Provisional Monthly Diagnostic Imaging Dataset Statistics

Diagnostic Imaging Dataset Statistical Release

Provisional Monthly Experimental Statistics 25th April 2013 2

Provisional Monthly Diagnostic Imaging Dataset Statistics April 2012 to December 2012, England

Experimental Official Statistics

Headline Messages  Over 23 million imaging tests were reported in England between April and December 2012. Plain Radiography (X-ray) was most common, followed by Ultrasound, CT Scan, MRI and Fluoroscopy.  The median period between the request being made and the test being performed varied greatly for the different tests, from the same day for X-ray and Fluoroscopy to at least three weeks for MRI.  The median period for the report to be issued after the test was the same day for CT scan, Ultrasound and Fluoroscopy, within a day or two for X-ray and up to three days for MRI.  Roughly a quarter of all tests1 that may have been used to diagnose or discount cancer were requested by GPs under direct access arrangements. Of these tests, the most commonly requested by GPs was Chest X-ray, followed by ultrasounds that may have been used to diagnose ovarian cancer (45% of which were requested by GPs).  With the exception of chest X-ray, for the key tests1 which may be used to diagnose or discount cancer, the median period from a test being requested to being performed is longer for GP direct access compared with all referrals. The main reason for this difference is that all referrals include tests on emergency admissions and inpatients, which have shorter waits. 1. Although these tests are used to diagnose cancer, many of the tests also have wider clinical uses. Within this data it is not possible to distinguish between the different uses of these tests.

Introduction The Diagnostic Imaging Dataset (DID) is a new monthly data collection covering data on diagnostic imaging tests on NHS patients in England. It includes estimates of GP usage of direct access to key diagnostics tests for cancer, for example chest imaging, non-obstetric ultrasound and MRI brain.

These data are labelled provisional and experimental because it is the first time that information stored on hospital’s Radiological Information Systems has been centrally compiled. Whilst efforts have been made to ensure that the data are complete and accurately reflect the activity, data issues may affect the correct analysis of data for some providers. Consequently, some data are omitted from the report and users should refer to the Technical Report and exercise care when interpreting the results.

Experimental Official Statistics Experimental official statistics are new official statistics undergoing evaluation. They are published in order to involve users and stakeholders in their development and as a means to build in quality at an early stage. We welcome feedback to assist with evaluation, please contact us at [email protected] 3

Data Quality Statement

These data are collated from Radiology Information Systems (RISs), which are hospital administrative systems used to manage the workflow of radiology departments.

Whilst the data were not originally intended for statistical purposes, and have some shortfalls, they do provide a rich resource with great potential. This data collection is aligned with the code of practice for official statistics in making better use of administrative data and evaluating existing data sources to limit the burden on respondents.

There are a large number of validations built into the DID upload system, verifying that the data provided by organisations makes sense. Whilst validations and other checks have been made to ensure that the data are complete and accurately reflect activity, data issues may affect activity for some providers. Therefore, users should exercise care when interpreting the results.

It is anticipated that the coverage and quality of records submitted will improve as data providers become more familiar and the information is further evaluated.

Details of coverage, completeness, comparability with other data sources, and a discussion on the types of data quality issues encountered are provided in the Technical Report.

Frequently Used Acronyms

Acronym Full name DID Diagnostic Imaging Dataset HSCIC Health and Social Care Information Centre RIS Radiology Information System

In this publication, imaging activity for:  April to July is based on submissions up to and including 22 October 2012,  August is based on submissions up to and including 30 November 2012;  September is based on submissions up to and including 1 January 2013  October is based on submissions up to and including 1 February 2013  November is based on submissions up to and including 28 February 2013  December is based on submissions up to and including 31 March 2013 4

Imaging Activity

Over 23 million imaging tests were reported in England between April and December 2012. Plain Radiography (X-ray) was most common, followed by Ultrasound, CT Scan, MRI and Fluoroscopy. The following table gives an England count of imaging activity by modality for each month April to December. Please see the definitions section for further information on those tests included.

