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Essential requirements of a CT colonography service
European Journal of Radiology 82 (2013) 1187–1191
Contents lists available at SciVerse ScienceDirect
European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Essential requirements of a CT colonography service Anika Hansmann, David Burling ∗ St. Mark’s Hospital, Intestinal Imaging Centre, Watford Road, HA1 3UJ Harrow, Middlesex, UK
a r t i c l e
i n f o
Article history: Received 2 March 2012 Received in revised form 7 March 2012 Accepted 8 March 2012 Keywords: Colonography Computed tomographic Diagnostic services CT colonography Colorectal cancer Virtual colonoscopy
a b s t r a c t There are many potential challenges to developing a high quality, efficient CT colonography service. Some are clear and predictable, for example creating CT capacity and securing financial resources, but some are less obvious, such as harnessing local support or changing referral practice amongst clinical colleagues. Notwithstanding, such barriers will need to be overcome to deliver a well-resourced, successful CT colonography programme. This article utilises the authors’ experience of developing their own CT colonography service from scratch (now examining >1200 patients per annum) and relevant published articles on ‘Standards’ of practice and training to recommend how others might provide CT colonography in their own patient communities. We offer a practical guide and will emphasise the need for a multi-disciplinary approach with locally agreed protocols and service objectives. © 2012 Published by Elsevier Ireland Ltd.
1. Introduction CT colonography is a potentially highly effective technique for investigating patients with symptoms and can be used as an adjunct to other test options in a colorectal cancer-screening programme. When performed well and interpreted by experienced, competent radiologists, CT colonography provides a safe, accurate and acceptable method for examining the colon [1–4]. However, these requisites may be challenging to achieve and require considerable effort and support over a long time period by all members of the team. It is therefore reasonable first to consider whether your team are planning to introduce CT colonography into an appropriate clinical environment and if you have sufficient enthusiasm and resources to successfully develop a service. 2. Should you develop a service in the first place?
use of new technologies [6] recommended the use of CT colonography as an alternative test for investigating symptomatic patients or those at high risk of developing colorectal cancer, whereas only a relatively minor role in the Bowel Cancer Screening Programme has been advocated [7]. Consequently, it would seem appropriate for UK teams implementing a new CT colonography service to initially develop their service for investigation of symptomatic patients, where it has an accepted role and where financial reimbursement is achievable. In contrast, in the USA, following guidance supporting CT colonography in colorectal cancer screening programs [5], several states now recommend reimbursement of CT colonography as a primary screening test option. In participating states, it may therefore be appropriate for teams to develop a ‘screening only’ CT colonography service. Recommendations and guidance on CT colonography practice and reimbursement will evolve over time and therefore target populations and their associated pathways can also be adapted accordingly.
2.1. National guidance Several countries across the World have established guidance on the role of CT colonography both for investigating patients with symptoms and for examining asymptomatic individuals as part of a national screening programme [4–6]. Such guidance will help teams target the right patient population initially and the optimal diagnostic pathways and protocols required for this population. For example, in the UK in 2005, the national body guiding doctors on
∗ Corresponding author. Tel.: +44 20 8235 4180, fax: +44 20 8235 4122. E-mail address: [email protected] (D. Burling). 0720-048X/$ – see front matter © 2012 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrad.2012.03.018
2.2. Is there a need for a new CT colonography service in your area? The demand for CT colonography in a particular region will be determined by a number of local factors including; general demand for colonic investigation [population age, sex, ethnicity and socio-economic demographics], colonoscopy provision (and waiting lists), attitudes of local gastroenterologists and colorectal surgeons, established referral pathways from general practitioners, number of trained radiologists with sufficient experience, CT scanner capacity, and radiology departmental priorities.
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A. Hansmann, D. Burling / European Journal of Radiology 82 (2013) 1187–1191
There may already be established CT colonography services [at different stages of evolution] in your region. In this scenario, we recommend a visit to these centres to learn from their experience and determine whether your plans will be complementary (or competitive). If complementary, you may be able to share protocols, expertise and provide support to each other for difficult cases (or even providing back up when capacity exceeds demand). We are aware of several ‘lone’ radiologists who have rapidly developed a CT colonography service but soon find themselves incapable of meeting demand (or return from leave to find a lengthy caseload, with no trained colleagues to help report the backlog).
3. Implications for your hospital and your patients A new CT colonography service will bring new opportunities. Patients are offered a credible alternative to optical colonoscopy, which provide more diverse and efficient diagnostic pathways for prevention and early treatment of colorectal cancer. Members of the CT department who develop an interest in CT colonography will have the opportunity to extend clinical roles by undergoing specialized training and via active participation in the multidisciplinary CT colonography team. Examples of extended role for radiographers include: performing and preliminary reading CT colonography under indirect supervision by a radiologist; managing the service; coordinating the rota; assessing the quality of the new service via audit; and research. All team members can benefit from training and research opportunities, which the new service provides. In several countries, radiology trainees involved in the CT colonography service will more easily fulfil new requirements of their core training curricula. Finally, the rapidly evolving focus on quality assurance will benefit the team’s approach to other aspects of their radiological work.
4. Setting up your team: the members and their role The CT colonography team is central to a programme’s success and members need to be highly motivated, competent and willing to embrace new roles. There is currently a paucity of information defining roles and responsibilities for members of the CT colonography team. As a result, the following represents the authors’ own recommendations based on their experience. 4.1. Director The Director is ultimately responsible for the entire programme and its clinical success. The Director should be an experienced radiologist and a good communicator, with an enlightened attitude to the need for a quality assurance framework. Their background experience should include sufficient knowledge and skills of CT colonography and colorectal cancer to undertake a high quality examination, interpret scan findings accurately and make appropriate patient management recommendations. The Director will usually be a radiologist with declared subspecialty interest in gastrointestinal radiology and suitable training experience (including two days or more hands-on CT colonography workshop and where available, a dedicated ‘Train the Trainers’ course). They will personally interpret a significant number of scans per year (for example >100) [7] to enable meaningful audit of their results, which can then be compared with agreed local or national standards. The Director will ensure the safety of patients and prioritise patient experience and outcomes as key objectives for the service. To this end, the Director should develop a clear team structure where members are aware of their role, objectives, competencies and opportunities for training and role extension.
