Workload measurement comes under scrutiny

Increasing workload is a common trend in radiology departments throughout Europe. The question is, How can we measure it effectively?

Counting the number of diagnostic imaging examinations performed today and comparing it with the number of examinations performed previously is not sufficient when assessing a change in workload. At my own institution, the number of CT examinations performed per month tripled between the beginning of 2001 and the end of 2004. During this time, we upgraded two old CT units to multislice systems. The number of MR scans increased by 400% over the same four-year period, while the number of conventional x-ray procedures fell slightly.

But the change in workload is not simply the change in absolute numbers. The time taken to acquire and report a cross-sectional imaging study is far higher than that required for conventional x-ray examinations. The nature of the radiological procedure must be taken into account as well.

In 2001, the Danish Radiology Society proposed a points system to measure radiological workload (www. drs.dk). Each examination was allocated a higher or lower number of points depending on its complexity and staffing requirements. A chest x-ray, for example, was allocated one point, breast ultrasound 1.5 points, head CT two points, MR of the knee three points, MR cholangiopancreatography four points, and pulmonary arteriography five points.

The total number of examinations performed in our department from 2001 to end-2004 increased by 40%. If we use the points system, however, we see that workload actually increased by 100%, while productivity per employee rose by more than 45% over the same period. These figures provide a more realistic picture of the change.

Finding an accurate way to measure workload is important because it is often linked to reimbursement payments. Many fee-per-procedure systems are not very good at reflecting the differing complexity of examinations. For example, an MR scan of the knee is a short, straightforward procedure. A combined MRI examination of the brain, spine, and pelvis takes much longer. At our institution, we would receive the same sum of money for both of these imaging investigations. The national health authority in Denmark has one figure for MR: Euro 340. It pays Euro 205 for CT, regardless of the length and complexity of the examination. The payment system should be more flexible than this.

The growth of the radiological workload is likely to continue. One of the reasons is that newer oncology treatments are proving to be more successful. Our department has seen a 27% rise in patients presenting for imaging follow-up after periods of chemotherapy and/or radiotherapy. Clinicians are also more likely to submit imaging requests than in previous years. Today arthroscopy is seldom scheduled unless there is an abnormal MRI of the joint.

University radiology departments usually have to deal with the most difficult and time-consuming cases. Patients referred for an MR scan because of abnormal joint pain can choose which imaging clinic or hospital department they attend. Oncology patients undergoing repeated follow-up imaging must return to the same scanner for each examination. Simple ultrasound scans may be performed in clinical departments now that the cost of a standard ultrasound scanner is so low. Ultrasound referrals to diagnostic radiology departments may consequently be more complex.

Increasing workload means longer patient waiting times. But the switch from conventional examinations to cross-sectional imaging need not always have a negative impact on productivity. Modern technology can provide a fast and economical service. We stopped performing intravenous urography in 2002, for example, and switched to unenhanced CT for investigating patients with renal colic. When three urology departments merged into our hospital 18 months ago, leading to a threefold increase in patients presenting with flank pain, we were able to manage this tripling of patient numbers successfully. With unenhanced CT, patients spend less time in the hospital, so the hospital can cope without more acute beds.

The points system is not widely used in Denmark to measure actual workload changes because it is not linked to the reimbursement system. We have been using the system at Herlev to demonstrate its value and hope that in the future such a system will be employed universally.

It will be interesting to consider alternative systems for measuring workload that are used in other countries. Although it will take time to find a commonly accepted solution, I hope that this proposal will stimulate the debate.

PROF. THOMSEN is chair of diagnostic radiology at Copenhagen University Hospital at Herlev, Denmark.