Moving beyond quality control in diagnostic radiology and the role of the clinically qualified medical physicist

A survey of gamma camera and SPECT/CT quality control programs across a sample of public hospitals in Australia

Performance testing of gamma cameras and single photon computed tomography/computed tomography (SPECT/CT) systems is not subject to regulatory requirements across states and territories in Australia. Internationally recognised testing standards from organisations such as the National Electrical Manufacturers Association (NEMA) describe methodologies for recommended tests. However, variations exist in suggested quality control (QC) schedules from professional bodies such as the Australia and New Zealand Society of Nuclear Medicine (ANZSNM). In this study, a survey was conducted to benchmark current QC programs across a selected sample of eight standalone and networked Australian public hospitals. Vendor-specific flood-field uniformity (intrinsic or extrinsic/system) verification without photomultiplier (PMT) tuning and CT QC were performed at all sites. Weekly and monthly PMT tuning followed by intrinsic flood-field verifications were performed at most sites. At least half of the sites performed monthly centre of rotation (COR) offset verifications. SPECT/CT alignment calibrations and verifications were undertaken by service engineers at all sites, and periodic verifications were performed by local staff at varying frequencies. Variations were observed for other periodic QC tests such as spatial resolution and planar sensitivity. Similarly, variations were observed for tests specific to whole-body systems and SPECT systems. Most sites checked daily and periodic QC results against pass/fail criteria set by vendors. Additional analyses of the QC results, including trend analysis and periodic reviews, were not common practice. The lack of regulatory requirements is likely to have led to variations in QC tests that are generally either harder to perform or are more labour intensive.

Education and training in radiation protection in Europe: an analysis from the EURAMED rocc-n-roll project

Background

A Strengths, weaknesses, opportunities and threats analysis was performed to understand the status quo of education and training in radiation protection (RP) and to develop a coordinated European approach to RP training needs based on stakeholder consensus and existing activities in the field. Fourteen team members represented six European professional societies, one European voluntary organisation, two international healthcare organisations and five professions, namely: Medical Physicists; Nuclear Medicine Physicians; Radiologists; Radiation Oncologists and Radiographers. Four subgroups analysed the “Strengths”, “Weaknesses”, “Opportunities” and “Threats” related to E&T in RP developed under previous European Union (EU) programmes and on the Guidelines on Radiation Protection Education and Training of Medical Professionals in the EU.

Results

Consensus agreement identified four themes for strengths and opportunities, namely: (1) existing structures and training recommendations; (2) RP training needs assessment and education & training (E&T) model(s) development; (3) E&T dissemination, harmonisation, and accreditation; (4) financial supports. Weaknesses and Threats analysis identified two themes: (1) awareness and prioritisation at a national/global level and (2) awareness and prioritisation by healthcare professional groups and researchers.

Conclusions

A lack of effective implementation of RP principles in daily practice was identified. EuRnR strategic planning needs to consider processes at European, national and local levels. Success is dependent upon efficient governance structures and expert leadership. Financial support is required to allow the stakeholder professional agencies to have sufficient resources to achieve a pan European radiation protection training network which is sustainable and accredited across multiple national domains.

Clinical translation of quantitative magnetic resonance imaging biomarkers - An overview and gap analysis of current practice

PURPOSE

This overview of the current landscape of quantitative magnetic resonance imaging biomarkers (qMR IBs) aims to support the standardisation of academic IBs to assist their translation to clinical practice.

METHODS

We used three complementary approaches to investigate qMR IB use and quality management practices within the UK: 1) a literature search of qMR and quality management terms during 2011-2015 and 2016-2020; 2) a database search for clinical research studies using qMR IBs during 2016-2020; and 3) a survey to ascertain the current availability and quality management practices for clinical MRI scanners and associated equipment at research institutions across the UK.

RESULTS

The analysis showed increased use of all qMR methods between the periods 2011-2015 and 2016-2020 and diffusion-tensor MRI and volumetry to be popular methods. However, the "translation ratio" of journal articles to clinical research studies was higher for qMR methods that have evidence of clinical translation via a commercial route, such as fat fraction and T2 mapping. The number of journal articles citing quality management terms doubled between the periods 2011-2015 and 2016-2020; although, its proportion relative to all journal articles only increased by 3.0%. The survey suggested that quality assurance (QA) and quality control (QC) of data acquisition procedures are under-reported in the literature and that QA/QC of acquired data/data analysis are under-developed and lack consistency between institutions.