Leading the team can be very rewarding but challenges occur and some radiologists find themselves propping up a service almost single-handedly, for example, covering other radiologists (and radiographers) during leave and being a universal point of contact for referrers, patients, carers and administrators alike. To combat this, the authors recommend the Director bring together a steering group, prior to service delivery, which allocates resource and responsibility across the team and engages with stakeholders to predict problems and develop strategies to deal with them before they occur (please see below). Obtaining resources and gaining support from stakeholders will frequently require a strong business case and the Director should ideally be the principal author of this. The Director will delegate tasks appropriately within the team to share the responsibility for workload and success and to keep members actively engaged in the service. Good delegation can motivate staff but this requires excellent communication skills to ensure tasks are undertaken accurately and on time. Examples include delegating radiographers to write patient protocols by researching the topic using web based resources (alongside experience gleaned from other established services); or training new team members. Being a good communicator will also benefit interactions with external stakeholders, as the Director is frequently the principal advocate of the service. Finally, the Director of service should embrace national quality assurance initiatives, which demonstrate service as safe and high quality; and also refine techniques according to evidence-based research. This requires active engagement with, and support for, the wider CT colonography community. This may comprise attendance at regional or national meetings, involvement in societies such as ESGAR (European Society of Gastrointestinal and Abdominal Radiology) or its national representative groups and should result in practical changes to daily practice. An example of this may be a monthly update of locally agreed key performance indicators (see below) derived from national standards [8] emailed to team members by the programme co-ordinator. 4.2. CT colonography programme co-ordinator The CT colonography programme co-ordinator is the ‘lynchpin’ of the team, involved in all aspects of the service and ensuring that patient pathways run smoothly [9]. Usually (but not exclusively) a senior radiographer with declared interest in colorectal cancer, this person will be focused on quality, efficiency and patient experience in day-to-day practice and must also be an excellent communicator. In our institution, a patient’s first encounter with the service is frequently via a phone call (mobile and static line number) with the programme co-ordinator who will give reassurance and advice about bowel preparation, diet and the logistics of examination. This interaction is key to improving patient experience (alleviating anxiety and allaying fears) and helping to ensure compliance with bowel preparation regimens. The co-ordinator will be the patient’s closest ally throughout the pathway, assisting communication between patient and medical team. To do so, the co-ordinator must be knowledgeable about bowel cancer and very experienced with patients. Our co-ordinator also supervises patient consent (for examination and retrospective audit of their data, which requires both tact and efficiency. The programme co-ordinator will often interface with clinical referrers (hospital consultants and family practitioners). The quality of this interface will influence popularity of the CT colonography service and therefore the co-ordinator will directly influence number of referrals and subsequent quality and efficiency of patient management. For example, our co-ordinator communicates directly with patient and endoscopists when planning ‘same day’ endoscopy for biopsy of detected cancers. The co-ordinator
A. Hansmann, D. Burling / European Journal of Radiology 82 (2013) 1187–1191
ensures a timely report is made available to the surgical team and family practitioner, and checks a management plan has been implemented. The programme co-ordinator is also responsible for helping assess appropriateness of referrals, particularly where additional information is required. They co-ordinate the radiographer (examination) and radiologist (interpretation) rotas and are responsible for accurate data capture and audit of patient experience and results. The programme co-ordinator can be the line manager and first point of contact for team members and therefore plays a key role in team efficiency and motivation. Our co-ordinator will regularly appraise individuals to receive feedback and encourage sharing of ideas. It is also important that individuals’ agendas and ambitions for CT colonography are acknowledged and aligned with service objectives.
4.3. CT colonography radiographer The CT colonography radiographer is a key member of the team. At our institution, over two sites, seven CT colonography trained radiographers support a rota whereby CT colonography examinations are performed each morning (five days per week) usually with direct supervision by the programme co-ordinator and indirect supervision of a radiologist. Frequently with a background of barium enema or CT experience, the radiographer is equipped to undertake all aspects of the CT colonography examination, from obtaining consent to initial review of scan data. Insertion of a rectal catheter, administration of hyoscine butylbromide and importance of patient positioning are familiar to barium enema radiographers but may be completely new skills for CT radiographers. Conversely, barium enema radiographers may be unable to acquire body CT scans. This differing background experience can be exploited in training environments. Irrespective of background experience, radiographers can be trained together where they share their knowledge and skills. The entire patient pathway is segmented and radiographers must be competent in each technical aspect; for example insertion of rectal catheter requires knowledge of anorectal anatomy and skills for safe insertion and balloon inflation. Image interpretation is generally the domain of radiologists but the authors recommend radiographers review CT colonography examinations whilst the patient is in the scanner room to ensure technical adequacy and to identify cancers. If trained adequately for this, radiographers can greatly improve quality of examinations for interpretation and diagnostic efficiency for colorectal cancer (same visit body CT staging and same day endoscopy for biopsy) [8,10].
