Assessing the Performance of Imaging Health Systems in Five Selected Hospitals in Uganda

Operational definitions of the imaging health system performance

Study design

This was a cross-sectional survey with triangulation. Triangulation was defined as combining two or more theories, data sources, methods or investigations when studying one phenomenon.[11–16] It was used because of its ability to improve the validity of the results, as errors that would result from the use of a single method were counteracted. Findings arising from such holistic triangulation studies could be used to generate interventions that were faithful to their qualitative and quantitative origins.

For the quantitative part of the study, cluster sampling was applied. A cluster was defined as one or more mutually exclusive groups within a sample. The grouping was based on geographical or administrative structures.[17]

The clusters were Obstetrics and Gynecology (OBS / GYN), Surgery, Internal Medicine, and Pediatrics. The qualitative part employed purposive sampling.

Imaging coverage

The overall IC for the five hospitals was 36%. The coverage was highest for the Mulago Tertiary Hospital, 56%, followed by Mbale Regional Hospital, 27%, and Masindi District Hospital 19%. The Kabale Regional Hospital and Rakai District Hospital had the lowest coverage at 13 and 10%, respectively.

Among the clusters, the IC was highest for the pediatric cluster (38%) followed by the internal medicine cluster (34%). The surgery cluster and the OBS/GYNAE cluster had lower coverage, 24% and 21% respectively [Figure 1].

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Figure 1

IC within clusters

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With regard to IC for types of examinations, general X-rays had the best IC (36%) followed by ultrasound (29%), computed tomography/magnetic resonance imaging/nuclear medicine (CT/MRI/NI) (18%), and X-ray contrast studies (7%).

Hospital-based utilization

There were a total of 1111 inpatients from all the five hospitals, making up 57% of the total sample size of 1961 patients. Out of these inpatients, 207 received imaging giving a hospital-based utilization of 186 per thousand inpatients. The relative contribution by each imaging modality was 63.0%, 31.0%, 3.8%, and 2.7% for general X-ray, ultrasound, CT, and contrast X-ray studies, respectively. The different HBUs for each hospital, broken down per modality, are shown in Table 1.

Table 1 HBU for individual hospitals broken down to modality

Results of the qualitative component of the study

Impact of resources on the performance of imaging health systems

Financial, human resource, and equipment distribution in the five study hospitals

It was noted that the all hospitals received less than 30 % of the required budget. The workforce and the equipment were also limited [Tables 2–4].

Table 2 Recurrent budgets in Uganda shillings for the five hospitals at the time of the study (consumables and equipment maintenance only)

Table 3 Human resource for imaging for the five hospitals at the time of the study

Table 4 Imaging equipment for the five hospitals at the time of the study

Policy standards and guidelines related to performance of imaging health systems

During the qualitative interviews, the participants voiced some contextual factors, which could impact efficiency. In particular, the absence of policy standards and guidelines was cited.

One clinician quoted one doctor as stating, “But if we had clear guidelines it would go a long way in minimizing inappropriate requisitions.” It was thought that guidelines would be a way to reduce unnecessary imaging; one radiologist concluded, “The guidelines will ensure that only those who need imaging are imaged so there will not be so many unnecessary reports to write.” Imaging guidelines were also thought to improve imaging reports. One doctor put it in these words, “Probably there could be developed some schedule or some format of report writing.”

Overall imaging coverage and the hospitalbased utilization

The IC of only 36% shows that the imaging system performance with regard to handling the prevailing IB is only 36%. This is an indication of the low response capacity of the system to the demand. The coverage is higher for the Mulago Hospital, which is an urban hospital, in comparison to rural-based hospitals like the Rakai and Masindi. This is thought to be due to limited resources in rural areas. The radiology utilization rates in non-rural health facilities in the US were found to be almost five times those in the rural and this was also thought to be due to fewer resources in rural areas.[21]

The closest indices to the IC are the hospital-based and population-based utilization indices. This HBU for all the five hospitals was 186 per thousand patients [Table 1]. This is less compared to similar values for the USA. In the USA, the non-invasive diagnostic imaging utilization for Medicare patients have been seen in one study to be 4404 per 1000.[22] In Uganda examination to patient ratio stands at 0.165 examinations per patient compared to a case-mixed ratio for the USA of 2.35 examinations per patient.[23] There is no literature on imaging utilization for any other African country.