CONCLUSIONS

We summarise current attempts to standardise and translate qMR IBs, and conclude by outlining the ideal quality management practices and providing a gap analysis between current practice and a metrological standard.

Webinar and survey on quality management principles within the Australian and New Zealand ACPSEM Workforce

Healthcare relies upon the accurate and safe delivery of patient care. This is only achievable when systems are developed to ensure high quality, robust outcomes, for instance quality management systems. The concept of quality management can take on a different meaning depending on the context in which it is found. To add complication, the amount of education required for quality management will vary depending on one's exposure to the implementation of quality systems. In part to address these issues, the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) Queensland Branch held a quality management webinar for members and non-members across Australia and New Zealand. The purpose of the webinar was to educate and facilitate discussion regarding the application of quality management principles for the ACPSEM profession. In conjunction, a pre- and post-webinar survey was conducted to gain an insight into existing knowledge and attitudes within the professions governed by the ACPSEM and students undertaking related studies. This paper authored by the webinar speakers reintroduces the quality management principles that were discussed in webinar, exemplifies the importance of quality management skills within the ACPSEM professions and presents the results of the surveys, promoting the need for more educational resources on quality management tools.

Quality Assurance of a Cross-Border and Sub-Specialized Teleradiology Service

BACKGROUND

The current literature discusses aspects of quality assurance (QA) and sub-specialization. However, the challenges of these topics in a teleradiology network have been less explored. In a project report, we aimed to review the development and enforcement of sub-specialized radiology at Telemedicine Clinic (TMC), one of the largest teleradiology providers in Europe, and to describe each step of its QA.

EVALUATION

The company-specific background was provided by the co-authors-current and former staff members of TMC. Detailed descriptions of the structures of sub-specialization and QA at TMC are provided. Exemplary quantitative evaluation of caseloads and disagreement rates of secondary reviews are illustrated. Description of Sub-specialization and Quality Assurance at TMC: Sub-specialization at TMC is divided into musculoskeletal radiology, neuroradiology, head and neck, a body, and an emergency section operating at local daytime in Europe and Australia. Quality assurance is based on a strict selection process of radiologists, specific reporting guidelines, feedback through the secondary reading of 100% of all radiology reports for new starters, and a minimum of 5% of radiology reports on a continuous basis for all other radiologists, knowledge sharing activities and ongoing training. The level of sub-specialization of each radiologist is monitored continuously on an individual basis in detail. After prospective secondary readings, the mean disagreement rate at TMC indicating at least possibly clinically relevant findings was 4% in 2021.

CONCLUSION

With continuing and current developments in radiology in mind, the essential features of sub-specialization and innovative QA are relevant for further expansion of teleradiology services and for most radiology departments worldwide to respond to the increasing demand for value-based radiology.

The Use of Anatomical Side Markers in General Radiology: A Systematic Review of the Current Literature

OBJECTIVES

The use of an anatomical side marker (ASM) on x-rays, be it digital or radiopaque, is an important quality and safety concept within general radiology. Using radiopaque ASMs is best practice, and lack of any ASMs may have dire consequences in terms of patient safety. To date, there have been no systematic reviews investigating the use of ASMs in clinical practice.

METHODS

A systematic search of electronic databases (CINAHL, the Cochrane Library, Medline, EMBASE, ERIC, and JBI) from inception to March 1, 2018, was undertaken. Gray literature searching (through Google) and pearling was conducted. Methodological quality was assessed using a modified version of the McMaster Critical Appraisal tool for quantitative studies. A customized data extraction tool was developed, which included characteristics of the studies.

RESULTS

Of 624 studies, 7 studies met the eligibility criteria. Despite diverse study designs, collectively, the studies demonstrated that only a small number of x-rays did not include an ASM. On x-rays that did use a radiopaque ASM, most of them were positioned in the primary radiation field. A noticeable shift in practice from the use of radiopaque ASMs to digital ASM was also identified. Multifaceted barriers were reported for the use of ASM in routine clinical practice.

CONCLUSIONS

Although missing ASMs on x-rays were a small feature, findings from this review highlight opportunities for improvement and a need to ameliorate barriers for ASM use.