5. Gastroenterologist (and relationship with endoscopy) Given the established role of endoscopy for biopsy and polypectomy, the role of CT colonography should be positioned to complement colonoscopy in local patient pathways, for example, same day CT colonography for incomplete colonoscopy and same day endoscopic biopsy (at flexible sigmoidoscopy or colonoscopy) where a cancer is found at CT. To this end, there needs to be excellent co-operation and understanding between endoscopy and radiology departments. The authors strongly recommend radiologists and their team members develop strong links with individual colleagues in endoscopy to facilitate evolution of their service. Radiologists are reliant on advocacy and support for their new service and this will be more likely in a ‘quid pro quo’ relationship between teams. The gastroenterologist, ideally leading the endoscopy service will
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therefore be a prime member of the CT colonography team, albeit in an allied role. Patient experience and safety will be enhanced by a service aligned to endoscopy with common goals, for example older symptomatic patients with non-specific abdominal symptoms [possibly related to extra-colonic neoplasia] or too frail to undergo sedation may be best investigated by CT colonography. In contrast, surveillance of younger patients with inflammatory bowel disease or a genetic predisposition to cancer will be best served by highest quality endoscopy. The authors would like to emphasise the importance of individualizing a patient pathway [choice of investigation, examination protocol and management recommendations] according to the target of the test i.e. small polyp, advanced polyp, colorectal cancer or extra-colonic cancer. A joint strategy for colorectal investigation will help an organisation distribute resources and manage demand. Adding CT colonography to the armamentarium could offload endoscopy waiting lists whilst more safely investigating co-morbid patients. An integrated service may also increases patient compliance. Patient compliance has been an ongoing major concern. Compliance rates of bowel cancer screening as less than 50% have been reported compared with compliance rates above 70% for breast, cervical and prostate cancer [11]. In a recent study by Moawad [12] 95% of patients who had both optical colonoscopy and CT colonography preferred the latter. The most common reasons given were convenience, recommendation by referrer and perceived safety. It is well recognized, that full bowel preparation is one of the main factors that reduce patient’s compliance [13]. A study by Liedenbaum et al. [14] showed that CT colonography using a reduced bowel preparation (1-day regime with meglumine ioxithalamate) results in an improved patient acceptability with no significant reduction in image quality. Thus, the use of CT colonography as an alternative examination method of the whole colon should improve patient’s compliance.
6. Steering committee Examples of steering group membership and their principal roles are summarized in Table 1. Table 2 outlines the primary variables of the patient pathway that should be agreed prior to implementation, for example a departmental policy on patient consent or joint radiology/endoscopy strategy for managing medium sized polyps. Careful planning is paramount so that the aims and objectives of a service are clearly communicated to the team and referrers. Agreement of patient examination protocols (Table 2), systems for ensuring safe, high quality examinations and aligned (radiology/endoscopy) management strategies are all pre-requisites for a successful CT colonography service. The steering group brings the right people together at the right time to help plan implementation including equitable allocation of jobs (according to expertise); support and encouragement to overcome barriers to implementation; and the momentum of regular meetings to ensure timelines are met. Meetings should be relatively short and not onerous. Not all steering group members are required for every meeting but attendance should be monitored to ensure appropriate input and effort from those involved. If a member fails to deliver or attend meetings, the Director should consider replacing that individual rather than completing their allocated tasks themselves. Practical issues will be addressed including volume of patients expected, frequency of radiographer and radiologist rotas, and impact on other services such as endoscopy. To decrease impact on other ‘competing services’, consider offering the CT colonography service early in the morning. Patients
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A. Hansmann, D. Burling / European Journal of Radiology 82 (2013) 1187–1191
Table 1 Members of the Steering Committee and their roles. Member
Role
- Director
- Experienced radiologist - Responsible for quality and success of programme
- Programme Co-ordinator
- Experienced GI radiographer - Leads and supervises radiographer team in performing CT colonography examinations
- Superintendant CT radiographer
- Leads and supervises the daily CT list - Coordinates specialized CT lists such as CT colonography according to demand and capacity - Responsible for finance and supporting service level agreements for program - Supports an integrated service that can offer same day optical colonoscopy and/or CT colonography to patients - Supports interface between primary and secondary care and advises team on referral pathways and local commissioning of services - Shares responsibility for ensuring trainee participation in service and helping refine balance between service and training commitments
- Manager of the Radiology Department - Endoscopist - General Practitioner - Representative of radiology trainees
also prefer this, as they are frequently hungry and keen to resume normal daily activity. Our patients also find it easier to park! 7. Equipment A successful service requires reliable, high quality equipment, fit for purpose and safe for the range of patients examined. For example newer generation CT scanners permit lower radiation dose protocols, an important consideration if younger patients are to be examined. Equipment is important for patient data acquisition, transfer and interpretation. Data acquisition requires a multi-detector row scanner, which facilitates single breath hold examinations, decreasing respiratory artefacts and improving patient experience. Use of automated insufflators improve colonic distension, are theoretically safer and enable more efficient examination technique. Data transfer considerations will aim to expedite transfer of CT examinations to a workstation located in a quiet, undisturbed reporting area, free from day-to-day interruptions. Consequently, radiographers may undertake the practical components of a CT colonography whereas radiologists can focus on accurate interpretation. Transfer may be via a hospital network to a remote location of external to hospital if systems will safeguard patient confidentiality. As indicated in the CT colonography Standards document [8], interpretation requires dedicated software incorporating both 2D and 3D displays of data. Both should be used routinely, albeit with choice of primary 2D or 3D (or combination) review contingent upon patient factors (quality of preparation, distension and severity of diverticulosis) and individual radiologist preference. The software should ideally permit different review methods between patients and radiologists. 8. Business plan Most organisations will mandate that new services be only introduced following executive level approval of a business plan.
