CT and MRI were two of the indicators that they directed health ministers to
consider for reporting. Some jurisdictions and individual facilities have already begun to
report wait time data.
• At the same time, first ministers committed to accelerating technology assessment
activities. Subsequently, the Canadian Coordinating Office for Health Technology
Assessment received additional federal funding over five years. Federal, provincial,
and territorial health ministers have also been directed to develop a comprehensive
strategy for technology assessment by September 2004.
• The Western Canada Waiting List Project recently received new funding in support
of on-going initiatives related to waiting list management, including exploring the
development of accepted standards for wait times.
65
Medical Imaging in Canada
66
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26
Stolberg HO. (2003). Yuppie scans from head to toe: Unethical entrepreneurism. Canadian Association of
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U.S Food and Drug Administration. (2002). Whole Body Scanning Using Computed Tomography (CT).
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29
Allan PL, Williams JR. (2003). Full-body CT scans: Are they worth the cost and the radiation exposure? Journal of the
Royal College of Physicians of Edinburgh, 33, 8-14.
30
American College of Radiology. (2002). ACR Statement on CT Screening Exams.
www.acr.org/departments/pub_rel/press_releases/total-bodyCT.html.
31
Mustard CA, McClarty B, MacEwan D. (1996). Influence of magnetic resonance imaging on diagnosis and
therapeutic intention. Academic Radiology, 3(7), 589-596.
32
Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T. (2000). The value of limited computed tomography with
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33
Horton MD, Counter SF, Florence MG, Hart MJ. (2000). A prospective trial of computed tomography and
ultrasonography for diagnosing appendicitis in the atypical patient. American Journal of Surgery, 179(5), 379-381.
34
Wilson EB, Cole JC, Nipper ML, Cooney DR, Smith RW. (2001). Computed tomography and ultrasonography in the
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35
Stroman DL, Bayouth CV, Kuhn JA, Westmoreland M, Jones RC, Fisher TL, McCarty TM. (1999). The role of
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38
McDonald GP, Pendarvis DP, Wilmouth R, Daley BJ. (2001). Influence of preoperative computed tomography on
patients undergoing appendectomy. The American Surgeon, 67, 1017-1021.
39
Perez J, Barone JE, Wilbanks TO, Jorgensson D, Corvo PR. (2003). Liberal use of computed tomography scanning
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40
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41
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42
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43
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44
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45
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46
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47
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48
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49
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50
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52
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5 Current Issues in Medical Imaging
27
67
Medical Imaging in Canada
68
56
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62
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63
Alberta Health and Wellness. (2003). Computerized Tomography—Volumes and Wait List.
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64
Alberta Health and Wellness. (2003). Magnetic Resonance Imaging—Volumes and Wait Times.
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65
University Health Network. (2003). Wait Times Currently Measured by UHN Program Groupings.
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66
Auditor General of Quebec. (2001). Report to the National Assembly for 2000–2001, Volume 1.
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67
Western Canada Waiting List Project. (2001). From Chaos to Order: Making Sense of Waiting Lists in Canada.
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68
Calgary Health Region. (2002). Diagnostic Imaging Guidelines for Prioritization of MRI Studies.
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69
Calgary Health Region. (2002). Diagnostic Imaging Guidelines for Prioritization of CT Studies.
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70
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71
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72
Needham G, Currie DG. (2002). Canadian CT head rule for patients with minor head injury. Clinical Radiology,
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73
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Medical Imaging in Canada:
An Incomplete Picture
As this report illustrates, use of medical imaging is increasing in Canada and other
developed countries. For example, the use and purchase of various technologies—
including CT and MRI scans—has grown steadily in recent years. At the same time,
polls suggest that access to imaging remains a key priority for Canadians.
Like many technologies, the value of medical imaging depends on how it is used
and its ability to improve the lives of patients and/or the practice of health care.
Recent reports on health care (eg, Romanow/Kirby) have called for action both to
address issues surrounding access to diagnostic services and to engage in research
to better understand the appropriate use of these technologies, now and in the future.
As plans move ahead, it helps to understand where we are starting from. The
information in this report is intended to summarize the current status of imaging
in Canada to contribute to this process. This summary includes:
• a brief history of the development of imaging technologies;
• current data about how many imaging technologies there
are in Canada and how they are used;
• information about the many health professionals who use these technologies; and
• a description of some of the issues surrounding their use.
This information, much of which was newly assembled or updated for this report,
is important, but significant pieces of the puzzle are missing, rendering the picture
incomplete. For example, we know how many CT and MRI scanners there are in
Canada, where they are located, and how old they are, but little about how they are
used. Nor do we know much about the relative opportunity costs of particular imaging
technologies in relation to each other or to other types of care.
6 Medical Imaging in Canada: An Incomplete Picture
6
Once a curiosity, medical imaging is now an indispensable part of modern medical
care. It was only a little over a hundred years ago that X-rays were “discovered”.
Within a few months, physicians in many parts of the world were experimenting with
them, and today a wide array of medical imaging technologies are used in the
diagnosis—and sometimes treatment—of a range of health conditions. For example,
a mother-to-be and her care provider can now see images of her unborn child through
an ultrasound and check for fetal abnormalities. Physicians can make definitive
diagnoses of broken bones with imaging technologies. And we can even obtain
clear pictures of the workings of the brain.
Medical Imaging in Canada
Only pockets of information exist about how scan rates compare across the country or around
the world, why scans were done, to what extent people who needed scans did (or did not)
receive them, and how long patients waited for tests. Even less is available about the resultant
effects on patient care, costs, and outcomes, partly because understanding the impact of
imaging on what patients and providers know and do is challenging. For instance, while
imaging technologies have revolutionized cancer detection, some cancer mortality rates remain
stubbornly resistant to therapeutic advances. And, while these technologies have the potential
to avert many exploratory surgeries, others may result when something unusual shows up on a
mammogram, CT scan, or X-ray.
70
As these examples illustrate, the “what we don’t know” sections of the report are compelling.
Yet public, practitioner, and policy interest in medical imaging is strong. We hope that this report
will help to inform debate and decisions about imaging today, as well as efforts to improve the
information base available to support informed choices, five or even ten years from now.