We sampled only five hospitals out of a total of almost 70 government plus NGO hospitals. We therefore, cannot calculate a nationwide population-based utilization index. However, the hospital-based utilization of 186 per 1000 [Table 1] is much lower than the population-based index of 600 per thousand for Nordic countries and 4176 per 1000 for USA.[24]

For Africa, the population-based utilization levels available in literature were calculated by Cockshott, way back in 1979.[25] These are 13, 18, 29, 22, and 28 per thousand for Senegal, Ghana, Congo, Kenya, and the Ivory Coast, respectively. Cockshott did not include Uganda in his research. These figures from Africa are probably outdated. Nonetheless, they portray a gloomy picture of the services.

Regarding the relative applicability of hospital- and population-based utilization for Uganda, the hospital-based indices are likely to be more applicable, as they are more representative of the utilization status, and are easier to measure. The marked variation in the IC between the various health levels (tertiary, regional, and general) indicates that there is no uniform utilization across the country. Burkahardt and Sunshine, commenting on the population-based utilization indices for the USA have made a similar observation.[26] They concluded that much variability exists in population-based utilization rates, and that the national or regional averages are not a good guide to utilization in specific patient populations. They advocated the use of actual data from patient populations as a better predictor for future utilization trends; even generalization of the hospital-based utilization of 165, for all levels of service delivery, may be realistic, because of variations in the IC among the levels.

With regard to the utilization for specific imaging modalities, the utilization was 117, 57, 7, and 5 per thousand for general X-ray, ultrasound, CT, and contrast X-ray, respectively [Table 1]. These figures are much lower than for the USA, for which the population-based indices per one thousand in 2003 were: 2057, 921, 391, 114, 215, 221, and 249 for general radiography, ultrasound, CT, MRI, interventional radiology, mammography, and nuclear medicine, respectively.[24] In 2008, the utilization per 1000 Medicare patients was 292, 262, 145, 405, and 292 for CT, Nuclear medicine, MRI, echocardiography, and ultrasound, respectively.[22]

The relative contribution by each imaging modality was 63.0, 31.0, 3.8, and 2.7% for general X-ray, ultrasound, CT, and contrast X-ray studies, respectively. This pattern differs from the USA where general radiography takes a significant majority of 55-58%, followed by CT, 11-20%, and ultrasound contributes to only 11%.[27] The differences may be due to patient population characteristics and Uganda′s lower level of technology sophistication.

This article has measured the HBU at one point in time, but for evidence-based policy and planning, it is ideal to record the trend of the HBU over time. This enables the projection of utilization levels for future planning. Uganda is undergoing rapid change in technology acquisition. Kampala city currently has five multi-slice CTs, and two low-field strength MRIs, and a 1.5 Tesla MRI is being purchased for installation next year. As the proportion and number of educated Ugandans rise, due to the recently introduced Universal Primary and Secondary Education, the population is becoming more aware of the capabilities of newer imaging technologies. Uganda's GDP per capita is growing at 6% per anum. It was 1283 US Dollars in 2010.[28]

The observed escalation of imaging utilization in developed countries, is therefore, likely to be played out in Uganda and other developing countries, but to a much lesser, although not an insignificant scale. It is therefore important to borrow a lead from trends in developed countries.

Interest in imaging utilization trends started in the early 1990s, and was most likely prompted by the advent and escalation of utilization and imaging costs, possibly attributed to the sophisticated cross-sectional imaging techniques like CT, MRI, ultrasound, and nuclear medicine, and the continuous and rapid developments in these technologies.

A panoramic view of trends in the USA is given by in an article by Rajas et al. Over a 20-year period from 1990 to 2009, X-ray utilization per 1000 Emergency Department patients fell by 86% in contrast to an increase in utilization of advanced imaging modalities like CT, MRI, and ultrasound. The highest increase was in CT, which increased 17.5-fold, and ultrasound increased by 51.6%. The clinical decision tools and appropriate criteria were recommended by the authors to curb the unnecessary utilization of expensive imaging modalities.[29]

As early as the mid 1980s, the curiosity in utilization trends had already sparked off. Khorsani R et al., in a retrospective study conducted from 1984 to 1993, in Boston, USA, for a 751-bed tertiary hospital, evaluated trends based on utilization per case-mix adjusted admission (CMAA), using linear regression analysis. In general, there was a decrease in the number of studies per CMAA. More specifically the utilization of ultrasound and conventional imaging (plain radiography and fluoroscopy) decreased, whereas, the use of more sophisticated techniques namely CT and MRI rose. Nuclear medicine trends showed no change. They recommended studies to understand the pattern of the usage of CT and MRI, so as to reduce inappropriate usage, and furthermore that the application of expensive imaging techniques should be justified by impact on patient outcomes and reduction in length of hospital admissions.[30]