This plan will detail specific aims of the new service and success will be judged against agreed performance indicators and measurable outcomes. Many organisations will demand a service be at least cost neutral or profit making depending upon its importance and other services offered by the organisation. For example CT colonography may be a primary source of income for one business whereas it is delivered as a loss leader, compensated for by more lucrative contracts in another. Understanding the financial plan for a new CT colonography service is essential when planning to write a business case. Writing a business case demands experience. Many organisations provide templates or will allow access to previous successful plans. The authors of this article recommend acquiring pilot data if possible to support a business case. Otherwise it may be difficult to accurately extrapolate data from other clinical and geographical environments to the satisfaction of local commissioners. 9. Quality metrics – are you successful? A new CT colonography service should ideally be implemented in a stepwise fashion so that each part of pathway can be refined and its impact monitored. Quality metrics are measures that reflect effectiveness of the program in key areas that directly improve patient care. Auditing a program by analysing this data helps quantify outcome and detect problems early. The authors recommend data is accrued and inputted into a clinical database for each patient undergoing CT colonography. Databases should combine demographics with a rapid and easy system for monitoring local performance according to agreed ‘key’ performance indicators. We have recommended examples of key performance indicators based on our own experience in Table 3. Once data is collated, different CT colonography service providers will ideally share tabletop enable benchmarking of performance.
Table 2 Protocols and management strategies to be agreed. Pre-CT colonography
Peri-CT colonography
Post-CT colonography
- Patient communication and consent
- Polyp management strategies
- Bowel preparation regimens and use of faecal tagging
- Radiation dose protocols tailored to target of test - Intravenous contrast
- Protocols for patients with comorbidities; e.g. diabetes, cardiovascular disease, cardiac valve replacement, warfarin, renal failure, recent diverticulitis.
- Spasmolytics agents such as hyoscine butylbromide - Patient positioning - Complications
- Same day examinations [CT colonography and optical colonoscopy] - Report templates - Management of extracolonic findings - Patient follow up
A. Hansmann, D. Burling / European Journal of Radiology 82 (2013) 1187–1191
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Table 3 Key performance indicators and standards.
a] Patient safety measures
b] Patient outcome measures
c] Patient experience measures
Key performance indicators
Standard
- Local patient referral criteria met - Complication rates: - Perforation rate - Other major complications - Radiation dose
≥95%
- Examination adequacy ratea - Template report criteria included - Report turn around times - Polyp and cancer pick up rate - Colonoscopy referral rate - Positive predictive value - Extracolonic findings: - Rate of referral of additional diagnostic tests - Pick up rate of major extracolonic findings
≥95% ≥95% Locally agreed standard Auditable outcome Auditable outcome Auditable outcome
- Patient satisfaction questionnaires
Auditable outcome
<1 in 3000 CT colonography examinations Auditable outcome Auditable outcome
Auditable outcome Auditable outcome
a
Adequacy is defined as high reader confidence for exclusion/detection of target pathology [which may differ between individual patients]. For example the target lesion in an elderly patient with altered bowel habit maybe cancer whereas the target includes a small polyp in a fifty-year-old patient undergoing a screening examination.
10. Summary CT colonography has been refined to the extent it is now ready for widespread clinical delivery. However, to deliver a credible alternative to colonoscopy demands rigorous and robust planning which combines training, experience and a comprehensive quality assurance framework. The CT colonography community must embrace such an approach to minimise geographical variation in quality and to safeguard patients. Locally, the authors recommend services be created in a systematic way with a steering group offering support and advocacy at multiple levels. To be successful, the team must be motivated and enthusiastic, working hard to establish excellent relationships with colleagues in primary and secondary care. The result will be an efficient, high quality service, which benefits all stakeholders. Conflict of interest None. Financial disclosure The corresponding author of this article receives an unrestricted educational grant from Bracco, UK, a manufacturer of devices for CT colonography. References [1] Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic review. Meta-analysis, and proposed minimum data set for study level reporting. Radiology 2005:893–904.
[2] Mulhall B, Veerappan GR, Jackson J. Meta-analysis: computed tomographic colonography. Annals of Internal Medicine 2005;142(8):635–50. [3] Sosna J, Morrin MM, Kruskal JB, Lavin PT, Rosen MP, Raptopoulos V. CT colonography of colorectal polyps: a metaanalysis. American Journal of Roentgenology 2003;181(December (6)):1593–8. [4] Taylor SA, Laghi A, Lefere P, Halligan S, Stoker J. European society of gastrointestinal and abdominal radiology (ESGAR): consensus statement on CT colonography. European Journal of Radiology 2007;17(February (2)):575–9. [5] Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians 2008;58(3):130–60. [6] National Institute for Health and Clinical Excellence. Computed tomographic colonography (virtual colonoscopy) 2005. Available via http://guidance.nice.org.uk/IPG129 [accessed 9.01.12]. [7] Guidelines for the use if imaging in the NHS Bowel Cancer Screening Programme 2010 Available via http://www.cancerscreening.nhs. uk/bowel/index.html [accessed 9.01.12]. [8] Burling D. CT colonography standards. Clinical Radiology 2010;65(June (6)):474–80. [9] Pickhardt PJ, Taylor AJ, Johnson GL, et al. Building a CT colonography program: necessary ingredients for reimbursement and clinical success. Radiology 2005;235:17–20. [10] Haycock A, Burling D, Wylie P, Muckian J, Ilangovan R, Thomas-Gibson S. CT colonography training for radiographers—a formal evaluation. Clinical Radiology 2010;65(December (12)):997–1004. [11] Nadel M, Blackman D, Shapiro J. Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey. Preventive Medicine 2002;35:199–206. [12] Moawad FJ, Maydonovitch CL, Cullen PA, Barlow DS, Jenson DW, Cash BD. CT colonography may improve colorectal cancer screening compliance. American Journal of Roentgenology 2010;195(November (5)):1118–23. [13] Jensch S, de Vries AH, Peringa J, et al. CT Colonography with limited bowel preparation. Radiology 2008;247(1):122–32. [14] Liedenbaum MH, de Vries AH, Gouw CIBF, et al. CT colonography with minimal bowel preparation: evaluation of tagging quality, patient acceptance and diagnostic accuracy in two iodine-based preparation schemes. European Radiology 2010;20(2):367–76.