Appendix A:
Fast Facts
List of Data Tables and Figures
Number of MRI Scanners by Province/Territory, Canada, 1991 to 2003
2.
Number of CT Scanners by Province/Territory, Canada, 1991 to 2003
3.
Number of Nuclear Medicine Physicians by Province/Territory, Canada,
1993 to 2001
4.
Number of Diagnostic Radiologists by Province/Territory, Canada, 1993 to 2001
5.
Number of Members of Medical Radiation Technologists’ Associations
in the Discipline of Nuclear Medicine by Province/Territory of Residence,
Canada, 1993 to 2002
6.
Number of Members of Medical Radiation Technologists’ Associations
in the Discipline of Radiological Technology by Province/Territory of Residence,
Canada, 1993 to 2002
7.
Distribution of Imaging Technologies Across Canada in January 2003
8.
Results from the Health Services Access Survey
9.
How Medical Imaging Equipment in Hospitals is Funded
10. Angiography Suites in Hospitals Across Canada, 2003
11. Catheterization Laboratories in Hospitals Across Canada, 2003
12. Computed Tomography (CT) Scanners in Hospitals Across Canada, 2003
13. Computed Tomography (CT) Scanners in Free-Standing Imaging Facilities Across
Canada, 2003
14. Magnetic Resonance Imaging (MRI) Scanners in Hospitals Across Canada, 2003
15. Magnetic Resonance Imaging (MRI) Scanners in Free-Standing Imaging Facilities
Across Canada, 2003
16. Nuclear Medicine Cameras in Hospitals Across Canada, 2003
17. Nuclear Medicine Cameras in Free-Standing Imaging Facilities Across Canada, 2003
18. Positron Emission Tomography (PET) Scanners in Hospitals and
in Free-Standing Imaging Facilities Across Canada, 2003
Appendix A: Fast Facts
1.
Medical Imaging in Canada
Number of MRI Scanners by Province/Territory, Canada, 1991 to 2003
1
1991
1992
1993
1994
1995
1997
2000
2001
2003
B.C.
3
5
5
6
7
9
10
14
18
Alta.
2
5
5
6
6
6
13
23
23
Sask.
1
1
1
1
1
1
3
3
3
Man.
1
1
1
0
1
1
3
3
3
Ont.
10
11
11
12
12
23
42
44
50
Que.
4
4
5
8
10
12
n/a
35
40
N.B.
0
0
0
0
1
1
2
5
5
N.S.
1
1
1
1
1
1
2
2
4
P.E.I.
0
0
0
0
0
0
0
0
0
N.L.
0
0
1
1
1
1
1
1
1
Nun.
0
0
0
0
0
0
0
0
0
N.W.T.
0
0
0
0
0
0
0
0
0
Y.T.
0
0
0
0
0
0
0
0
0
Notes: 1) Surveys were not carried out in 1996, 1998, 1999 and 2002.
2) CCOHTA notes that Quebec data were incomplete for 2000; therefore, they are not included.
3) Units located both in hospitals and in free-standing imaging facilities are included for
Canada for all years. The number of MRI scanners in free-standing imaging facilities was
imputed for years prior to 2003 based on data collected in the 2003 National Survey of
Selected Medical Imaging Equipment.
4) 2003 data are as of January 2003. Some additional equipment has subsequently been installed.
Source: National Inventory of Selected Imaging Equipment, Canadian Coordinating
Office for Health Technology Assessment (MRIs in hospitals, 1991–2001)
National Survey of Selected Medical Imaging Equipment, CIHI (2003)
Number of CT Scanners by Province/Territory, Canada, 1991 to 2003
2
1991
1992
1993
1994
1995
1997
2001
2003
B.C.
23
23
23
24
25
28
38
44
Alta.
22
22
24
23
23
23
25
30
Sask.
5
6
6
6
6
7
9
10
Man.
8
8
9
10
10
10
13
14
Ont.
65
68
72
76
79
84
91
95
Que.
58
60
60
62
68
69
92
94
N.B.
6
7
7
7
7
8
9
9
N.S.
7
8
8
8
9
9
14
15
P.E.I.
1
1
1
1
1
1
2
2
N.L.
5
5
6
6
6
6
9
11
Nun.
0
0
0
0
0
0
0
0
N.W.T.
0
0
0
0
0
0
1
1
Y.T.
0
0
0
0
0
0
0
1
Notes: 1) Surveys were not carried out in 1996, 1998 to 2000, and 2002.
2) Units located both in hospitals and in free-standing imaging facilities are included for
included for Canada for all years. The number of CT scanners in free-standing imaging
facilities was imputed for years prior to 2003 based on data collected in the 2003 National
Survey of Selected Medical Imaging Equipment.
3) 2003 data are as of January 2003. Some additional equipment has subsequently been installed.
Source: National Inventory of Selected Imaging Equipment, Canadian Coordinating Office for Health
Technology Assessment (CTs in hospitals, 1991–2001)
National Survey of Selected Medical Imaging Equipment, CIHI (2003)
1993
1994
1995
1996
1997
1998
1999
2000
B.C.
15
21
21
20
19
21
22
22
22
Alta.
7
10
11
13
14
13
15
14
13
Sask.
5
3
3
4
3
3
3
3
3
Man.
8
8
7
7
8
8
8
8
6
Ont.
56
57
59
62
66
67
74
74
75
Que.
78
83
88
88
88
89
87
87
85
N.B.
2
2
3
3
3
3
3
3
3
N.S.
2
3
3
3
3
3
4
4
5
P.E.I.
0
0
0
0
0
0
0
0
0
N.L.
2
2
2
2
2
2
2
2
2
Y.T.
0
0
0
0
0
0
N.W.T.
Nun.
Canada
0
0
0
0
0
0
175
189
197
202
206
209
Notes: 1) Data exclude residents and physicians who are not licensed to
provide clinical practice and have requested to the Business Information
Group (formerly Southam Medical Group) that their data not be published.
2) Data as of December 31 of given year.
Includes physicians in clinical and/or non-clinical practice,
including research, teaching or administration.
Specialty is based on most recent certified specialty, and data
may differ from other sources of provincial/territorial physician data
that categorize physicians on some other basis (e.g. functional
specialty, payment specialty, or provisional licenses).