Table 1: Count of imaging activity in England, on NHS patients, for April - December

CT Scan Ultrasound Fluoroscopy MRI X-ray Total1 % of (Computerised (Diagnostic (Magnetic (Plain organisations Axial Ultrasonography) Resonance Radiography) included Tomography) Imaging) Apr 230,495 503,700 69,385 159,745 1,567,800 2,531,125 96.3% May 264,605 592,260 83,335 181,580 1,832,855 2,954,635 96.3% Jun 225,730 485,530 66,795 161,365 1,564,395 2,503,815 92.6% Jul 248,015 546,560 76,530 178,010 1,677,735 2,726,850 92.6% Aug 258,840 555,120 76,325 184,095 1,647,305 2,721,690 92.6% Sep 242,430 515,520 68,460 173,050 1,596,935 2,596,400 92.6% Oct 252,360 564,640 74,065 175,775 1,631,065 2,697,905 88.8% Nov 244,010 501,215 69,655 161,400 1,587,215 2,563,495 90.4% Dec 222,980 419,820 57,430 144,770 1,408,320 2,253,320 91.5% 1 This total only includes those imaging scans counted in this table; other imaging scans such as nuclear medicine, medical photography and PET scans are not counted in this total.

Please see Additional Tables 1a-1i for a break down of imaging by modality and by provider.

The table includes the percentage of organisations for which data has been included for each month. Data submitted for some organisations has not been included in the data tables owing to data quality issues, and not all organisations have submitted data each month.

Patient Test Times

The DID collects data on four dates associated with each imaging event: - Date of test request (request made by health care professional) - Date of test request received (by the organisation providing the imaging) - Date of test - Date of test report issued (by health care professional interpreting the imaging output)

The month an imaging event is reported under in the DID is determined by the date of test.

The median period between the request being made and the test being performed varied greatly for the different tests, from the same day for X-ray and Fluoroscopy to over three weeks for MRI. 5

The following table gives the median number of days between the ‘date of test request’ and the ‘date of test’, split by the test modality for each month April to December.

In the following table, median values of 0 occur where at least 50% of activity has a 'date of test request' and 'date of test' which is recorded as the same day. Records where either of these dates is missing are not used to calculate median values.

Table 2: Median number of days between ‘date of test request’ and ‘date of test’ for imaging activity, April – December 2012

CT Scan Ultrasound Fluoroscopy MRI X-ray (Computerised (Diagnostic (Magnetic (Plain Axial Ultrasonography) Resonance Radiography) Tomography) Imaging) Apr 2 13 0 26 0 May 2 13 0 24 0 Jun 2 13 0 25 0 Jul 2 12 0 22 0 Aug 2 13 0 23 0 Sep 1 13 0 23 0 Oct 2 12 0 21 0 Nov 2 14 0 22 0 Dec 1 14 0 23 0

Please see Additional Tables 2a-2i for the median number of days between ‘date of test request’ and ‘date of test’ for imaging activity by modality and by provider.

These figures should not be compared to “waiting time” statistics that measure how long patients are on a waiting list, since these figures include both planned and unplanned imaging activity. In addition, these figures may not have been adjusted for any cancelled or missed appointments and they count the period for each individual test not each patient appointment.

The median period for the report to be issued after the test was the same day for CT scan, Ultrasound and Fluoroscopy, within a day or two for X-ray, and up to three days for MRI. The following table gives the median number of days between ‘date of test’ and ‘date of test report issued’, split by the test modality for each month April to December.

In the following table, median values of 0 occur where at least 50% of activity has a 'date of test' and 'date of test report issued date' which is recorded as the same day. Records where either of these dates is missing are not used to calculate median values. Table 3: Median number of days between ‘date of test’ and ‘date of test report issued’ for imaging activity and percentage of records where date of test report issued equals date of test, split by modality, for April – December 2012 6

CT Scan Ultrasound Fluoroscopy MRI X-ray (Computerised Axial (Diagnostic (Magnetic Resonance (Plain Radiography) England Tomography) Ultrasonography) Imaging) % % same % same % same same % same Measure Median day Median day Median day Median day Median day Apr 0 56% 0 84% 0 61% 3 25% 2 29% May 0 55% 0 84% 0 61% 2 26% 1 29% Jun 0 56% 0 84% 0 62% 3 25% 2 27% Jul 0 55% 0 84% 0 62% 3 26% 2 28% Aug 0 56% 0 85% 0 63% 3 27% 2 29% Sep 0 57% 0 86% 0 62% 3 26% 2 28% Oct 0 58% 0 86% 0 63% 2 28% 1 32% Nov 0 58% 0 85% 0 63% 2 28% 1 32% Dec 0 60% 0 86% 0 66% 2 29% 1 33%

Please see Additional Tables 3a-3i for median number of days between ‘date of test’ and ‘date of test report issued’ for imaging activity by modality and by provider.