Contents lists available at SciVerse ScienceDirect
European Journal of Radiology journal homepage: www.elsevier.com/locate/ejrad
Essential requirements of a CT colonography service Anika Hansmann, David Burling ∗ St. Mark’s Hospital, Intestinal Imaging Centre, Watford Road, HA1 3UJ Harrow, Middlesex, UK
a r t i c l e
i n f o
Article history: Received 2 March 2012 Received in revised form 7 March 2012 Accepted 8 March 2012 Keywords: Colonography Computed tomographic Diagnostic services CT colonography Colorectal cancer Virtual colonoscopy
a b s t r a c t There are many potential challenges to developing a high quality, efficient CT colonography service. Some are clear and predictable, for example creating CT capacity and securing financial resources, but some are less obvious, such as harnessing local support or changing referral practice amongst clinical colleagues. Notwithstanding, such barriers will need to be overcome to deliver a well-resourced, successful CT colonography programme. This article utilises the authors’ experience of developing their own CT colonography service from scratch (now examining >1200 patients per annum) and relevant published articles on ‘Standards’ of practice and training to recommend how others might provide CT colonography in their own patient communities. We offer a practical guide and will emphasise the need for a multi-disciplinary approach with locally agreed protocols and service objectives. © 2012 Published by Elsevier Ireland Ltd.
1. Introduction CT colonography is a potentially highly effective technique for investigating patients with symptoms and can be used as an adjunct to other test options in a colorectal cancer-screening programme. When performed well and interpreted by experienced, competent radiologists, CT colonography provides a safe, accurate and acceptable method for examining the colon [1–4]. However, these requisites may be challenging to achieve and require considerable effort and support over a long time period by all members of the team. It is therefore reasonable first to consider whether your team are planning to introduce CT colonography into an appropriate clinical environment and if you have sufficient enthusiasm and resources to successfully develop a service. 2. Should you develop a service in the first place?
use of new technologies [6] recommended the use of CT colonography as an alternative test for investigating symptomatic patients or those at high risk of developing colorectal cancer, whereas only a relatively minor role in the Bowel Cancer Screening Programme has been advocated [7]. Consequently, it would seem appropriate for UK teams implementing a new CT colonography service to initially develop their service for investigation of symptomatic patients, where it has an accepted role and where financial reimbursement is achievable. In contrast, in the USA, following guidance supporting CT colonography in colorectal cancer screening programs [5], several states now recommend reimbursement of CT colonography as a primary screening test option. In participating states, it may therefore be appropriate for teams to develop a ‘screening only’ CT colonography service. Recommendations and guidance on CT colonography practice and reimbursement will evolve over time and therefore target populations and their associated pathways can also be adapted accordingly.
2.1. National guidance Several countries across the World have established guidance on the role of CT colonography both for investigating patients with symptoms and for examining asymptomatic individuals as part of a national screening programme [4–6]. Such guidance will help teams target the right patient population initially and the optimal diagnostic pathways and protocols required for this population. For example, in the UK in 2005, the national body guiding doctors on
∗ Corresponding author. Tel.: +44 20 8235 4180, fax: +44 20 8235 4122. E-mail address: [email protected] (D. Burling). 0720-048X/$ – see front matter © 2012 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrad.2012.03.018
2.2. Is there a need for a new CT colonography service in your area? The demand for CT colonography in a particular region will be determined by a number of local factors including; general demand for colonic investigation [population age, sex, ethnicity and socio-economic demographics], colonoscopy provision (and waiting lists), attitudes of local gastroenterologists and colorectal surgeons, established referral pathways from general practitioners, number of trained radiologists with sufficient experience, CT scanner capacity, and radiology departmental priorities.
1188
A. Hansmann, D. Burling / European Journal of Radiology 82 (2013) 1187–1191
There may already be established CT colonography services [at different stages of evolution] in your region. In this scenario, we recommend a visit to these centres to learn from their experience and determine whether your plans will be complementary (or competitive). If complementary, you may be able to share protocols, expertise and provide support to each other for difficult cases (or even providing back up when capacity exceeds demand). We are aware of several ‘lone’ radiologists who have rapidly developed a CT colonography service but soon find themselves incapable of meeting demand (or return from leave to find a lengthy caseload, with no trained colleagues to help report the backlog).
3. Implications for your hospital and your patients A new CT colonography service will bring new opportunities. Patients are offered a credible alternative to optical colonoscopy, which provide more diverse and efficient diagnostic pathways for prevention and early treatment of colorectal cancer. Members of the CT department who develop an interest in CT colonography will have the opportunity to extend clinical roles by undergoing specialized training and via active participation in the multidisciplinary CT colonography team. Examples of extended role for radiographers include: performing and preliminary reading CT colonography under indirect supervision by a radiologist; managing the service; coordinating the rota; assessing the quality of the new service via audit; and research. All team members can benefit from training and research opportunities, which the new service provides. In several countries, radiology trainees involved in the CT colonography service will more easily fulfil new requirements of their core training curricula. Finally, the rapidly evolving focus on quality assurance will benefit the team’s approach to other aspects of their radiological work.