Appendix A: Fast Facts
Number of Nuclear Medicine Physicians by Province/Territory, Canada, 1993 to 2001
2001
0
0
0
0
0
0
0
0
0
218
217
214
3) Caution must be exercised when comparing Northwest Territory data
prior to 1999 with Northwest Territory data after 1998, since some of the
change may be attributable to the creation of the Nunavut Territory.
4) Yukon and Alberta data in 2000 (and subsequently the Canada total)
do not reflect the annual update from the Government of the Yukon or
the College of Physicians and Surgeons of Alberta, respectively.
3
Source: Southam Database, CIHI
Number of Diagnostic Radiologists by Province/Territory, Canada, 1993 to 2001
1993
1994
1995
1996
1997
1998
1999
2000
2001
B.C.
228
224
229
233
242
236
234
236
230
Alta.
149
150
150
153
159
168
182
180
192
Sask.
45
48
50
50
51
50
49
51
45
Man.
60
57
62
62
65
63
64
63
60
Ont.
661
666
656
650
666
675
689
702
721
Que.
437
462
473
484
493
505
504
500
506
N.B.
38
41
41
43
43
44
44
46
42
N.S.
70
71
69
66
69
73
79
81
70
P.E.I.
4
5
5
4
6
6
6
6
6
N.L.
27
25
27
27
27
30
31
31
30
Y.T.
0
0
0
0
0
0
N.W.T.
Nun.
Canada
2
1
1
1
2
2
1,721
1,750
1,763
1,773
1,823
1,852
Notes: 1) Data exclude residents and physicians who are not licensed to
provide clinical practice and have requested to the Business Information
Group (formerly Southam Medical Group) that their data not be published.
2) Data as of December 31 of given year.
Includes physicians in clinical and/or non-clinical practice,
including research, teaching or administration.
Specialty is based on most recent certified specialty, and data
may differ from other sources of provincial/territorial physician data
that categorize physicians on some other basis (e.g. functional
specialty, payment specialty, or provisional licenses).
0
0
0
2
2
1
0
0
0
1,884
1,898
1,903
3) Caution must be exercised when comparing Northwest Territory data
prior to 1999 with Northwest Territory data after 1998, since some of the
change may be attributable to the creation of the Nunavut Territory.
4) Yukon and Alberta data in 2000 (and subsequently the Canada total)
do not reflect the annual update from the Government of the Yukon or
the College of Physicians and Surgeons of Alberta, respectively.
Source: Southam Database, CIHI
4
Medical Imaging in Canada
Number of Members of Medical Radiation Technologists’ Associations in the Discipline
of Nuclear Medicine by Province/Territory of Residence, Canada, 1993 to 2002
5
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
B.C.
153
171
169
171
178
181
180
186
191
192
Alta.
125
126
124
120
117
125
121
140
142
151
Sask.
26
27
27
29
25
27
32
30
33
35
Man.
45
44
45
44
44
46
47
45
44
45
Ont.1
5252
577
572
593
593
604
604
615
638
647
Que.3
••
••
••
••
••
••
••
••
395
403
N.B.
26
29
32
34
36
36
38
42
43
47
N.S.
63
63
70
65
66
68
64
62
63
73
P.E.I.
3
3
3
2
3
4
5
5
5
6
N.L.
14
15
17
15
16
15
15
14
16
13
Terr.
••
••
••
••
••
••
••
••
••
••
Canada
980
1,055
1,059
1,073
1,078
1,106
1,106
1,139
1,570
1,612
2
Notes: ••Not available
Members qualifying in other disciplines are counted in other disciplines.
1
Ontario data represent active registered members of the College of Medical Radiation Technolgists of Ontario.
The 1993 data were generated by the Board of Radiological Technicians and include other members other than “active.”
Therefore, the data are not comparable with data after 1993.
3
Quebec data represent active registered members of the Ordre des technologues en radiologie du Québec.
Source: Health Personnel in Canada, CIHI
Number of Members of Medical Radiation Technologists’ Associations in the Discipline of
Radiological Technology by Province/Territory of Residence, Canada, 1993 to 2002
6
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
B.C.
1,258
1,292
1,298
1,315
1,350
1,337
1,319
1,352
1,316
1,290
Alta.
1,204
1,142
1,128
1,093
1,101
1,151
1,153
1,187
1,208
1,226
Sask.
351
368
360
355
356
356
356
369
377
369
Man.
548
567
580
570
537
543
530
526
509
511
Ont.1
4,5942
4,346
4,319
4,198
4,118
4,158
4,133
4,136
4,163
4,202
Que.3
••
••
••
••
••
••
••
••
2,991
2,999
N.B.
368
378
388
393
382
399
403
398
393
409
N.S.
457
446
432
414
428
411
405
399
383
391
P.E.I.
67
62
63
64
62
67
63
60
64
62
N.L.
239
240
245
235
236
235
234
237
249
251
Terr.
Canada
••
••
••
••
••
••
••
••
••
••
9,086
8,841
8,813
8,637
8,570
8,657
8,596
8,664
11,653
11,710
2
Notes: ••Not available
Members qualifying in other disciplines are counted in other disciplines.
1
Ontario data represent active registered members of the College of Medical Radiation Technolgists of Ontario.
The 1993 data were generated by the Board of Radiological Technicians and include other members other than “active.”
Therefore, the data are not comparable with data after 1993.
3
Quebec data represent active registered members of the Ordre des technologues en radiologie du Québec.
Source: Health Personnel in Canada, CIHI
Nuclear
Medicine
Cameras
FS
13
10
2
-
CT Scanners
Angiography
Suites
Jurisdiction
B.C.
Alta.
Sask.
Man.
Ont.
Que.
N.B.
N.S.
P.E.I.
N.L.
Nun.
N.W.T.
Y.T.
