British Journal of Radiology (2005) 78, 538-542
© 2005 British Institute of Radiology
doi: 10.1259/bjr/13870613
The effect of introducing radiographer reporting on the availability of reports for Accident and Emergency and General Practitioner examinations: a time-series analysis
S D Brealey, PhD1 and
P A Scuffham, PhD2,3
1 York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, 2 York Health Economics Consortium Ltd, University of York, York YO10 5NH, UK and 3 School of Population Health, University of Queensland, Brisbane, Australia
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Abstract
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This study explores whether the introduction of selectively trained radiographers reporting Accident and Emergency (A&E) X-ray examinations of the appendicular skeleton affected the availability of reports for A&E and General Practitioner (GP) examinations at a typical district general hospital. This was achieved by analysing monthly data on A&E and GP examinations for 1993–1997 using structural time-series models. Parameters to capture stochastic seasonal effects and stochastic time trends were included in the models. The main outcome measures were changes in the number, proportion and timeliness of A&E and GP examinations reported. Radiographer reporting X-ray examinations requested by A&E was associated with a 12% (p=0.050) increase in the number of A&E examinations reported and a 37% (p
0.001) decrease in the time taken to report on these examinations. Radiographer reporting of A&E X-ray examinations was also associated with a 14% (p=0.067) decrease in the time taken for GP examinations to be reported. That is, radiographer reporting A&E X-ray examinations allowed an increase in the time available to radiologists to report on examinations requested by GPs. An increase in the proportion of GP examinations reported by radiologists was associated with longer reporting times for A&E examinations. In conclusion, selectively trained radiographers reporting on A&E X-ray examinations significantly improved the availability of reports for A&E and GP examinations.
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Introduction
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A shortage of doctors and the need to address increasing demand in a healthcare system with scarce resources has brought about changes in Government policy that promote a more flexible and creative use of allied healthcare professional skills [1, 2]. In X-ray departments, a national shortage of radiologists [3, 4] and a continuing rise in workload [5] provide a climate that has encouraged the development of radiographers in a written reporting role [6, 7]. This skill mix initiative was seen to be a natural extension of what radiographers were already doing in normal clinical practice such as marking Accident and Emergency (A&E) radiographs with a red dot to alert casualty officers to the possible presence of an abnormality [8] or the triage of A&E radiographs as normal, insignificantly abnormal, or significantly abnormal [9]. There is now evidence that selectively trained radiographers can provide accurate written text reports describing A&E radiographic appearances [10–12] resulting in a growing number of radiographers performing this task [13, 14].
In recent years, one criticism of reporting services has been clinicians' dissatisfaction with reports not being provided for all examinations and not received in time to influence patient management [15]. Therefore, not only is it important that radiographs are interpreted accurately but that they are all reported promptly. This is repeatedly emphasised as quality standards by the Royal College of Radiologists (RCR) [3, 16]. The standards suggest that all A&E examinations are reported before the patient leaves the X-ray department [3] and all general practitioner (GP) examinations should be reported within 24 h of the arrival of the patient [13, 17]. In practice, a recent survey has shown that of 110 X-ray departments, A&E examinations were not reported in 13 (15%) of the 87 hospitals that responded [18]. In a further study of 102 hospitals, only 50% of GP examinations were reported after 22 h [19]. Delays in the availability of a report may affect patient outcomes and lead to an increase in other more expensive investigations. The deployment of selectively trained radiographers in an A&E written reporting role might help X-ray departments to ensure that all A&E examinations are reported promptly. Furthermore, if this alleviates radiologists' workload, it may free their time to improve the availability of reports for other examinations, such as those requested by GPs. Can this potential be achieved?
In February 1995, following a period of training, two radiographers at a typical district general hospital began to report A&E X-ray examinations of the appendicular skeleton judged normal or insignificantly abnormal by the casualty officers. This provided an opportunity to assess whether the introduction of radiographer reporting could help to ensure that all A&E examinations were reported promptly and how this affected the reporting of GP examinations.
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Methods
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A time-series study was undertaken to assess whether the introduction of the radiographers in a reporting role affected the availability of reports for examinations requested from A&E or general practice. The X-ray department performs more than 7500 examinations per month, of which 29% are referred from A&E and 25% from general practice. This corresponds with the findings from a recent national report which indicated that 27% of radiology workload is generated by referral from A&E and 21% from GP referrals [15].