High frequency residues: A new set of signals for detectability studies of an X-ray imaging system

A new set of signals for studying detectability of an X-ray imaging system is presented. The results obtained with these signals are intended to complement the NEQ results. The signals are generated from line spread profiles by progressively removing their lower frequency components and the resulting high frequency residues (HFRs) form the set of signals to be used in detectability studies. Detectability indexes for these HFRs are obtained using a non-prewhitening (NPW) observer and a series of edge images are used to obtain the HFRs, the covariance matrices required by the NPW model and the MTF and NPS used in NEQ calculations. The template used in the model is obtained by simulating the processes of blurring and sampling of the edge images. Comparison between detectability indexes for the HFRs and NEQ are carried out for different acquisition techniques using different beam qualities and doses. The relative sensitivity shown by detectability indexes using HFRs is higher than that of NEQ, especially at lower doses. Also, the different observers produce different results at high doses: while the ideal Bayesian observer used by NEQ distinguishes between beam qualities, the NPW used with the HFRs produces no differences between them. Delta functions used in HFR are the opposite of complex exponential functions in terms of their support in the spatial and frequency domains. Since NEQ can be interpreted as detectability of these complex exponential functions, detectability of HFRs is presented as a natural complement to NEQ in the performance assessment of an imaging system.

Evaluation of a no-reference image quality metric for projection X-ray imaging using a 3D printed patient-specific phantom

PURPOSE

Feasability of a no-reference image quality metric was assessed on patient-like images using a patient-specific phantom simulating a frame of a coronary angiogram.

METHODS

One background and one contrast-filled frame of a coronary angiogram, acquired using a clinical imaging protocol, were selected from a Philips Integris Allura FD (Philips Healthcare, Best, The Netherlands). The background frame's pixels were extruded to a thickness proportional to their grey value. One phantom was 3D printed using composite 80% bronze filament (max. thickness of 5.1 mm), the other was a custom PMMA cast (max thickness of 8.5 cm). A vessel mold was created from the contrast-filled frame and injected with a solution of 320 mg I/ml contrast fluid (75%), water and gelatin. Still X-ray frames of the vessel mold + background phantom + 16 cm PMMA were acquired at manually selected different exposure settings using a Philips Azurion (Philips Healthcare, Best, The Netherlands) in User Quality Control Mode and were exported as RAW images. The signal-difference-to-noise-ratio-squared (SDNR²) and a spatial-domain-equivalent of the noise equivalent quanta (NEQ_SDE) were calculated. The Spearman's correlation of the latter parameters with a no-reference perceptual image quality metric (NIQE) was investigated.

RESULTS

The bronze phantom showed better resemblance to the original patient frame selected from a coronary angiogram of an actual patient, with better contrast and less blur than the PMMA phantom. Both phantoms were imaged using a comparable imaging protocol to the one used to acquire the original frame. The bronze phantom was hence used together with the vessel mold for image quality measurements on the 165 still phantom frames. A strong correlation was noted between NEQ_SDE and NIQE (SROCC = -0.99, p < 0.0005) and between SDNR² and NIQE (SROCC = -0.97, p < 0.0005).

CONCLUSION

Using a cost-effective and easy to realize patient-specific phantom we were able to generate patient-like X-ray frames. NIQE as a no-reference image quality model has the potential to predict physical image quality from patient images.

The scientific publications of AIFM members in 2015-2019: A survey of the FutuRuS working group

PURPOSE

Within the Italian Association of Medical Physics and Health Physics (AIFM) working group "FutuRuS" we carried out a survey regarding the number of the peer-reviewed articles by AIFM members.

METHODS

We surveyed papers published in the years 2015-2019. Data extracted from Scopus included information regarding authors, title, journal, impact factor (IF), leading or standard authorship by AIFM members, keywords, type of collaboration (monocentric/multicentric/international), area of interest [radiation oncology (RO), radiology (RAD), nuclear medicine (NM), radioprotection (RP) and professional issue (PI)] and topics.

RESULTS

We found 1210 papers published in peer-reviewed journals: 48%, 22%, 16%, 6%, 2 and 6% in RO, RAD, NM, RP, PI and other topics, respectively. Forty-seven percent of the papers involved monocentric teams, 31% multicentric and 22% international collaborations. Leading authorship of AIFM members was in 56% of papers, with a corresponding IF equal to 52% of the total IF (3342, IF_mean = 2.8, IF_max = 35.4). The most represented journal was Physica Medica, with 15% of papers, while a relevant fraction of IF (54%) appeared in clinically oriented journals. The number of papers increased significantly between 2015 and 2016 and remained almost constant in 2017-2019.