H
61
41
14
16
234
149
18
23
2
10
1
-
Rate
14.7
17.2
13.9
13.9
20.1
20.2
23.8
24.4
14.2
18.8
24.2
-
H FS Rate
43 1 10.6
27 3 9.6
10 - 9.9
14 - 12.2
95 - 7.8
89 5 12.6
9
- 11.9
15 - 15.9
2
- 14.2
11 - 20.7
1
- 24.2
1
- 33.5
H
20
15
4
3
66
38
9
5
1
4
-
Canada
569 25 18.9
317 9 10.3
165
FS Rate
- 4.8
- 4.8
- 4.0
- 2.6
- 5.5
- 5.1
- 11.9
- 5.3
- 7.1
- 7.5
-
5.2
MRI
Scanners
Catheterization
Labs
H FS
14 4
17 6
3
3
50 24 16
5
3
1
1
-
Rate
4.3
7.3
3.0
2.6
4.1
5.5
6.6
4.2
1.9
-
H
11
11
4
4
36
21
2
3
2
-
120 27
4.7
94
PET
Scanners
FS Rate
2.6
3.5
4.0
3.5
3.0
2.8
2.6
3.2
3.8
-
Appendix A: Fast Facts
Distribution of Imaging Technologies Across Canada in January 2003
H FS Rate
1 1 0.5
2 - 0.6
6 - 0.5
4 - 0.5
-
3.0
13
1
0.4
Note: Rate = Numbers of units per million population of selected imaging technologies in provincial and territorial hospitals and free-standing
imaging facilities as of January 2003; H = Number of selected imaging technologies in hospitals; FS = Number of selected imaging
technologies in free-standing imaging facilities.
7
Source: National Survey of Selected Medical Imaging Equipment, CIHI
Results from the Health Services Access Survey
Selected parameters for Canadians aged 15 and over who reported receiving a non-emergency angiography,
CT, or MRI in 2001.
Parameter
Angiography3
CT3
MRI3
Approximate number age 15 and over who had a test1
220,000*
787,000
647,000
% of population age 15 and over who had a test
1%*
3%
3%
• % under 45 years
–
33%
40%*
• % age 45-64
52%*
41%
40%
• % age 65 and over
37%*
26%
19%*
48%*
50%
53%
77%
–
7%*
• Cancer
13%*
–
–
• Joints or fractures
–
13%*
18%*
• Neurological or brain disorders
–
29%
12%*
• Other/not specified
–
37%
46%
• Hospital/Public Clinic
98%
96%
92%
• Other2
2%
4%
8%
–
17%*
15%*
Age distribution of test recipients
% of test recipients who were male
Reason for test
• Heart or stroke disease
Place of test
% who reported any difficulties in accessing the test
3
Notes: 1 Rounded to the nearest 1,000 persons.
2
“Other” includes private clinics and other locations not specified.
“–” means data are suppressed due to extreme sampling variability.
*Interpret with caution due to sampling variability.
Source: Health Services Access Survey, Statistics Canada
8
Medical Imaging in Canada
How Medical Imaging Equipment in Hospitals is Funded
Funding arrangements for selected medical imaging equipment operating costs flowing through ministries of health in each
province and territory, 2003
Equipment
MRI
CT
B.C.
Alta.
Sask.
Man.
FA
PF
FA
PF
FA
PF
FA
!
!
!
!
"
!
!
!
%
%
!
"
%
!
"
%
!
!
!
%
PET
Que.*
PF
FA
!
!
"
!
PF
N.B.
FA
"
N.S.
FA
!
!
"
%
!
PF
!
N.L.
PF FA
PF FA
!
!
!
%
!
%
%
!
"
%
!
!
"
%
%
Cardiac
!
Catherization
"
%
%
Nuclear
Medicine
Cameras
!
Ultrasound
!
%
%
!
!
"
%
%
!
!
"
%
X-ray
%
!
%
%
!
!
"
"
9
%
%
%
FA = Facility Fees
PF = Professional Fees
%
%
!
!
!
"
"
!
%
%
%
%
%
%
%
%
%
%
%
%
%
!
%
%
%
!
"
%
%
!
"
!
"
!
"
%
!
%
%
!/! =
"/" =
%/% =
%
%
!
!
%
!
!
%
%
!
"
%
%
"
%
!
"
%
!
"
%
%
"
%
!
!
"
!
"
"
%
"
%
!
!
"
%
!
%
"
!
%
"
%
!
"
!
"
%
!
"
%
!
%
!
"
"
%
!
%
PF
"
%
!
!
"
%
%
"
!
"
"
"
%
!
!
FA
!
"
%
Y.T.
PF
!
%
Angiography
Nun.* N.W.T.*
FA
"
%
!
%
P.E.I.
FA
"
%
"
%
PF
!
"
%
%
PF
!
%
"
%
!
Ont.
FA
"
%
!
PF
"
%
!
"
%
%
%
"
%
%
Regional/Hospital Global Budgets
Included in FFS payments
Interprovincial reciprocal billings
*At the time of publication funding arrangements for other technologies in these
provinces/territories were unavailable. Data presented are as of 1999.
Source: Adapted from a 2001 Alberta Report entitled: Magnetic Resonance Imaging Report
of Findings and Recommendations prepared by the Imaging Advisory Committee.
Appendix A: Fast Facts
Angiography Suites in Hospitals Across Canada, 2003
Angiography Suites
by Population Density
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
Angiography suite
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
10
Catheterization Laboratories in Hospitals Across Canada, 2003
Catheterization Laboratories
by Population Density
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
Catheterization Laboratory
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
11
Medical Imaging in Canada
Computed Tomography (CT) Scanners in Hospitals Across Canada, 2003
Computed Tomography Scanners
by Population Density
12
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
CT scanner
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
Computed Tomography (CT) Scanners in Free-Standing Imaging Facilities Across Canada, 2003
Computed Tomography Scanners
by Population Density
13
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
CT scanner
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
Appendix A: Fast Facts
Magnetic Resonance Imaging (MRI) Scanners in Hospitals Across Canada, 2003
Magnetic Resonance Imaging Scanners
by Population Density
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
MRI scanner
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
14
Magnetic Resonance Imaging (MRI) Scanners in Free-Standing Imaging Facilities Across Canada, 2003
Magnetic Resonance Imaging Scanners
by Population Density
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
MRI scanner
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
15
Medical Imaging in Canada
Nuclear Medicine Cameras in Hospitals Across Canada, 2003
Nuclear Medicine Cameras
by Population Density
16
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
Nuclear Medicine Camera
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
Nuclear Medicine Cameras in Free-Standing Imaging Facilities Across Canada, 2003
Nuclear Medicine Cameras
by Population Density
17
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
Nuclear Medicine Camera
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
Appendix A: Fast Facts
Positron Emission Tomography (PET) Scanners in Hospitals and
in Free-Standing Imaging Facilities Across Canada, 2003
Positron Emission Tomography
Scanners by Population Density
Greater than or equal to 100,000 population in health region
50,000 to less than 100,000 population
Less than 50,000 population
PET scanner
Source: National Survey of Selected Medical Imaging Equipment, CIHI, 2003
18
Appendix B:
Glossary of Terms
Angiogram: An X-ray of a blood vessel that has been injected with a contrast agent.