The 1990s saw a rapid escalation in the utilization of non-invasive diagnostic imaging (NID). Based on information from the Medicare Part B claim files, for the six-year period between 1993 and 1996, there was an overall increased utilization of NID by radiologists and non-radiologist groups. The increase was most marked among non-radiologists in comparison to radiologists, with the proportion of NID performed by radiologists falling from 73.0% in 1993 to 67.4% in 1996.[3132]

In a retrospective study by Matin et al., spanning a period of ten years, (1993-2002), in Boston, USA, there was an overall decrease in number of studies per case-mix adjusted admission (CMAA), from 1.55 to 1.33. More specifically the utilization per CMAA of ultrasound and radiography decreased, whereas, use of more sophisticated techniques like nuclear medicine, CT, and MRI rose. The increase in utilization of the sophisticated imaging techniques was thought to be due to the rapid increase in the clinical use of these techniques, practice pattern, social expectations, and patient complexity. The authors recommended that there should be efforts to reduce inappropriate utilization. Requisitioning should be justified by impact on clinical decision-making and patient outcomes. [23]

Surveys carried out between 2000 and 2005 showed an unabated upward trend for utilization of sophisticated imaging techniques in the US. Mitchel JM et al. evaluated the utilization of highly re-imbursed advanced imaging techniques among privately insured individuals in California and recorded the increase in utilization. The increase in PET was 400%, and in MRI and CT 50%. The increase was most marked in independent diagnostic testing and in physician self-referral arrangement facilities, but less marked in a hospital setting. The author concluded that imaging guidelines could play a role in reducing unnecessary utilization of highly reimbursed advanced imaging techniques, resulting in a considerable potential for saving.[33]

In order to obtain a detailed understanding of the population-based utilization trends for different modalities, regions, and population in the USA, between 1988 and 2001, Bhargavan M et al., studied the aggregate claims data of 25,000 Medicare enrolees. In 2001, the utilization was 4176 per 1000 for diagnostic imaging and 274 per 1000 for interventional procedures. Almost 50% of imaging utilization was due to radiography and the rest due to cross-sectional imaging (CT, MRI, ultrasound, interventional radiology, nuclear medicine, and mammography). Between 1988 and 2001, there had been an increase in utilization, with advanced imaging techniques increasing up to 16% in contrast to radiography, which increased by only 1%. Increase in utilization varied per region and state, with the North-East having the highest increase. States with higher populations, higher number of radiologists, and Medicare services also had higher increases.[34]

The turning point came after 2005, and it was exposed by Levin CD et al., who through analysis of the annual nationwide Medicare Part B databases for the period 2005 to 2008, demonstrated a slowdown of the compounded annual growth (CAGR) rate from 4.8 to 1.4%, between 1988 and 2005. Specifically the slowdown was for fee-for-service, noninvasive diagnostic imaging. The utilization had grown rapidly from 3,190 noninvasive procedures per 1000 climbing steeply to 4,230 in 2005, and then surprisingly less rapidly to 4,404, in 2008. In 2008, the utilization per 1000 Medicare patients was 292, 262, 145, 405, and 292 for CT, Nuclear medicine, MRI, echocardiography, and ultrasound, respectively. The slowdown had been mostly for MRI and nuclear imaging. It abated for CT, ultrasound, and echocardiography as well. The earlier higher growth was thought to be due to a growth in the utilization of sophisticated imaging techniques. Furthermore, the growth in utilization had been shown to be twice by non-radiologists and self-referring physicians (6.6%) as compared to radiologists (3.4%). The recently observed slowdown was believed to be due to reduction in re-imbursement for imaging.[22]

To further illustrate the general trend in increased utilization, the workload for radiologists has shown a steady rise, increasing by 8.5% between 1995-1996 and 1998-1999.[243536]