CONCLUSIONS

This survey led to the first quantitative assessment of the number and theme distribution of peer-reviewed scientific articles contributed by AIFM members. It constitutes a ground basis to support future AIFM strategies and promote working groups on scientific activity of medical physicists, and to build the basis for rational comparison with other countries, first of all within Europe.

Quality control of fetal biometric evaluation and Doppler ultrasound

In recent years quality control in obstetric ultrasound has become recommended and an essential component of obstetric scanning. This is to minimize the inaccuracy and variability related to fetal measurements, to provide an effective quality assurance system to sonographers to certify their practice and decrease the impact of medical litigations. For a quality control system in obstetric ultrasound to be useful clinically, multiple strategies need to be employed: certified training, practical standardization exercise, image storing, qualitative and quantitative quality control. Qualitative quality control consists of the evaluation of images obtained for fetal biometry and Doppler scans using an objective score against predefined criteria. Quantitative quality control consists of analyzing quantitatively the performance of a sonographer and the impact on measurements values. Quantitative analysis could be performed either using estimates of intraobserver or interobserver reproducibility of plane acquisition and caliper placements.

Artificial Intelligence and the Medical Physicist: Welcome to the Machine

Artificial intelligence (AI) is a branch of computer science dedicated to giving machines or computers the ability to perform human-like cognitive functions, such as learning, problem-solving, and decision making. Since it is showing superior performance than well-trained human beings in many areas, such as image classification, object detection, speech recognition, and decision-making, AI is expected to change profoundly every area of science, including healthcare and the clinical application of physics to healthcare, referred to as medical physics. As a result, the Italian Association of Medical Physics (AIFM) has created the “AI for Medical Physics” (AI4MP) group with the aims of coordinating the efforts, facilitating the communication, and sharing of the knowledge on AI of the medical physicists (MPs) in Italy. The purpose of this review is to summarize the main applications of AI in medical physics, describe the skills of the MPs in research and clinical applications of AI, and define the major challenges of AI in healthcare.

Critical Care Nursing in India

Critical care nursing and medicine have evolved significantly over the past few decades. Critical care in India began the major urban hospitals and has not yet become established in rural health care facilities. The formation of Indian critical care nursing and medical societies led to emerging regular conferences, updates, continuing nursing and medical education, workshops, and training programs for the further training of nurses and doctors. Future challenges include development of guidelines and consolidation of research activities on the outcome of patients with critical illness. This article describes the organization and practice of critical care nursing in India.

Technical Note: MRQy - An open-source tool for quality control of MR imaging data

PURPOSE

There is an increasing availability of large imaging cohorts [such as through The Cancer Imaging Archive (TCIA)] for computational model development and imaging research. To ensure development of generalizable computerized models, there is a need to quickly determine relative quality differences in these cohorts, especially when considering MRI datasets which can exhibit wide variations in image appearance. The purpose of this study is to present a quantitative quality control tool, MRQy, to help interrogate MR imaging datasets for: (a) site- or scanner-specific variations in image resolution or image contrast, and (b) imaging artifacts such as noise or inhomogeneity; which need correction prior to model development.

METHODS

Unlike existing imaging quality control tools, MRQy has been generalized to work with images from any body region to efficiently extract a series of quality measures (e.g., noise ratios, variation metrics) and MR image metadata (e.g., voxel resolution and image dimensions). MRQy also offers a specialized HTML5-based front-end designed for real-time filtering and trend visualization of quality measures.

RESULTS

MRQy was used to evaluate (a) n = 133 brain MRIs from TCIA (7 sites) and (b) n = 104 rectal MRIs (3 local sites). MRQy measures revealed significant site-specific variations in both cohorts, indicating potential batch effects. Before processing, MRQy measures could be used to identify each of the seven sites within the TCIA cohort with 87.5%, 86.4%, 90%, 93%, 90%, 60%, and 92.9% accuracy and the three sites within the rectal cohort with 91%, 82.8%, and 88.9% accuracy using unsupervised clustering. After processing, none of the sites could be distinctively clustered via MRQy measures in either cohort; suggesting that batch effects had been largely accounted for. Marked differences in specific MRQy measures were also able to identify outlier MRI datasets that needed to be corrected for common acquisition artifacts.