Angioplasty: The use of a small balloon on the tip of a catheter inserted into a blood
vessel to open up an area of blockage inside the vessel.
Bone Density: A diagnostic test that measures the amount of mineral in bones. The
most commonly used test is dual energy X-ray absorptiometry (DXA), a low dose X-ray
beam that scans the spine, hip, or both.
Cardiac Catheterization: A form of coronary angiography used to image the blood
vessels in the heart, to examine the function of the heart, and to dilate narrowed blood
vessels that are not supplying adequate amounts of blood to heart muscles.
CAT: See Computed Tomography Scan
Computed Tomography Scan (CT) or Computed Assisted or Axial Tomography
(CAT) Scan: A diagnostic technique that uses X-rays and computer technology to
produce cross-sectional images (often called slices), both horizontally and vertically, of
the body. A CT scan can show detailed images of various parts of the body, including
the bones, muscles, fat, and organs. They are more detailed than general X-rays.
Contrast Media: A radiopaque substance used during an X-ray exam (or some other
exams) to provide visual contrast in the pictures of different tissues and organs. This
substance can be given orally or intravenously (by injection).
Contrast Resolution: The ability of an imaging method to distinguish one tissue from
another, or diseased from normal tissue.
Coronary Angiography: A diagnostic technique used to image coronary arteries. A
catheter is used to inject the arteries with a contrast agent (X-ray dye), and an X-ray
is taken.
CT: See Computed Tomography Scan
Doppler Ultrasound: Measures change in echo frequency to calculate how fast an
object is moving, thus permitting measurement of the velocity and direction of
blood flow.
Fluoroscopy: A study of moving body structures, similar to an X-ray ‘movie.’ A
continuous X-ray beam is passed through the body part being examined, and is
transmitted to a TV-like monitor so that the body part and its motion can be seen
in detail.
Gamma Camera: A device used in nuclear medicine to scan patients who have been
injected with small amounts of radioactive materials.
Appendix B: Glossary of Terms
Angiography: A technique that enables blood vessels to show up on X-rays. A dense
contrast agent (X-ray dye) is injected into the blood vessel, and an X-ray is taken. This
outlines the blood vessel, revealing blockages or other abnormalities.
Medical Imaging in Canada
Interventional Radiology: An area of specialty within the field of radiology which uses various
radiology techniques (such as X-ray, CT scans, MRI scans, and ultrasounds) to place wires, tubes, or
other instruments inside a patient to diagnose or treat an array of conditions.
Ionizing Radiation: Produces charged particles (ions) in matter. The particles are produced by
unstable atoms, which have an excess of energy or mass or both, and are said to be radioactive.
Radiation is the emission of this excess energy or mass needed to reach stability.
Lithotripsy: The crushing of a stone in the renal pelvis, ureter, or bladder, by mechanical force or
sound waves.
Magnetic Resonance Imaging (MRI): A diagnostic technology that uses a large magnet, radio waves, and
computer to scan a patient’s body and produce two- or three-dimensional images of tissues and organs.
Magnetic Resonance Spectroscopy (MRS): A type of MRI that measures concentrations of
metabolites to produce images of chemical processes.
Mammography: Uses low dose X-ray with high contrast, high-resolution film, to create detailed images
of the breast.
Modality: A treatment, or method of examination (e.g. X-ray, ultrasound, CT scan, MRI).
MRI: See Magnetic Resonance Imaging
MRS: See Magnetic Resonance spectroscopy
Nuclear Medicine: A medical specialty where organ function and structure are examined by
administering small amounts of radioactive contrast materials to the patient and taking scans with
a gamma camera or other device for the purpose of diagnosing and treating disease.
PACS: See Picture Archiving and Communications System
PET: See Positron Emission Tomography
Picture Archiving and Communications System (PACS): A system that acquires, transmits, stores,
retrieves, and displays digital images and related patient information from a variety of imaging sources
and communicates the information over a network.
Positron Emission Tomography (PET): A non-invasive diagnostic technology that measures the
metabolic activity of cells.
RAD: See Radiation Absorbed Dose
Radiation: The emission and flow of energy in the form of high speed particles and electromagnetic
waves. For example, visible light and radio, television, ultra violet (UV), and micro waves are made up of
electromagnetic waves.
Radiation Absorbed Dose (RAD): A unit that measures radiation in terms of the absorbed dose. For
radiological procedures it is equivalent to the REM, and the two units are used interchangeably.
Radiograph: A photographic image produced on a radiosensitive surface by radiation other than visible
light (especially by X-rays or gamma rays).
Radiography: The process of making a radiograph.
Radiology: The scientific discipline of medical imaging using ionizing radiation, radionuclides, nuclear
magnetic resonance, and ultrasound for the diagnosis and treatment of disease.
REM: See Roentgen Equivalent Man
Roentgen Equivalent Man (REM): A unit used to derive a quantity called ‘equivalent dose,’ which
relates the absorbed dose in human tissue to the effective biological damage of the radiation.
Radiopharmaceutical (Tracer or Radionuclides.): Basic radioactively-tagged compound necessary to
produce a nuclear medicine image.
Single Photon Emission Computed Tomography (SPECT): A type of nuclear medicine. It measures
the concentration of radionuclides introduced into a patient’s body. One or more gamma cameras
rotates around the patient and takes pictures from many angles, which a computer then uses to form a
tomographic (cross-sectional) image.
Sonography: See Ultrasound Imaging
SPECT: See Single Photon Emission Computed Tomography
Spatial Resolution: The ability of an imaging method to resolve anatomic detail.