The Systems and Network Services department provided monthly data on numbers of examinations taken, reported, the time taken to report the examinations, the profession responsible for reporting the examinations, and the referral source. This was for the period February 1993 (2 years before the intervention) to January 1998 (3 years after the intervention). A total of 418 362 examinations were performed over this 5 year period and 325 902 were reported (78%).
Radiographers were trained to report on examinations for patients referred from A&E; therefore, the primary analysis was restricted to A&E. The primary hypothesis was that reporting on A&E examinations by radiographers had no effect on the number and timing of A&E reports. Indirect effects from radiographer reporting may be present; for example, radiologists may reduce their time spent reporting A&E examinations and may have more time to report on GP examinations, and therefore, more GP examinations may be reported. This is a factor we tested in the analyses, with the hypothesis that reporting on A&E examinations by radiographers had no effect on the time taken to report GP examinations. Descriptive data for these groups are shown in Table 1
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Three statistical models for time-series regression analysis were specified: the number of A&E examinations reported (Model 1); the time to report A&E examinations (Model 2); and the time to report GP examinations (Model 3). Independent variables included total A&E and total GP examinations performed and the intervention variable. These factors were included in all models for two reasons – radiologists may substitute their time away from reporting on A&E examinations to reporting GP examinations, and when demands for examinations are high (either A&E or GP examinations), radiologists may have less time to report A&E examinations. The intervention variable used for all models was the proportion of A&E examinations reported by radiographers. In the time to report models (Models 2 and 3), the proportions of A&E and GP examinations reported were also included as explanatory variables.
Time-series data often contain trends that, without proper control, can violate the statistical properties of normality, and thus, the usual inference procedures to test hypotheses are invalid. Trends and seasonal variations can be incorporated explicitly and efficiently through structural time-series models (STSM), and thus, with a correctly specified model, the usual statistical inferences apply [20, 21]. The STSM is a general form of the Box-Jenkins autoregressive integrated moving average (ARIMA) models [22]; however, trends and seasonal components can be allowed to vary stochastically over time in response to disturbances rather than being omitted from the modelling process as occurs in ARIMA models. Therefore, valuable information can be retained in the model as the data do not require differencing, detrending or deseasonalising [20]. The seasonal component was specified as a smooth sine-wave that was allowed to vary over time.
To capture any delayed effects in the variables, three lags of each variable were included in the models. (For example, the dependent variables may respond to the explanatory variables after a time lapse; in these models, one lag, denoted t–1, is 1 month and so forth.) To obtain parsimonious models (i.e. models with all non-significant factors omitted), an iterative testing-down procedure was used where the variable with the least significance was omitted and the model re-estimated. This process was continued until the variables retained in the final models had a statistical significance of at least 90%. Similarly, the stochastic trend or seasonal component could be replaced with a deterministic component when there was no variation to the component over time. All models were subjected to tests for normality, including tests on the error terms for zero mean, constant variance, skewness, kurtosis, and importantly, serial correlation. Goodness of fit was based on the usual R2 and an R2 around seasonal differences (RS2).
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Results
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The fit was reasonable for all three models, with RS2 between 0.55 and 0.93. In all models a stochastic trend was retained owing to variation in the disturbances affecting the trend; however, the stochastic seasonal component showed no variation in all models (i.e. the seasonal pattern was constant). Therefore, the stochastic seasonality was reduced to deterministic seasonality in all models.
For the number of A&E examinations reported (Model 1), the total number of examinations and the proportion reported by radiographers were significant factors (Table 2). Radiographer reporting was associated with an increase in the number of A&E examinations reported, after controlling for increases in total A&E examinations taken, by 12% per month (p=0.050). Interestingly, an increase in the proportion of GP examinations reported was associated with an increase in A&E examinations reported in the same month but a decrease in the next month. This oscillation suggests reporting is undertaken in batches with some storing of work. The parameter estimates were used to predict the number of A&E examinations reported in the absence of the intervention (Figure 1).
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Figure 1. Number of accident and emergency (A&E) examinations reported by staff and predicted number of examinations reported in the absence of radiographer reporting.
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The time taken to report A&E examinations (Model 2) was dependent on the proportion of A&E examinations reported by radiographers and the proportion of GP examinations reported. An increase in the proportion of A&E examinations reported by radiographers reduced A&E reporting times by 36.8% (p<0.001). An increase in GP examinations reported was associated with increased A&E reporting times. The effect on A&E reporting times from radiographer reporting is illustrated in Figure 2 where the observed time to report A&E examinations is contrasted against the longer predicted time in the absence of the intervention.