4. Setting up your team: the members and their role The CT colonography team is central to a programme’s success and members need to be highly motivated, competent and willing to embrace new roles. There is currently a paucity of information defining roles and responsibilities for members of the CT colonography team. As a result, the following represents the authors’ own recommendations based on their experience. 4.1. Director The Director is ultimately responsible for the entire programme and its clinical success. The Director should be an experienced radiologist and a good communicator, with an enlightened attitude to the need for a quality assurance framework. Their background experience should include sufficient knowledge and skills of CT colonography and colorectal cancer to undertake a high quality examination, interpret scan findings accurately and make appropriate patient management recommendations. The Director will usually be a radiologist with declared subspecialty interest in gastrointestinal radiology and suitable training experience (including two days or more hands-on CT colonography workshop and where available, a dedicated ‘Train the Trainers’ course). They will personally interpret a significant number of scans per year (for example >100) [7] to enable meaningful audit of their results, which can then be compared with agreed local or national standards. The Director will ensure the safety of patients and prioritise patient experience and outcomes as key objectives for the service. To this end, the Director should develop a clear team structure where members are aware of their role, objectives, competencies and opportunities for training and role extension.
Leading the team can be very rewarding but challenges occur and some radiologists find themselves propping up a service almost single-handedly, for example, covering other radiologists (and radiographers) during leave and being a universal point of contact for referrers, patients, carers and administrators alike. To combat this, the authors recommend the Director bring together a steering group, prior to service delivery, which allocates resource and responsibility across the team and engages with stakeholders to predict problems and develop strategies to deal with them before they occur (please see below). Obtaining resources and gaining support from stakeholders will frequently require a strong business case and the Director should ideally be the principal author of this. The Director will delegate tasks appropriately within the team to share the responsibility for workload and success and to keep members actively engaged in the service. Good delegation can motivate staff but this requires excellent communication skills to ensure tasks are undertaken accurately and on time. Examples include delegating radiographers to write patient protocols by researching the topic using web based resources (alongside experience gleaned from other established services); or training new team members. Being a good communicator will also benefit interactions with external stakeholders, as the Director is frequently the principal advocate of the service. Finally, the Director of service should embrace national quality assurance initiatives, which demonstrate service as safe and high quality; and also refine techniques according to evidence-based research. This requires active engagement with, and support for, the wider CT colonography community. This may comprise attendance at regional or national meetings, involvement in societies such as ESGAR (European Society of Gastrointestinal and Abdominal Radiology) or its national representative groups and should result in practical changes to daily practice. An example of this may be a monthly update of locally agreed key performance indicators (see below) derived from national standards [8] emailed to team members by the programme co-ordinator. 4.2. CT colonography programme co-ordinator The CT colonography programme co-ordinator is the ‘lynchpin’ of the team, involved in all aspects of the service and ensuring that patient pathways run smoothly [9]. Usually (but not exclusively) a senior radiographer with declared interest in colorectal cancer, this person will be focused on quality, efficiency and patient experience in day-to-day practice and must also be an excellent communicator. In our institution, a patient’s first encounter with the service is frequently via a phone call (mobile and static line number) with the programme co-ordinator who will give reassurance and advice about bowel preparation, diet and the logistics of examination. This interaction is key to improving patient experience (alleviating anxiety and allaying fears) and helping to ensure compliance with bowel preparation regimens. The co-ordinator will be the patient’s closest ally throughout the pathway, assisting communication between patient and medical team. To do so, the co-ordinator must be knowledgeable about bowel cancer and very experienced with patients. Our co-ordinator also supervises patient consent (for examination and retrospective audit of their data, which requires both tact and efficiency. The programme co-ordinator will often interface with clinical referrers (hospital consultants and family practitioners). The quality of this interface will influence popularity of the CT colonography service and therefore the co-ordinator will directly influence number of referrals and subsequent quality and efficiency of patient management. For example, our co-ordinator communicates directly with patient and endoscopists when planning ‘same day’ endoscopy for biopsy of detected cancers. The co-ordinator
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ensures a timely report is made available to the surgical team and family practitioner, and checks a management plan has been implemented. The programme co-ordinator is also responsible for helping assess appropriateness of referrals, particularly where additional information is required. They co-ordinate the radiographer (examination) and radiologist (interpretation) rotas and are responsible for accurate data capture and audit of patient experience and results. The programme co-ordinator can be the line manager and first point of contact for team members and therefore plays a key role in team efficiency and motivation. Our co-ordinator will regularly appraise individuals to receive feedback and encourage sharing of ideas. It is also important that individuals’ agendas and ambitions for CT colonography are acknowledged and aligned with service objectives.
4.3. CT colonography radiographer The CT colonography radiographer is a key member of the team. At our institution, over two sites, seven CT colonography trained radiographers support a rota whereby CT colonography examinations are performed each morning (five days per week) usually with direct supervision by the programme co-ordinator and indirect supervision of a radiologist. Frequently with a background of barium enema or CT experience, the radiographer is equipped to undertake all aspects of the CT colonography examination, from obtaining consent to initial review of scan data. Insertion of a rectal catheter, administration of hyoscine butylbromide and importance of patient positioning are familiar to barium enema radiographers but may be completely new skills for CT radiographers. Conversely, barium enema radiographers may be unable to acquire body CT scans. This differing background experience can be exploited in training environments. Irrespective of background experience, radiographers can be trained together where they share their knowledge and skills. The entire patient pathway is segmented and radiographers must be competent in each technical aspect; for example insertion of rectal catheter requires knowledge of anorectal anatomy and skills for safe insertion and balloon inflation. Image interpretation is generally the domain of radiologists but the authors recommend radiographers review CT colonography examinations whilst the patient is in the scanner room to ensure technical adequacy and to identify cancers. If trained adequately for this, radiographers can greatly improve quality of examinations for interpretation and diagnostic efficiency for colorectal cancer (same visit body CT staging and same day endoscopy for biopsy) [8,10].
