Mobile radiography services in nursing homes - utilisation, costs and organisation

Abstract

Background: Due to demographic changes in the western world, with an ageing population and fewer resources for health services, there is a need for a new way of organising and delivering health services to the population. An increase in the number of nursing home residents worldwide is expected as people live longer and have multiple comorbidities. In addition, the number of persons living with dementia is increasing rapidly. There is a drive internationally towards more integrated, people-centred health services focusing on the needs of the population and individuals, rather than a cure-based hospital or disease-centred health service. In diagnostic imaging, mobile radiography services could be a way of delivering imaging services to nursing home residents focused on their needs for a familiar environment and coordinated care. Mobile radiography service is a telemedicine application, where the health service is delivered at different localisations connected by information and communication technology. The use of more telemedicine applications is highlighted as one of the measures necessary to meet future challenges in the health services. However, telemedicine applications are often blocked for wider implementation in the current health services because of organisational, financial and legislative barriers, or reluctance to use new technology. To increase the quality of telemedicine studies and produce knowledge useful to decision-makers, a model for the assessment of telemedicine services (MAST) has been developed. This is used in my thesis to assess conditions for and current knowledge on mobile radiography services, and to explore mobile radiography services in nursing homes in three of MAST’s domains. Furthermore, mobile radiography services in nursing homes will be analysed in a people-centred health service perspective.

Aim: The main aim of this thesis is to explore utilisation of mobile radiography services in nursing homes and the economic and organisational aspects of these services, thus contributing to the delivery of integrated, people-centred health services to nursing home residents. This aim was achieved through four studies.

Materials and methods: MAST was used as a model for structuring the assessment of mobile radiography services.

Paper I: A systematic review of the outcomes of mobile radiography services for nursing home residents and society. Searches were made in Medline, Cochrane, PubMed, Embase, and Swemed+. Through predefined inclusion criteria, all titles and abstracts were screened. In addition, a full text assessment was made including a quality appraisal using MMAT or CASP appraisal tools. Data were extracted using a summary table. Results were narratively summarised.

Paper II: Exploring utilisation of diagnostic imaging among nursing home residents and the effects of mobile radiography services. Data on referred examinations from nursing homes in 2015 were collected from radiology information systems at eleven hospitals from all health regions of Norway. Hospitals were divided into two categories: with and without mobile radiography services. The Chi-squared test was used to compare these categories.

Paper III: A cost-analysis using a decision tree model in TreeAge Pro. The model compared two alternatives: mobile radiography services combined with hospital-based services and hospital-based services alone. The model included both the examination and treatment of the nursing home residents. Input probabilities and costs were derived from previous research, reports and hospital data. Monte Carlo simulations of 1000 residents were run through the model in a probabilistic sensitivity analysis (PSA) and paired-samples t-tests was used to compare the alternatives.

Paper IV: Semi-structured interviews with eleven managers from both hospitals and municipalities were conducted in order to explore barriers and facilitators for implementing mobile radiography services in Norway. The interview guide focused on barriers and facilitators in different phases of implementation. Thematic analysis through the framework method was used for inductive-deductive analysis of data by a research team.

Results: Paper I: The review included ten publications. Overarching, resident, and societal outcomes were identified. The overarching outcomes were interlinked with the outcomes for residents and society. The reduction in hospitalisations and outpatient visits and transfers, and at the same time an increase in radiographic examinations were considered overarching outcomes. These lead to better treatment and care for nursing home residents as well as increased psychosocial well-being. These outcomes also gave a more efficient use of resources and thus lower costs per examination on a societal level.

Paper II: The analysis showed an underuse of diagnostic imaging among nursing home residents compared to the general population (0.9 examinations per person per year), with 0.5 (with mobile radiography) and 0.36 (without mobile radiography) examinations per nursing home bed per year. Mobile radiography services increased the proportion of plain radiography significantly. However, the proportion of CT and ultrasound reduced significantly when a mobile services was present. Of 11,066 examinations, 87% were plain radiography examinations, 8% were CT scans and 4% were ultrasound. The use of MRI, nuclear medicine, and other modalities was less than 1% each.

Paper III: The analysis showed a 30% cost reduction from a mean cost of €2,790 per resident examined and treated with hospital-based services to a mean cost of €1,946 with a combined service alternative. The difference in costs was significant (p <0.001). The PSA showed cost reduction in all runs and the reduction would most likely be €560 to €1,080 per resident examined and treated in southeast Norway.

Paper IV: Barriers and facilitators for mobile radiography services were found on both micro, meso, and macro levels of the health services. The managers interviewed mainly experienced that the implementation was impeded by financial (reimbursement system), structural (lack of cross-level management), and procedural (lack of compatible communication systems) barriers. The main facilitators were external funding, and support and engagement from individuals in the cooperating organisations.

Conclusions: This thesis showed that: Mobile radiography services contribute to increased access to imaging services. This could provide more accurate diagnosis and thus better treatment and care for most nursing home residents, tailored to their need for a familiar environment and coordinated services. Mobile radiography services contribute to the strengthening of primary care. An increase in treatment given in the nursing home transfers tasks from hospitals to primary care, in line with the strategies for integrated, people-centred health services. Mobile radiography services contribute to a better utilisation of healthcare resources, and reduce the cost per examination and treatment by 30%. Barriers exist within the health services to large-scale implementation of mobile radiography services. These barriers are present in the management and funding of health services, and in the information technology systems.

Recommendation: This thesis showed a need for changes in the funding of health services in Norway in order to facilitate coordination and integration of health services and telemedicine applications. In addition, there is a need for stronger cooperative management across health service levels. Furthermore, there is a need for integrated information systems across organisations and a system for safe, wireless image transfer from mobile modalities.

Further research: This thesis suggests that more research is needed in the mobilisation of diagnostic imaging and spreading mobile radiography to other populations in need of diagnostic imaging outside hospitals and imaging centres.