Teleradiology: Teleradiology is a means of electronically transmitting radiographic patient images and
consultative text from one location to another.
Temporal Resolution: The ability of an imaging method to reflect changing physiological events such
as cardiac motion, or disease remission, or progression as a function of time.
Tomography: A method whereby a three-dimensional image of the internal structures of the human
body is produced.
Ultrasound Imaging (Sonography): Uses high frequency sound waves to make pictures of the body
organs. Echoes from the sound waves are recorded and displayed as a real-time, visual image.
X-ray (radiograph): A small amount of radiation (electromagnetic waves) directed toward a specific
part of the body to produce an image on a film on the other side of the body. Radiologists study the
X-ray images to detect and diagnose disease or injury. Common X-ray methods and procedures include
fluoroscopy, mammography, and angiography.
Appendix B: Glossary of Terms
Roentgen (R): A unit used to measure a quantity called ‘exposure’ and which can only be used to
describe an amount of gamma and X-rays, and only in air. This unit measures the ionizations of the
molecules in a mass of air.
Index
Note: Page numbers in italic indicate that the
information appears in a table, figure or sidebar.
Canada Health Infostructure Partnerships Program 32
Canadian Association of Medical Radiation Technologists
founded 6
training and certification requirements 47, 59
Canadian Association of Radiologists
concerns about CT scans of healthy individuals 57
concerns about ultrasound 57
founded 6
PACS survey 39
recommendations on equipment life 36
Canadian Association of Radiologists’ Journal 6
Canadian Association of Registered Diagnostic
Ultrasound Professionals 49
Canadian Cancer Society 17, 18
Canadian Community Health Survey 16, 18
Index
Accord on Health Care Renewal 38, 39
age
of imaging equipment 35–6
of imaging professionals 46
Alberta
costs of imaging 24
free-standing imaging facilities 60
mammography prevalence 18
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31, 32
wait times 62, 63
ambulatory care 16
American Cancer Society 17, 18
American College of Radiology
Expert Panel on Cardiovascular Imaging 18, 19
on full-body screening 57
American Institute of Ultrasound in Medicine 57
American Medical Association 7
American Registry of Diagnostic Sonographers 49
Anger, Hal 6
angiography
applications 7, 18, 19
definition 7
developed 6
equipment aging 35
equipment supply 29, 31
free-standing facilities 60
how it works 7
prevalence 20
wait times 61–2, 63
angioplasty 7, 18, 62
atoms 6, 10
Australia
CT use 21
MRI supply 32, 33–4
professional certification requirements 47
supply of imaging professionals 44
Austria
CT machines in 33
MRI machines in 33
Bell, Alexander Graham 6, 9
Bloch, Felix 6
bone mineral densitometry
applications 7
definition 7
wait times 63
brain imaging
use of CT 20
use of MRI 10
use of SPECT 12
breast cancer
deaths from 17
incidence 17
possible future technologies 13
screening for 17–8
breast examination (clinical) 17, 18
breastfeeding and X-rays 7
breast self-examination 17
Brinkley, James 12
British Columbia
costs of imaging 24
equipment supply 31
mammography prevalence 18
MRI costs 24
PACS 32
PET equipment 22
professional training 47–8
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
British Royal College of Radiologists 36
Medical Imaging in Canada
Canadian Coordinating Office for Health Technology
Assessment (CCOHTA) 30, 65
Canadian Institute for Health Information (CIHI)
data on imaging professionals 52
data sources 16, 30
imaging workload measurement system 16, 26
survey on medical technologies 30, 39
Canadian Task Force on Preventive Health Care 17, 18
cancer see oncology; specific type of cancer
cardiac catheterization
costs 23–4, 25
definition 7
wait times 62
cardiologists 42
cardiology
appropriateness of different tests 19
use of CT 19
use of MRI 19
use of PET 19
use of ultrasound 8
cardiology technologists 50
Cassen, Benedict 6
CAT (computer assisted tomography)
see computed tomography
catheterization see cardiac catheterization
costs 23–4, 25
definition 7
equipment aging 35
equipment supply 29, 31
free-standing facilities 60
history 6
wait times 62
certification 47, 49
chiropractors 41
CIHI see Canadian Institute for Health Information
cobalt-60 6
computed radiology 12
computed tomography (CT)
applications 9–10, 19–20, 58
combined with PET 11–2
compared to other imaging technologies 12
costs 23–4, 25, 37, 38
data sources on 16, 30
effect on patient outcomes 58
equipment aging 35–6
equipment supply 29, 30–4
example of image 12
facilities where offered 20, 35, 60
full-body scans 57
history 6, 9, 29
how it works 9
incidence of use 19–20, 21
international comparisons 32, 33–4
radiation dosages 56
SPECT 12
wait times 61 62, 63, 64
when to use 19–20
computers in imaging 8–9
contrast media
history 6
how they work 7
in CT 9
in MRI 10
Coolidge tubes 6
Cormack, Allan 6, 9
coronary angiography see angiography
costs
balanced with benefits 56, 57–8
data sources on 16
funding sources 24, 60, 61
of buying and replacing imaging equipment 35–8
of catheterization 23, 25
of CT 12, 23, 24, 25, 37, 38
of equipment 12, 23, 24, 36–8
of MRI 12, 23, 24–5, 37, 38
of nuclear medicine 12, 23, 25
of PET 22, 37
of ultrasound 12, 23, 25, 37, 38
of X-rays 23, 25, 37, 38
CT see computed tomography
Curie, Irene 5
Curie, Marie 5
Curie, Pierre 5, 8
cyclotrons 11, 22, 37
Czech Republic
CT supply 33–4
MRI supply 32, 33–4
Dandy, Walter 6
Denmark
CT supply 33
MRI supply 33
dentists 41
Diagnostic and Medical Equipment Fund 38, 52
diagnostic radiology physicians 41, 42, 43–4, 45–6
digital technologies 8, 9, 32
disease diagnosis 5, 7, 8, 10, 13, 23, 55, 57, 69
disorders of blood vessels 7
Doppler ultrasound 8
dual-energy X-ray absorptiometry (DXA) 7
Dussik, Karl Theodore 8
DXA (dual-energy X-ray absorptiometry) 7