Imaging Tests that could contribute to Early Diagnosis of Cancer

A main driver for the creation of the DID is to assess use of diagnostic imaging that could contribute to the early diagnosis of cancer, and in particular, General Practitioner (GP) direct access to these tests. To enable this analysis a subset of procedures particularly used to identify or discount a diagnosis of cancer have been identified:

Brain (MRI) . This may diagnose brain cancer, this includes – MRI of brain (often with contrast); Kidney or bladder (Ultrasound) . This may diagnose kidney or bladder cancer, this includes – ultrasound of kidney, ultrasound scan of bladder or ultrasound and doppler scan of kidney; Chest and/or abdomen (CT) . CTs which may diagnose lung cancer, this includes - Chest + Abdominal CT, CT of chest (high resolution or other), CT thorax + abdomen with contrast, CT thorax with contrast or CT chest + abdomen; Chest (X-ray) . This may diagnose lung cancer, this includes – Plain chest X-ray only; Abdomen and/or pelvis (Ultrasound) . This may diagnose ovarian cancer, this includes – Ultrasonography of pelvis, Ultrasonography of abdomen (upper, lower or other) or abdomen + pelvis. Note, brain MRI, chest x-ray and ultrasounds of the abdomen and pelvis to diagnose Ovarian Cancer are three of the key tests which are outlined in Improving Outcomes: a Strategy for Cancer. 7

Although these tests are used to diagnose cancer, many of the tests also have wider clinical uses. Within this data it is not possible to distinguish between the different uses of these tests.

Over a quarter of the tests that may have been used to diagnose or discount cancer were requested by GPs under direct access arrangements. Of these, the most common test requested by GPs was Chest X-ray, followed by diagnostic tests that may have been used to diagnose ovarian cancer (45% of which were requested by GPs). The following table gives a count of tests carried out on NHS patients that may have been used to make an early diagnosis of cancer. It includes the total number of these tests carried out, regardless of patient source setting, and a subset of this total; where the patient source setting was recorded as “GP Direct Access”.

Table 4: Count of imaging activity, using groups of tests suitable for diagnosing cancer, labelled by body site, for all patients referred and those directly referred by a GP, April - December 2012

Brain (MRI) Kidney or Chest and/or Chest (X-ray) Abdomen and/or % of bladder abdomen pelvis organi- (Ultrasound) (CT) (Ultrasound) sations included All GP All GP All GP All GP All GP Apr 32,805 1,970 15,740 4,905 26,305 1,905 581,625 137,210 83,695 38,360 96.3% May 36,995 2,340 17,910 5,510 31,265 2,435 669,585 191,820 97,865 44,875 96.3% Jun 33,025 2,215 14,630 4,280 25,905 1,945 585,680 163,590 80,100 35,960 92.6% Jul 36,015 2,350 16,510 5,040 28,955 2,415 608,865 164,950 89,930 41,190 92.6% Aug 37,400 2,535 17,205 5,085 29,545 2,560 579,720 150,360 91,810 42,905 92.6% Sep 35,100 2,325 16,350 4,895 27,245 2,105 550,940 130,260 87,045 40,720 92.6% Oct 35,755 2,535 17,900 5,740 29,010 2,375 576,350 145,760 90,970 42,980 88.8% Nov 37,510 2,500 17,850 5,745 29,915 2,510 587,510 145,545 91,415 43,050 90.4% Dec 33,930 2,410 15,140 4,690 26,515 2,195 568,130 118,725 75,525 34,055 91.5%

Please see Additional Tables 4a-4i for a count of imaging activity, using tests suitable for diagnosing Cancer, by body site, for all patients referred and those directly referred by a GP, by provider for April - December 2012

In the following table, median values of 0 occur where at least 50% of activity has a 'date of test request' and 'date of test' which is recorded as the same day. Records where either of these dates is missing are not used to calculate median values.