CONCLUSIONS

MRQy is designed to be a standalone, unsupervised tool that can be efficiently run on a standard desktop computer. It has been made freely accessible and open-source at http://github.com/ccipd/MRQy for community use and feedback.

A clinical audit of anatomical side marker use in a pediatric medical imaging department: A quantitative and qualitative investigation

BACKGROUND

The presence of a radiopaque or digital anatomical side marker (ASM) is an important diagnostic feature on radiographs and should be a routine feature on every radiographic image. Despite its importance, research has indicated numerous instances where ASMs were absent which have the potential to lead to adverse events. To date, few studies have systematically examined the use of ASMs in clinical practice and explored medical imaging professionals' perspectives on ASM use. This research aimed to address this knowledge gap.

METHODS

This investigation was conducted in two stages. Stage 1 involved a retrospective clinical audit of 421 randomly selected radiographs within 12-months at a pediatric medical imaging department. The data were analyzed for overall presence and type of marker use. Stage 2 comprised of semi-structured interviews with 11 radiographers to garner their perspectives on ASM use, and barriers and enablers to their use in clinical practice. The interviews were transcribed verbatim and thematically analyzed.

RESULTS

The overall presence of ASMs (radiopaque and digital) was observed on 99 per cent of radiographs. There was a noticeable shift towards the use of digital (78.8 per cent) compared to radiopaque ASMs (20.2 per cent), highlighting the growing trend towards using ASM in post-processing. A handful of images (N = 4) did not include any ASMs. Semi-structured interviews revealed multifaceted barriers (time, infection precautions, and patient factors) and few enablers (professionalism, legal requirement) for ASM use.

CONCLUSION

This investigation, informed by quantitative and qualitative research paradigms, has shed new light on an important area of radiography practice. While missing ASMs were a small feature, there continue to remain opportunities where best practice standards can be improved. The increasing use of digital ASMs potentially highlights a shift in clinical practice standards.

An Investigation into the Infrastructure and Management of Computerized Tomography Units in Ghana

INTRODUCTION

In Ghana, there is a need to document computed tomography (CT) infrastructure and management systems for the development of interventions to promote CT practices while ensuring patient protection through the establishment of diagnostic reference levels and improved dose management systems.

METHODS

A quantitative inquiry using a descriptive, cross-sectional approach was used to collect data, using a semistructured questionnaire related to CT infrastructure and management from the technical heads responsible for CT scanners. Data collected included the scanner characteristics, basic management system and organizational arrangements, number of attending practitioners, clinical indications for CT examinations, and the operation of CT facilities in Ghana.

RESULTS

Of the 35 CT scanners installed across the country, 31 were involved in the study. The majority (29%) were Toshiba models. Equipment slices ranged from 1 to 640, of which 45.2% were 16-slice scanners. Many (n = 28, 90.3%) were functioning, and most were installed in the capital city, Accra. The equipment mean age was 7.3 ± 4.4 years, and 25.6% were 10 or more years old. There were 107 operating radiographers, 60 reporting radiologists, and 10 medical physicists employed across the facilities. A total of 204,760 CT examinations were performed yearly (6.8 CT procedures per 1000 people in Ghana). Head CT procedures were the most common, and suspicion of cerebrovascular accident or stroke (32.8%) was the most common indication. Some basic quality management system and policy driving CT infrastructure in Ghana were lacking.

CONCLUSION

The results have provided essential information on the status of CT infrastructure and management systems for policy development and planning in CT facilities in Ghana. This study provides those interested in CT services, jobs, or medical equipment investment in Ghana the information needed to make appropriate decisions.

1st European Congress of Medical Physics September 1-4, 2016; Medical Physics innovation and vision within Europe and beyond

Medical Physics is the scientific healthcare profession concerned with the application of the concepts and methods of physics in medicine. The European Federation of Organisations for Medical Physics (EFOMP) acts as the umbrella organization for European Medical Physics societies. Due to the rapid advancements in related scientific fields, medical physicists must have continuous education through workshops, training courses, conferences, and congresses during their professional life. The latest developments related to this increasingly significant medical speciality were presented during the 1st European Congress of Medical Physics 2016, held in Athens, September 1-4, 2016, organized by EFOMP, hosted by the Hellenic Association of Medical Physicists (HAMP), and summarized in the current volume.