echo planar imaging (EPI) 6
electrical impedance imaging 13
electron beam CT/multihead ultrafast CT with contrast 19
emergency departments
as data source 16
guidelines for imaging use 56–7
physicians’ roles 42, 59
use of CT 20
use of ultrasound 8
emission reconstruction tomography 6
federal government
funding for imaging equipment 24, 38, 52, 60
technology assessment 65
Finland
age of equipment 36
CT supply 33
MRI supply 33
fluoroscopy
applications 6, 7
definition 7
Forssmann, Werner 6
France
age of equipment 36
CT supply 33–4
MRI supply 33–4
Fraser Institute National Waiting List Survey 63
free-standing imaging facilities 35, 60
functional magnetic resonance imaging (fMRI) 11
fusion imaging 11–2
gadolinium chelates 10
gamma cameras 6, 12, 42
gamma rays in PET 11
Germany
age of equipment 36
imaging equipment from 37
Greece
CT supply 33–4
MRI supply 32, 33–4
Greenes, Robert 12
gynecologists 41–2
gynecology 8
Health Canada 50, 51, 57
health care professionals
compensation for imaging 24–5, 50
scopes of practice 59
worklife 50–1
Health Infostructure Atlantic 32
health insurance 24, 60, 61
health outcomes 55, 57–8
Health Services Access Survey 16, 20, 21, 61, 62, 63
heart disease 18, 19, 57
hospitals 16, 20, 21–5, 26, 30, 32, 56, 59, 60, 61, 63
Hounsfield, Godfrey 6, 9
Hungary
CT supply 33
MRI supply 33
imaging capsules 13
imaging equipment
aging of 35–6
costs of buying and replacing 36–7
data sources on 16
funding of 24, 61
information gaps 28, 39, 65
international comparisons 32, 33–4, 36
national survey on 16, 24, 29, 30–1, 32, 35, 60, 61
numbers of 29, 30, 31, 32, 33–4
where located 35, 39, 60
who pays for 60, 61
imaging facilities
free-standing vs. hospital 60, 61
hours of operation 63
imaging professionals
compensation 24–5, 50
education 47–9
information gaps 50
radiation risks 51
regulation 49
scopes of practice 43, 59
supply trends 45–6
types 42–4
worklife 50–1
infarct avid imaging 19
Institute for Clinical Evaluative Sciences 22, 23, 43, 63
international comparisons
education of MRTs 47
imaging equipment 32, 33, 34, 36, 37
wait times 64
international medical graduates 52
interventional radiology
definition 7
use of ultrasound 8
iodine, radioactive 6
Italy
age of equipment 36
CT supply 33
MRI supply 33
Japan
CT supply 32, 33
imaging equipment from 37
MRI supply 33
Joliot, Frederick 5
Kirby Committee 38, 69
Korea
CT supply 32, 33
MRI machines in 33
Kuhl, David 6
law, use of medical imaging in 5
left ventricular angiography 19
lithotriptors 19
Ludwig, George 8
lung cancer 17, 57
LV (left ventricular) angiography 19
Index
England
CT supply 32, 33
CT use 21
MRI supply 22, 33
MRI use 22
EPI (echo planar imaging) 6
equipment see imaging equipment; specific technologies
Medical Imaging in Canada
magnetic resonance angiography (MRA) 11, 19
magnetic resonance imaging (MRI)
applications 10–1, 19, 58
compared to other imaging technologies 12
costs 12, 23–5, 37
effect on patient outcomes 57
equipment aging 35–6
equipment supply 29, 30–1, 32, 33–4
example of image 10
facilities where offered 35, 60, 61
free-standing facilities 60, 61
history 6, 21
how it works 10
international comparisons 32, 33–4
introduced in Canada 21
prevalence of use 21–2
scan rates 22
technologists 42
types 10–1
wait times 61–3
when not to use 10
who orders 43
magnetic resonance spectroscopy (MRS) 11
mammography
applications 7
definition 7
free-standing facilities 60
history 7
prevalence 18
recommendations for 17, 18
wait times 63
Management Information Systems Database 16, 25, 31
Manitoba
mammography prevalence 18
MRI equipment and use 21–2
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
study on patient outcomes 57
supply of imaging equipment 31
wait times 63
Medical Devices Industry Survey 37
Medical Equipment Fund 38, 52
medical imaging, see also specific technologies
comparison of technologies 12
costs of 23–5, 36–7
cost-effectiveness 57–8
data sources on 16
facilities where offered 35, 60
funding 24, 60, 61
guidelines for use 55–7
history 5–7
information gaps 26, 39, 65
projections for future 13
safety 51, 56
service delivery 60
types of, today 7–12
use of new and old technologies 58
wait times 61–4
medical physicists 41, 42, 44, 45, 47–9
medical radiation technologists (MRTs)
age of 46
certification 47, 49
definition 41–2
education of 47 48
full-time vs. part-time 50
gender of 46
income 50
job satisfaction 51
radiation risks 51
scopes of practice 59
supply of 44–6
men
imaging professionals 46
Mexico
CT supply 33
MRI supply 33
molecular imaging 13
Moniz, Egas 6
Montreal Neurological Institute 6
MRA (magnetic resonance angiography) 11, 19
MRI see magnetic resonance imaging
MR perfusion studies 19
MRS (magnetic resonance spectroscopy) 11
MRTs see medical radiation technologists
National Ambulatory Care Reporting System 16, 20
National Physician Database 16
National Survey of Selected Medical Imaging Equipment
16, 24, 30, 31–2, 34–5, 60–1
neurologists 42, 43
neurology
use of CT 20
use of MRI 10
use of PET 23
use of SPECT 12
neuroradiology physicians 47
New Brunswick
costs of imaging 24
growth in CT scan use 19, 21
mammography prevalence 18
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
Newfoundland and Labrador
growth in CT scan use 19, 21
mammography prevalence 18
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31, 32
obstetricians 42
obstetrics 8, 57
oncologists 42
oncology
use of CT 10
use of PET 11, 23
use of ultrasound 8
Ontario
costs of imaging 23, 24, 25, 38
emergency departments 16, 20
growth in CT scan use 19–20, 21
mammography prevalence 18
medical equipment funding 38
MRI use and costs 22, 23, 24, 25
PACS 32
PET studies 22
professional training 47, 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
wait times 62–3
X-ray costs 25
optical imaging 13
Ordre des technologues en radiologie du Québec 49
Organization for Economic Cooperation and Development
32, 33–4
orthopedic surgeons 42, 43