5. Gastroenterologist (and relationship with endoscopy) Given the established role of endoscopy for biopsy and polypectomy, the role of CT colonography should be positioned to complement colonoscopy in local patient pathways, for example, same day CT colonography for incomplete colonoscopy and same day endoscopic biopsy (at flexible sigmoidoscopy or colonoscopy) where a cancer is found at CT. To this end, there needs to be excellent co-operation and understanding between endoscopy and radiology departments. The authors strongly recommend radiologists and their team members develop strong links with individual colleagues in endoscopy to facilitate evolution of their service. Radiologists are reliant on advocacy and support for their new service and this will be more likely in a ‘quid pro quo’ relationship between teams. The gastroenterologist, ideally leading the endoscopy service will
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therefore be a prime member of the CT colonography team, albeit in an allied role. Patient experience and safety will be enhanced by a service aligned to endoscopy with common goals, for example older symptomatic patients with non-specific abdominal symptoms [possibly related to extra-colonic neoplasia] or too frail to undergo sedation may be best investigated by CT colonography. In contrast, surveillance of younger patients with inflammatory bowel disease or a genetic predisposition to cancer will be best served by highest quality endoscopy. The authors would like to emphasise the importance of individualizing a patient pathway [choice of investigation, examination protocol and management recommendations] according to the target of the test i.e. small polyp, advanced polyp, colorectal cancer or extra-colonic cancer. A joint strategy for colorectal investigation will help an organisation distribute resources and manage demand. Adding CT colonography to the armamentarium could offload endoscopy waiting lists whilst more safely investigating co-morbid patients. An integrated service may also increases patient compliance. Patient compliance has been an ongoing major concern. Compliance rates of bowel cancer screening as less than 50% have been reported compared with compliance rates above 70% for breast, cervical and prostate cancer [11]. In a recent study by Moawad [12] 95% of patients who had both optical colonoscopy and CT colonography preferred the latter. The most common reasons given were convenience, recommendation by referrer and perceived safety. It is well recognized, that full bowel preparation is one of the main factors that reduce patient’s compliance [13]. A study by Liedenbaum et al. [14] showed that CT colonography using a reduced bowel preparation (1-day regime with meglumine ioxithalamate) results in an improved patient acceptability with no significant reduction in image quality. Thus, the use of CT colonography as an alternative examination method of the whole colon should improve patient’s compliance.
6. Steering committee Examples of steering group membership and their principal roles are summarized in Table 1. Table 2 outlines the primary variables of the patient pathway that should be agreed prior to implementation, for example a departmental policy on patient consent or joint radiology/endoscopy strategy for managing medium sized polyps. Careful planning is paramount so that the aims and objectives of a service are clearly communicated to the team and referrers. Agreement of patient examination protocols (Table 2), systems for ensuring safe, high quality examinations and aligned (radiology/endoscopy) management strategies are all pre-requisites for a successful CT colonography service. The steering group brings the right people together at the right time to help plan implementation including equitable allocation of jobs (according to expertise); support and encouragement to overcome barriers to implementation; and the momentum of regular meetings to ensure timelines are met. Meetings should be relatively short and not onerous. Not all steering group members are required for every meeting but attendance should be monitored to ensure appropriate input and effort from those involved. If a member fails to deliver or attend meetings, the Director should consider replacing that individual rather than completing their allocated tasks themselves. Practical issues will be addressed including volume of patients expected, frequency of radiographer and radiologist rotas, and impact on other services such as endoscopy. To decrease impact on other ‘competing services’, consider offering the CT colonography service early in the morning. Patients
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Table 1 Members of the Steering Committee and their roles. Member
Role
- Director
- Experienced radiologist - Responsible for quality and success of programme
- Programme Co-ordinator
- Experienced GI radiographer - Leads and supervises radiographer team in performing CT colonography examinations
- Superintendant CT radiographer
- Leads and supervises the daily CT list - Coordinates specialized CT lists such as CT colonography according to demand and capacity - Responsible for finance and supporting service level agreements for program - Supports an integrated service that can offer same day optical colonoscopy and/or CT colonography to patients - Supports interface between primary and secondary care and advises team on referral pathways and local commissioning of services - Shares responsibility for ensuring trainee participation in service and helping refine balance between service and training commitments
- Manager of the Radiology Department - Endoscopist - General Practitioner - Representative of radiology trainees
also prefer this, as they are frequently hungry and keen to resume normal daily activity. Our patients also find it easier to park! 7. Equipment A successful service requires reliable, high quality equipment, fit for purpose and safe for the range of patients examined. For example newer generation CT scanners permit lower radiation dose protocols, an important consideration if younger patients are to be examined. Equipment is important for patient data acquisition, transfer and interpretation. Data acquisition requires a multi-detector row scanner, which facilitates single breath hold examinations, decreasing respiratory artefacts and improving patient experience. Use of automated insufflators improve colonic distension, are theoretically safer and enable more efficient examination technique. Data transfer considerations will aim to expedite transfer of CT examinations to a workstation located in a quiet, undisturbed reporting area, free from day-to-day interruptions. Consequently, radiographers may undertake the practical components of a CT colonography whereas radiologists can focus on accurate interpretation. Transfer may be via a hospital network to a remote location of external to hospital if systems will safeguard patient confidentiality. As indicated in the CT colonography Standards document [8], interpretation requires dedicated software incorporating both 2D and 3D displays of data. Both should be used routinely, albeit with choice of primary 2D or 3D (or combination) review contingent upon patient factors (quality of preparation, distension and severity of diverticulosis) and individual radiologist preference. The software should ideally permit different review methods between patients and radiologists. 8. Business plan Most organisations will mandate that new services be only introduced following executive level approval of a business plan.
