The METIS project for generalist ultrasonography

The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland

Background

Ultrasound imaging is utilized in Swiss primary care; however, little is known regarding the extent to which it is performed. With this study, we aim to (1) provide an overview of ultrasound use by general practitioners (GPs), and (2) determine the clinical indications of ultrasound in Swiss general practice.

Methods

This is a quantitative study, analyzing 15 years of billing data from 213 GPs in Central Switzerland, and cross-sectional survey data completed by 61 GPs attending 26 certification and refresher courses offered by the Swiss Society of Ultrasound in Medicine (SGUM).

Results

According to billing data, 49% of the GPs used ultrasound and provided 130,245 exams to 67,180 patients between 2004 and 2018. Over the years, ultrasound use became more frequent among GPs. Male GPs provide more ultrasound exams than female GPs. Patients that are female, ≥65 years, and multi-morbid had more ultrasound exams compared to males, patients < 65 years, and those with only one morbidity, respectively. GPs provided a mean of 129 ultrasound exams per physician-year. Abdominal ultrasound comprised almost 69% of all exams. According to survey data, indications covered many organ systems and clinical conditions, with abdominal indications being most frequent among them.

Conclusions

The use of ultrasound is high among general practitioners and it covers a wide range of clinical indications. Ultrasound is utilized primarily in the diagnosis of clinical indications of the abdomen, and more often for female than male patients.

Ultrasound and the Complete Urologist Part 2: Outcomes

Outcome studies help establish the benefits of tests or procedures that can change the delivery of medical care. Through this discourse, the current status of outcomes with respect to the use of ultrasound imaging for AMH as well as its general use during a routine urologic physical examination are explored. The changes in today's health care environment focus on cost reduction and outcomes that produce value in the context of patient satisfaction. The question is whether we have to wait for outcome results (that can take a lengthy period of time to achieve) before the benefits produced by ultrasound can be applied. This report reviews the literature and the role ultrasound can play in today's urologic health care environment. Supportive evidence demonstrates the value that ultrasound use brings to the urologic examining table for AMH and to daily urologic practice to the benefit of both patient and physician.

Ultrasound and the Complete Urologist Part 1: Methodology

Computed tomography (CT) scanning is considered as the imaging study of choice for asymptomatic microhematuria according to the American Urological Association guidelines. For those patients with persistence of microhematuria after a negative initial examination, the guidelines suggest repeating the evaluation including CT scanning within 3 to 5 years. However, the cost and risk involved for utilizing this technology going forward is an issue, especially when the yield of finding significant pathology on subsequent imaging studies is exceedingly low. To minimize those concerns, I have proposed incorporating the utilization of ultrasound rather than the guideline-recommended CT for reasons and considerations to be discussed. In addition, I propose extending the use of ultrasound beyond evaluation of asymptomatic microhematuria to the routine urologic physical examination as it is superior to the current standard of palpation and percussion. The original concept of applying sound to a physical examination led to the technique of percussion. Technological advancement has taken the same sound, converted it to a digital image, and allowed us to see what we hear to achieve a greater diagnostic accuracy. The literature on this subject is reviewed and demonstrates support for just such a change in the delivery of urologic healthcare. I conclude by proposing that the quality of urologic care can be enhanced during a routine urologic physical examination through upgrading the technique of palpation and percussion by routinely utilizing ultrasound, creating the Complete Urologist.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Variation in the use of point-of-care ultrasound in general practice in various European countries. Results of a survey among experts

BACKGROUND

Before implementing point-of-care ultrasound in general practice in Denmark, we sought inspiration from other countries/regions.

OBJECTIVES

To collect information about the use and organizational aspects of point-of-care ultrasound in general practice in different European countries/regions.

METHODS

Fifteen key persons with knowledge about the use of ultrasound in general practice in Austria, Catalonia, Denmark, Finland, Germany, Greenland, Iceland, the Netherlands, Norway, Scotland, Sweden, and Switzerland were included. Participants received a link to a web-based questionnaire. The primary outcome measures were educational aspects regarding the use of point-of-care ultrasound; clinical application and use; financial aspects; and main barriers to using ultrasound in general practice.

RESULTS

In eight out of 12 countries/regions there were national societies for the use of ultrasound in general practice. The respondents from three countries/regions reported that the use of ultrasound was integrated into undergraduate medical education. In nine of the countries/regions, there was formalized training for general practitioners, but only three reported this to be part of the specialization to become a general practitioner. In seven out of 12 countries/regions, general practitioners received payment for ultrasound scans. However, the payment and the requirements for reimbursement differed between countries. Lack of time, lack of training, and financial aspects were important common barriers across countries/regions.

CONCLUSION

There were significant differences regarding the use and organizational aspects of point-of-care ultrasound in general practice in Europe. Lack of time and training as well as financial aspects were important barriers to the use of point-of-care ultrasound in general practice.[Box: see text].