Table 5: Median number of days between ‘date of test request’ and ‘date of test’ for imaging activity using groups of tests suitable for diagnosing cancer, labelled by body site, split by patient source setting “GP Direct Access”, for April - December 2012 8

Brain (MRI) Kidney or bladder Chest and/or Chest (X-ray) Abdomen and/or (Ultrasound) abdomen pelvis (CT) (Ultrasound) All GP All GP All GP All GP All GP Apr 24 26 14 26 13 17 0 0 17 26 May 21 25 13 23 12 15 0 0 15 23 Jun 23 28 14 25 13 17 0 0 16 26 Jul 21 24 13 25 12 16 0 0 15 23 Aug 21 26 13 26 12 16 0 0 15 24 Sep 21 25 14 26 12 15 0 0 15 23 Oct 19 25 13 22 12 15 0 0 13 21 Nov 20 25 13 23 12 16 0 0 14 21 Dec 21 26 13 22 12 17 0 0 14 21

With the exception of Chest X-ray, for the key tests which may be used to diagnose or discount cancer, the median period from a test being requested to being performed is longer for GP direct access compared with all referrals. The main reason for this difference is that all referrals includes tests on emergency admissions and inpatients, which have shorter waits.

Please see Additional Tables 5a-5i for median number of days between ‘date of test request’ and ‘date of test’ for imaging activity using tests suitable for diagnosing Cancer, by body site, split by patient source setting “GP Direct Access” and by provider for April – December.

In the following table, median values of 0 occur where at least 50% of activity has a 'date of test' and 'date of test report issued date' which is recorded as the same day. Records where either of these dates is missing are not used to calculate median values. 9

Table 6: Median number of days between date of test and date of test report issued for imaging activity and percentage of records where date of test report issued equals date of test, using groups of tests suitable for diagnosing cancer, labelled by body site, split by patient source setting “GP Direct Access”, for April –December 2012

Month Measure Apr May Jun Jul Aug Sep Oct Nov Dec Brain (MRI) All Median 2 2 2 2 2 2 1 2 2 All % Same Day 30% 31% 29% 30% 30% 31% 33% 33% 34% GP Median 4 3 3 3 4 3 2 2 3 GP % Same Day 14% 16% 17% 15% 14% 16% 18% 19% 18% Kidney or All Median 0 0 0 0 0 0 0 0 0 bladder All % Same Day 84% 84% 86% 86% 86% 85% 86% 85% 86% (Ultrasound) GP Median 0 0 0 0 0 0 0 0 0 GP % Same Day 79% 80% 81% 81% 80% 79% 81% 79% 79% Chest and/or All Median 1 1 1 1 1 1 1 1 1 abdomen All % Same Day 41% 43% 41% 41% 41% 41% 43% 42% 44% (CT) GP Median 2 1 2 2 2 1 1 1 2 GP % Same Day 33% 37% 31% 31% 30% 35% 36% 34% 32% Chest All Median 2 2 3 2 2 2 2 2 2 (X-ray) All % Same Day 24% 25% 22% 23% 24% 23% 26% 26% 27% GP Median 2 2 2 2 2 2 1 1 1 GP % Same Day 28% 28% 24% 25% 27% 28% 31% 31% 35% Abdomen and/or All Median 0 0 0 0 0 0 0 0 0 pelvis All % Same Day 85% 85% 85% 85% 86% 86% 87% 87% 88% (Ultrasound) GP Median 0 0 0 0 0 0 0 0 0 GP % Same Day 82% 83% 83% 83% 85% 85% 86% 85% 85%

Please see Additional Tables 6a-6i for median number of days between date of test and date of test report issued for imaging activity specific to the early diagnosis of cancer, split by patient source setting “GP Direct Access” and by provider for April – December.

