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THE FACTORS BEHIND THE INCREASING TREND IN THE USE OF DIAGNOSTIC IMAGING IN THE PHILIPPINE GENERAL HOSPITAL FROM THE RADIOLOGISTS’ POINT OF VIEW DANLEN C. MASANGYA, MD JOHANNA PATRICIA A. CAÑAL, MD, MHA, FPCR ABSTRACT This study aims to obtain the perspective of radiologists on the increasing demand for and possible perceived utility of radiologic examinations in the UP-Philippine General Hospital (UP- PGH). This is a descriptive study wherein information was collected through the use of a questionnaire adapted from the parent study conducted in Norway in 2009. A total of 44 consultants, fellows and resident physicians of the UP-PGH Department of Radiology participated in this study. In the questionnaire, the radiologists were asked to rate the frequency of potential causes of increased demand for diagnostic imaging, their level of participation in the decision making of requesting physicians, and their perceived role in patient care using five- point scales. Responses were analyzed and ranked using the Likert scoring system, and grouped and ranked using Factor Analysis. According to the respondents, the most important causes of increased volume of radiologic examinations are the lack of communication between radiologists and requesting physicians, and the availability of new imaging technology. Repeated examinations and vague referrals contribute to unnecessary investigations. These can be addressed by maintaining a healthy relationship between the clinician and radiologist, as well as with the formulation of hospital policies that will ensure the appropriate allocation of limited resources. INTRODUCTION In the past few years, there has been an children are more sensitive to the effects of increasing trend in the use of diagnostic radiation, have a longer life expectancy imaging in the clinical setting. In the UP- compared to adults, and may receive higher Philippine General Hospital (UP-PGH) doses of radiation per study per body weight Department of Radiology, there has a if the proper machine settings are not used. significant increase in the number of radiologic examinations being performed on In addition, increased use of imaging has a daily basis – around 1.5 to 2.5 times larger exponentially increased the cost of compared to the number of examinations healthcare. In the Philippines, where done during the same period the previous majority of health costs are out-of-pocket, year. This has resulted in considerable patients must be able to allocate their limited delays in the scheduling of examinations. financial resources for both diagnostics and treatment. In the UP-PGH, a significant The increased use of imaging modalities that portion of the budget is utilized to subsidize employ the use of radiation translates to diagnostic imaging costs. increased radiation dose for patients, or more patients receiving radiation. Pediatric The increase in the requests for radiologic patients are especially vulnerable since examinations from attending physicians has 1 been attributed to various factors, including mechanisms behind increased and increased patients' expectations, clinical unnecessary use of diagnostic imaging uncertainty, the advent of defensive studies can provide important input for medicine, and the lure of incentives with managing the increasing numbers of increased revenues. Radiologists are in the diagnostic imaging examinations and best position to educate ordering physicians avoiding over-utilization. as to which imaging tests, if any, are most appropriate for any given clinical situation. The objective of this study is to determine the UP-PGH radiologists' perception of the causes of increasing use of radiological investigations. Their perceptions of the METHODOLOGY OBJECTIVES A survey was conducted among the General Objectives consultants, fellows and resident physicians currently affiliated with the UP-PGH 1. To obtain radiologists' perspective Department of Radiology using a on the causes of increasing use of questionnaire adapted from the study by radiological investigations, taking into Lysdahl and Hofmann (Appendix A). All consideration their level of experience. consultants, fellows and residents were 2. To formulate recommendations to invited to participate in the study. Informed maximize the efficiency and benefits of consent was obtained from each participant. diagnostic imaging in the management of Participation was completely voluntary, and patients. consent was allowed to be revoked for any reason at any time, without any Specific Objectives consequences. In the questionnaire, the 1. To enumerate the causes that radiologist was asked to rate potential causes contribute to the increasing demand for and of increased investigation volume and possible irrational use of diagnostic imaging unnecessary investigations using five-point and how strongly they affect the volume of descriptive scales. The radiologists also radiological examinations in the Philippine answered questions regarding the level of General Hospital. his/her participation in the decision-making process of the requesting physician, and 2. To determine the extent of his/her perceived role in patient participation of the radiologist in the management. decision making process of the referring physician in the scope of diagnostic The questionnaires were collected within a imaging. week after distribution. The demographics (age, sex, duration of radiology practice) of 3. To provide specific suggestions to the participants were noted. Responses were prevent over-utilization of diagnostic grouped according to the level of imaging in the Philippine General Hospital. experience/designation of the respondent – junior resident (1st-2nd year), senior resident (3rd-4th year), fellow, and 2 consultant – and were analyzed using the the UP-PGH: 1) repeating investigations Likert scale. The responses of the which have already been done; 2) participants for the questions with ordinal insufficient clinical information and unclear options were assigned arbitrary values. In questions in the referral; and 3) over- addition, Factor Analysis of all the items investigation and investigating too often. was performed to group and rank the similar Most of these problems can easily be resolved with effective communication responses and determine which factors among physicians and improved patient- contribute the most to the increase in the doctor relationship. In the UP-PGH, requests for diagnostic imaging in UP-PGH. clinicians are encouraged to furnish the Recommendations for better utilization of request with the complete clinical diagnostic imaging procedures in the UP- impression of the patient. However, requests PGH were then formulated. with incomplete and/or inaccurate patient information are still encountered in the RESULTS AND DISCUSSION department. Sadly, some patients repeatedly According to the respondents, the most undergo the same examinations because significant factors behind the increase in the their requesting physicians forget to verify volume of radiological examinations in the with them or the co-managing services if UP-PGH are the following: 1) referring these have already been performed. physicians have less tolerance for When asked about the factors that may uncertainty; 2) expanded clinical indications prevent them from doing a questionable for radiology; and 3) increased possibilities examination, the radiologists ranked the due to new radiological technology. With following the highest: 1) high risk of serious increasing threat of litigation due to medical complications or side effects; 2) the patient malpractice and widespread accessibility of or guardian does not want the examination; medical information in the internet to and 3) the examination requires a high patients and their caregivers, clinicians have radiation dose. As radiologists, the less room for error in their diagnosis and respondents are more aware of the adverse management. Moreover, the availability of effects of radiation and are thus more new imaging modalities and discovery of conscious when it comes to limiting new applications of existing techniques have radiation doses of patients. also greatly contributed to the increased utilization of diagnostic imaging in daily Meanwhile, the factors that greatly practice. contribute to performing the examination as requested are: 1) great respect for the It is also interesting to note that most of the referring physician’s professional judgment; residents have subjectively reported that 2) the patient/guardian wants the referring physicians have less knowledge examination; and 3) fear of legal about the accurate use of radiology. This is consequences and demand for efficiency at probably due to the fact that the radiology work. A high reimbursement rate apparently residents receive referrals from fellow does not affect the decision of radiologists to trainees who usually have less than 4 years carry out questionable requests. of clinical experience. The respondents are generally in agreement The respondents claimed that the following with the following statements: 1) causes of increased radiological radiologists gain professional respect when examinations occur the most frequently in 3 they actively discuss with and guide The study shows that there are 4 different clinicians in the appropriate use of latent factors that determine the increasing radiology; 2) radiologists have part of the trend in the use of diagnostic imaging in the responsibility for limiting total health costs Philippine General Hospital. It seems that

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