This plan will detail specific aims of the new service and success will be judged against agreed performance indicators and measurable outcomes. Many organisations will demand a service be at least cost neutral or profit making depending upon its importance and other services offered by the organisation. For example CT colonography may be a primary source of income for one business whereas it is delivered as a loss leader, compensated for by more lucrative contracts in another. Understanding the financial plan for a new CT colonography service is essential when planning to write a business case. Writing a business case demands experience. Many organisations provide templates or will allow access to previous successful plans. The authors of this article recommend acquiring pilot data if possible to support a business case. Otherwise it may be difficult to accurately extrapolate data from other clinical and geographical environments to the satisfaction of local commissioners. 9. Quality metrics – are you successful? A new CT colonography service should ideally be implemented in a stepwise fashion so that each part of pathway can be refined and its impact monitored. Quality metrics are measures that reflect effectiveness of the program in key areas that directly improve patient care. Auditing a program by analysing this data helps quantify outcome and detect problems early. The authors recommend data is accrued and inputted into a clinical database for each patient undergoing CT colonography. Databases should combine demographics with a rapid and easy system for monitoring local performance according to agreed ‘key’ performance indicators. We have recommended examples of key performance indicators based on our own experience in Table 3. Once data is collated, different CT colonography service providers will ideally share tabletop enable benchmarking of performance.
Table 2 Protocols and management strategies to be agreed. Pre-CT colonography
Peri-CT colonography
Post-CT colonography
- Patient communication and consent
- Polyp management strategies
- Bowel preparation regimens and use of faecal tagging
- Radiation dose protocols tailored to target of test - Intravenous contrast
- Protocols for patients with comorbidities; e.g. diabetes, cardiovascular disease, cardiac valve replacement, warfarin, renal failure, recent diverticulitis.
- Spasmolytics agents such as hyoscine butylbromide - Patient positioning - Complications
- Same day examinations [CT colonography and optical colonoscopy] - Report templates - Management of extracolonic findings - Patient follow up
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Table 3 Key performance indicators and standards.
a] Patient safety measures
b] Patient outcome measures
c] Patient experience measures
Key performance indicators
Standard
- Local patient referral criteria met - Complication rates: - Perforation rate - Other major complications - Radiation dose
≥95%
- Examination adequacy ratea - Template report criteria included - Report turn around times - Polyp and cancer pick up rate - Colonoscopy referral rate - Positive predictive value - Extracolonic findings: - Rate of referral of additional diagnostic tests - Pick up rate of major extracolonic findings
≥95% ≥95% Locally agreed standard Auditable outcome Auditable outcome Auditable outcome
- Patient satisfaction questionnaires
Auditable outcome
<1 in 3000 CT colonography examinations Auditable outcome Auditable outcome
Auditable outcome Auditable outcome
a
Adequacy is defined as high reader confidence for exclusion/detection of target pathology [which may differ between individual patients]. For example the target lesion in an elderly patient with altered bowel habit maybe cancer whereas the target includes a small polyp in a fifty-year-old patient undergoing a screening examination.
10. Summary CT colonography has been refined to the extent it is now ready for widespread clinical delivery. However, to deliver a credible alternative to colonoscopy demands rigorous and robust planning which combines training, experience and a comprehensive quality assurance framework. The CT colonography community must embrace such an approach to minimise geographical variation in quality and to safeguard patients. Locally, the authors recommend services be created in a systematic way with a steering group offering support and advocacy at multiple levels. To be successful, the team must be motivated and enthusiastic, working hard to establish excellent relationships with colleagues in primary and secondary care. The result will be an efficient, high quality service, which benefits all stakeholders. Conflict of interest None. Financial disclosure The corresponding author of this article receives an unrestricted educational grant from Bracco, UK, a manufacturer of devices for CT colonography. References [1] Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic review. Meta-analysis, and proposed minimum data set for study level reporting. Radiology 2005:893–904.
[2] Mulhall B, Veerappan GR, Jackson J. Meta-analysis: computed tomographic colonography. Annals of Internal Medicine 2005;142(8):635–50. [3] Sosna J, Morrin MM, Kruskal JB, Lavin PT, Rosen MP, Raptopoulos V. CT colonography of colorectal polyps: a metaanalysis. American Journal of Roentgenology 2003;181(December (6)):1593–8. [4] Taylor SA, Laghi A, Lefere P, Halligan S, Stoker J. European society of gastrointestinal and abdominal radiology (ESGAR): consensus statement on CT colonography. European Journal of Radiology 2007;17(February (2)):575–9. [5] Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians 2008;58(3):130–60. [6] National Institute for Health and Clinical Excellence. Computed tomographic colonography (virtual colonoscopy) 2005. Available via http://guidance.nice.org.uk/IPG129 [accessed 9.01.12]. [7] Guidelines for the use if imaging in the NHS Bowel Cancer Screening Programme 2010 Available via http://www.cancerscreening.nhs. uk/bowel/index.html [accessed 9.01.12]. [8] Burling D. CT colonography standards. Clinical Radiology 2010;65(June (6)):474–80. [9] Pickhardt PJ, Taylor AJ, Johnson GL, et al. Building a CT colonography program: necessary ingredients for reimbursement and clinical success. Radiology 2005;235:17–20. [10] Haycock A, Burling D, Wylie P, Muckian J, Ilangovan R, Thomas-Gibson S. CT colonography training for radiographers—a formal evaluation. Clinical Radiology 2010;65(December (12)):997–1004. [11] Nadel M, Blackman D, Shapiro J. Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey. Preventive Medicine 2002;35:199–206. [12] Moawad FJ, Maydonovitch CL, Cullen PA, Barlow DS, Jenson DW, Cash BD. CT colonography may improve colorectal cancer screening compliance. American Journal of Roentgenology 2010;195(November (5)):1118–23. [13] Jensch S, de Vries AH, Peringa J, et al. CT Colonography with limited bowel preparation. Radiology 2008;247(1):122–32. [14] Liedenbaum MH, de Vries AH, Gouw CIBF, et al. CT colonography with minimal bowel preparation: evaluation of tagging quality, patient acceptance and diagnostic accuracy in two iodine-based preparation schemes. European Radiology 2010;20(2):367–76.