Note: These statistics should not be compared to diagnostic test waiting time statistics, as these are collected using different definitions. Unlike these statistics, the DM01 diagnostic test waiting times statistics exclude records where, for example:  The patient is waiting for a planned (or surveillance) diagnostic test/procedure, i.e. a procedure or series of procedures as part of a treatment plan which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency, e.g. 6-month check cystoscopy;  The patient is currently admitted to a hospital bed and is waiting for a diagnostic/test procedure as part of their inpatient treatment.

In addition, for the data published here, only approximately 80% of tests had a date of test request included and only approximately 90% of tests had a date of test report issue included. 10

Definitions Computerised Axial Tomography (CT Scan) Computed tomography (CT), sometimes called CAT scan, uses special x-ray equipment to obtain image data from different angles around the body, then uses computer processing of the information to show a cross-section of body tissues and organs. In the DID this means all codes mentioning CAT or computed tomography, including PET CT.

Diagnostic Ultrasonography (Ultrasound) The use of ultrasonic waves for diagnostic or therapeutic purposes, specifically to image an internal body structure, monitor a developing foetus, or generate localised deep heat to the tissues. In the DID this means any code relating to ultrasound.

Fluoroscopy Fluoroscopy is an imaging technique commonly used by physicians to obtain real-time images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an x-ray source and fluorescent screen between which a patient is placed. In the DID this is a collection of codes mentioning fluoroscopy or using fluoroscopic guidance, Barium enema or swallow. Interventional procedures are classified under imaging modalities which provide guidance. Almost all interventional procedures are under fluoroscopy procedure. A very small number of interventional procedures are under CT or MRI procedures.

Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is a method of producing extremely detailed pictures of body tissues and organs without the need for x-rays. The electromagnetic energy that is released when exposing a patient to radio waves in a strong magnetic field is measured and analysed by a computer, which forms two- or three-dimensional images that may be viewed on a TV monitor. In the DID this means all codes mentioning MRI.

Plain Radiography (X-ray) A Radiograph is an image produced on a radiosensitive surface, such as a detector, by radiation other than visible light, especially by x-rays passed through an object or by photographing a fluoroscopic image. In the DID this means any code referring to radiography or X-ray.

Median The median is the preferred measure of the average time between pairs of dates within records as it is less susceptible to extreme values than the mean. The median number of days between pairs of dates is calculated by ordering the values obtained by subtracting the dates for each record and selecting the middle value when all records are ranked by these number of days. For example, to calculate the median number of days between date of test and data of test request, for all records where the date of test falls into the month of interest, the number of days between the two dates is calculated. The number of days for all records are ordered from lowest to highest; the middle number in the list is the median.

Modality The broad procedure or method used for examination, for example MRI. This may include procedures assisted by the method, eg biopsy or injection. In the DID the modality of the examination is dervived from SNOMED or NICIP.

Patient source setting This is a categorisation of the department or organisation making the referral for the imaging activity. It includes categories for admitted patient care, outpatients, GP Direct Access, A&E and health care providers different to the organisation providing the imaging activity, as well as an ‘other’ category. Restricted Statistics – These Statistics are restricted until 9:30 22nd November 2012

Contact Us

Feedback We welcome feedback on this publication. Please contact us at [email protected]

iView The HSCIC will be allowing health sector colleagues to access DID information through their web-based reporting tool, iView. Registered users will be able to access annonymised data at aggregate level in a consistent and flexible format: Access Information – choose from a variety of data areas. Build Reports – select data to suit your needs. Generate Charts – customise report tables and graphs. Export Data – copy to Excel and manipulate data your way. Save Reports – store your favourite views for future use. If you would like to register to use iView for DID, please email [email protected] (subject: DID iView Access). For more information, please visit the iView website https://iview.ic.nhs.uk/?aspxerrorpath=/_

Website The DID website can be found here: https://did.ic.nhs.uk/

The DID Additional Tables and Technical Report can be found here: http://www.england.nhs.uk/statistics/diagnostic-imaging-dataset/

Additional Information For press enquiries contact the Department of Health Media Centre. Please refer to the Department of Health’s website for the relevant contact details: http://mediacentre.dh.gov.uk/about/

The Government Statistical Service (GSS) statistician responsible for producing these data is: Mark Svenson Analytical Service (Operations) NHS England Room 8E28, Quarry House, Quarry Hill, Leeds LS2 7UE Email: [email protected]