Osler, Sir William 8
PACS (picture archiving communication systems) 9, 32, 39
patients
outcomes 55, 57–8
wait times 61–4
pediatric radiology physicians 47
physicians
as data sources 16
certification and regulation 49
migration of 45
ordering tests 43
scopes of practice 59
surveyed on wait times 63
training 48
types 41–4
picture archiving and communication systems (PACS)
9, 32, 39
plain film radiography 13
pneumo-encephalography 6
positron emission tomography (PET)
applications 11, 19, 22–3
combined with CT 11–2
costs of equipment 22, 37
equipment aging 35
equipment needed 11, 22
equipment supply 31
example of image 11
history 6, 22
how it works 11
radiation dosages 56
pregnancy
and MRI 10
and ultrasound 57
and X-rays 7
Prince Edward Island
growth in CT scan use 19, 21
mammography prevalence 18
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
private health care 60
professional training 47–8
Index
New Zealand
CT supply 33–4
NORad 32
NORTH Network 32
Northwest Territories
mammography prevalence 18
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
Nova Scotia
mammography prevalence 18
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
teleradiology 9
wait times 63
X-ray history 6
nuclear magnetic resonance 6
nuclear medicine
compared to other imaging technologies 12
costs 12, 23–5
equipment aging 35
equipment supply 29, 31
free-standing facilities 60, 61
history 6
nuclear medicine physicians 42, 44, 46, 48–9
nuclear medicine technologists (NMTs) 42, 46, 47, 49
Nunavut
mammography prevalence 18
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
Medical Imaging in Canada
provinces, see also specific province
Accord on Health Care Renewal 39
certification and regulation 48–9
funding of imaging 24, 36–8, 60, 61
growth in CT scan use 19–20, 21
growth in MRI use 22
mammography prevalence 18
professional training 48
public accountability for imaging use 26, 65
ratio of MRIs to CTs 32
referrals for scans 43
supply of imaging equipment 31–2
survey on imaging equipment 31
technology assessment 65
Purcell, Edward Mills 6
Quebec
costs of imaging 24
first X-ray diagnosis 5
growth in CT scan use 19, 21
mammography prevalence 18
PET study 23
professional training 48
radiology research 7–8
ratio of MRIs to CTs 32
recommendations on equipment life 36
referrals for scans 43
regulation 49
supply of imaging equipment 31
wait times 62–3
radiation dosages 51, 56
radiation treatments 10
radiographers 41–2
radiography see X-rays
radiological technologists 41–2, 50
radiology
history 5–13
interventional 7, 8, 43
radiology assistant program 59
radiology assistants 59
radionuclide myocardial perfusion scan 19
radionuclides 6, 11, 12, 13
radionuclide ventriculogram 19
rare earth screens 6
Roentgen, Wilhelm Conrad 5, 6
Romanow Commission 38
Royal College of Physicians and Surgeons of Canada
42, 43, 48, 49
Rutherford, Ernest 5, 6
safety of medical imaging 51, 56
Saskatchewan
cobalt-60 unit developed 6
costs of imaging 24
mammography prevalence 18
MRI use and costs 24
numbers of imaging tests 58
PACS 32
professional training 48
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
scintillation scanner 6
self-regulation of imaging professionals 49
single-photon emission computed tomography (SPECT) 9, 12
skin cancer among radiologists 51
Slovak Republic
CT supply 33
MRI supply 33
sonographers
demographics of 46
education of 47, 48
full-time vs. part-time 50
income 50
job satisfaction 51
numbers of 42
regulation of 49
roles 42
Spain
age of equipment 36
CT supply 33–4
MRI supply 32, 33–4
SPECT (single-photon emission computed tomography) 9, 12
Statistics Canada
data sources 16
Medical Devices Industry Survey 37
survey on wait times 61–3
Sweden
age of equipment 36
CT supply 33
MRI supply 33
Switzerland
CT supply 33
MRI supply 33
Tc-99m 6
TEE (transesophageal echocardiography) 19
telehealth 9, 32
teleradiology 9
territories, see also specific territory
funding of imaging 24, 37–8, 60
mammography prevalence 18
ratio of MRIs to CTs 32
referrals for scans 43
regulation 49
supply of imaging equipment 31
thyroid cancer 6
tracer principle 6
transesophageal echocardiography 19
transthoracic echocardiography 19
TTE (transthoracic echocardiography) 19
Turkey
CT supply 33
Von Hevesy, Georg 6
wait times 61–4, 65
Western Canada Waiting List Project 62, 65
women, see also mammography
angiographies 20
breastfeeding and X-rays 7
imaging professionals 46
pregnancy and use of imaging 7, 10, 57
Workers’ Compensation Board 24, 61
X-rays
applications 5, 7, 19, 58
costs 23, 25, 37
history 5–7
radiation dosages 51, 56
radiation risks 7, 51, 56
teleradiology 9
Yukon Territory
regulation 49
mammography prevalence 18
PACS 32
ratio of MRIs to CTs 32
referrals for scans 43
supply of imaging equipment 31
Index
ultrasonography 13
ultrasound
applications 8, 57
compared to other imaging technologies 12
costs 12, 23, 25, 37–8
history 6, 8
how it works 8
wait times 62, 63
United Kingdom
British Royal College of Radiologists 36
on full-body scans 57
professional certification requirements 47
professional roles 59
professional supply 44
United States
American Cancer Society 17, 18
American College of Radiology 18, 19, 57
American Institute of Ultrasound in Medicine 57
American Medical Association 7
American Registry of Diagnostic Sonographers 49
CT scan criteria 21
Food and Drug Administration 57
growth in CT scan use 21
imaging equipment from 37
MRI machines in 33
Preventive Services Task Force 17
professional regulation 49
urology 8
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About This Report
Medical Imaging Technologies:
The Past, Present, and Future
Medical Imaging in Practice
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Medical Imaging Professionals
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Medical Imaging
Medical Imaging in Canada:
An Incomplete Picture
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