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Figure 2. Observed time to report accident and emergency (A&E) examinations and predicted time in the absence of radiographer reporting.
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Similarly, radiographer reporting on A&E examinations significantly reduced the time taken by radiologists to report GP examinations (Model 3), but this effect was delayed by 1 month. That is, increased radiographer reporting in 1 month reduced the reporting time of GP examinations (by 14%, p=0.067) in the next. In addition, an increase in reporting times of GP examinations in 1 month was associated with an increase in reporting time in the next, suggesting backlogs could build up.
In the time to report models (Models 2 and 3), the total number of A&E examinations taken, the total number of GP examinations and the proportion of A&E examinations reported had no statistically significant effect on the time taken to report either A&E or GP examinations.
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Discussion
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A policy of both the American College of Radiology [23] and the RCR [16] is that all images should be accompanied by a written report. The Ionising Radiation (Medical Exposure) Regulations are also integral to ensuring that patients are not unnecessarily exposed to potentially harmful radiation without the benefit of the image being reported. The RCR recommends the need for images to be reported promptly; notably that A&E examinations are reported before the patient leaves the X-ray department [3] and all GP examinations are reported within 24 h of the arrival of the patient [13, 17]. In practice, surveys have shown considerable variation in the proportion of A&E examinations reported by radiologists and their timeliness [24–27]. The conclusion of a recent national audit of 102 hospitals in the UK was that X-ray departments are often unable to meet targets set for providing GPs with a prompt reporting service [19]. The availability of a report is important for influencing the referring clinician's decision-making and in turn may affect patient outcome and the need for other more expensive investigations.
A shortage of radiologists and changes in Government policy over the last decade have resulted in relaxation of restrictions on who should provide written text reports. There is now substantial evidence that selectively trained radiographers can report A&E X-ray examinations to a similar level of accuracy as radiologists [10–12]. Our analyses show that the intervention of radiographer reporting was associated with an increase in the number of A&E examinations reported. Before the introduction of radiographer reporting there were occasions when it was not feasible for the radiologists to report some A&E examinations because of excessive workloads, but subsequent to the intervention this has not occurred. Radiographer reporting also decreased times taken to report both A&E and GP examinations.
There were interactions between reporting times for A&E and GP examinations. Increases in the proportion of GP examinations reported increased reporting times for A&E examinations; and increased reporting of A&E examinations by radiographers decreased GP examination reporting times. That is, when radiologists increase GP reporting, the time taken to report A&E examinations increased as the availability of radiologists for reporting A&E examinations was reduced; and when radiographers reported A&E examinations, the radiologist's time available to report GP examinations increased and thus reduced the reporting times for GP examinations. These features show radiologists substitute their time from reporting on A&E examinations to GP examinations (and vice versa) and reporting is undertaken in batches with occasional backlogs.
Whether the results from this study are generalizable to different hospital settings and other selectively trained radiographers remains to be tested. Furthermore, the data were provided by the hospital's information management database. Problems such as duplicate records of patients' attendance for examinations or inaccurate allocation of patients' to a referral source may limit the data quality. Our findings complement those from a similar study that found the introduction of radiographer reporting in four NHS Trusts brought about a significant increase in the proportion of A&E skeletal X-ray examinations reported and timeliness of report availability [28]. However, the findings were limited by the short pre- and post-intervention study periods and the chi-squared test used for analysis. These factors meant that the apparent effect of radiographer reporting could have been due to seasonal effects alone.
In conclusion, whilst taking into consideration the possible limitations of the data available, this study provides evidence that with appropriate training and careful supervision the introduction of radiographers in a reporting role can improve the availability of reports for A&E and GP examinations, and therefore, help X-ray departments meet quality standards. This is important not only for referring clinicians' decision-making and ultimately patients' health but also the future development of radiographers' professional status and practice and addressing the shortage in radiologists.
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Acknowledgments
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The authors are extremely grateful for the help of the staff at the hospital for providing the data and in particular Mr Ian Crawshaw.
Received for publication February 11, 2004.
Revision received December 1, 2004.
Accepted for publication January 5, 2005.
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Abstract
Introduction