There have been several attempts to analyze the causes of increased and inappropriate utilization and to recommend solutions. Kessler D and McClellan M pointed at “defensive medicine” as a major driver to escalating medical costs in the management of cardiac disease. They observed that malpractice liability reforms that directly limit awards and benefits from lawsuits lead to a substantial reduction in the escalation of medical costs, with no negative impact on the treatment outcomes.[37] Lysdahl KB and Hofmann BM, in Norway, through interviews of radiologists, found that the major reasons were introduction of newer technologies, demand from patients, the referrers' inability to tolerate what they think is wrong, expanded clinical information, and availability of the technique. They recommended that it was important to instill a measure, which supported the decision process, possibly through guidelines.[38] The type of payment system could have an impact on the utilization rates. Bhurkhardt JH et al., using data from Medicare, Health Management Organizations (HMO), and conventional insurances, demonstrated a great variability in utilization, for patients in different payment systems. Utilization was found to be almost three times more for Medicare enrolees in comparison to HMO.[26] Physician self-referral is thought to be a major contributor to unnecessary imaging utilization. Levin DC et al., reviewed the different measures undertaken to overcome unnecessary utilization of imaging through physician self-referral arrangement.[39]

This study has identified anomalies in the hierarchical chain, routine requisitioning, patient self-referral, pressure from patients, and lack of clinical imaging guidelines, as the major drivers to inappropriate requisitioning and utilization in our health facilities. Defensive medicine is not yet a key factor, but is bound to increase as patients get more enlightened. Increase in the number and distribution of sophisticated technologies, compounded by lack of imaging guidelines for these technologies, may in the future be a major driver to overutilization in our health facilities.

Impact of resources on the efficiency of the imaging system

Less than 30% of the budget for imagimg is funded [Tables 2–4]. Even if the actual budget was 100% realized, it would not cater to the Imaging Burden, because the budgets were based on non-evidence-based 5 - 20% utilization. The shortfall in the budget may explain why there are chronic shortages of consumables and almost half the total number of machines are non-functional at any given time.

The Masindi Hospital has a higher annual expenditure per patient, in comparison to the other four hospitals [Table 2]. The explanation is that the government allocates a uniform annual recurrent fee of 12,000,000.00 shillings per general (district) hospital, per year, but the yearly patient imaging load for Masindi, of 1027 patients, is the lowest, among all the five hospitals. The study found that patients attending the Masindi Hospital had fewer conditions that required imaging, in comparison to the other four hospitals. Therefore, each patient takes a larger share of the total allocation, in comparison to the other hospitals, which have a higher proportion of patients requiring imaging.

The fact that Uganda's national imaging budget is based on a presumptive utilization of 15-20% sets a policy limit for the IC and the utilization levels.[40] This is further worsened by the fact that only 30% of the national health budget is financed.[1] This under-funding is automatically reflected in the IC, which is 36%.

Odaga and Lachoro pointed out that health budget ceiling was the single most important hindrance to health service delivery in Uganda.[8] The ceiling on the budget for MoH was to ensure macro-economic stability. This policy on budget ceiling directly impacts the efficiency of the imaging system, and is most likely the basis for 30% funding of the imaging budget, with a resultant 36% IC. Cockshott also partly attributed the inefficiencies in Africa's imaging services to inadequate budgets.[25]

Only 68% of the established posts for imaging staff are in the city. Posts for radiologists only exist at the tertiary and regional level hospitals, and these hospitals total to only 14. There is an unmanageable workload of 140 to 211 examinations per radiologist, per day. Cockshott observed a shortage of radiologists and radiographers in several African countries and coined the phrase, ‘capital city syndrome’.[25] In the USA, the average annual workload per radiologist is 14,900, examinations.[36] From the figures in this study, the workload for the Ugandan radiologists averages 16,000 examinations per radiologist per year.

Frequent breakdown of equipment and long downtimes were reported at all five hospitals [Table 4]. The supplies of consumables were irregular. Contrast X-rays and CT/MRI had the lowest IC. This could be explained by the frequent breakdowns and / or total absence of these more technically sophisticated imaging modalities. The country does not have enough equipment maintenance and service personnel.

It should be noted that appropriate requisitioning was 94%. Based on the total imaging load of all the five hospitals, which is 379,548 patients [Table 2], and on the fact that 6% of all requisitions were inappropriate, a total of 22,772 examinations were inappropriate. Based on a calculation that takes into consideration the total imaging load of all the five hospitals and the total budget of all these hospitals, which is 340,000,000.00 shillings [Table 2], 895 shillings are budgeted to be spent on each patient. This implies that for the 22,772 inappropriate examinations, 20,385,415.00 shillings were wasted in inappropriate imaging.