Internal Controlling of a Radiology Department.

Caused by legal reform initiatives there is a continuous need to increase effectiveness and efficiency in hospitals and surgeries, and thus to improve processes.Consequently the successful management of radiological departments and surgeries requires suitable structures and optimization processes to make optimization in the fields of medical quality, service quality and efficiency possible.In future in the DRG System it is necessary that the organisation of processes must focus on the whole clinical treatment of the patients (Clinical Pathways). Therefore the functions of controlling must be more established and adjusted. On the basis of select Controlling instruments like budgeting, performance indicators, process optimization, staff controlling and benchmarking the target-based and efficient control of radiological surgeries and departments is shown.

Leadership in the tug of war between what is desired, what is possible, and what is allowed - knowledge and ideas gained from 25 years of senior management experience in radiology.

A decisive factor in the difference between the success and failure of the development of practices and hospitals is the quality and number of suitable staff members, together with their motivation to devote their skills to the particular organization. Senior management is not required or paid to paint dramatic pictures of current and future problems, but to achieve success within given framework conditions (e. g. health funding, local circumstances, suitability of senior staff). Success must be measurable and verifiable within the dimensions of medical quality, service quality and economic viability - but also regarding staff loyalty and staff recruitment. This paper is intended to encourage critical reflection on structures and roles in the organization of hospitals and practices on the basis of knowledge and ideas gained from 25 years of senior management experience. The content of this article will apply only in part or not at all for a number of successful hospitals and practices. The aim of this paper is to increase that proportion.

[Efficient IT solutions in radiology: prerequisite for successful management]. / Effiziente IT-Lösungen in der Radiologie: Voraussetzung für ein erfolgreiches Management.

For hospitals and radiology departments an efficient hospital information system (HIS), a radiology information system (RIS) and a picture archiving system (PACS) with high availability, reliability, flexibility and simple operation are necessary for survival. Besides the networking of patients and pictures data IT systems must also be capable of continuous process optimization in the dimensions of medical quality, service quality and profitability. What is not measurable is not improvable. A successful management demands current, medium-term and long-term indicators for the control. These performance and cost data are also available for benchmarking with other departments or for analysis for manpower requirements. In contrast to the past indicators must now concentrate on the use of resources by interdepartmental process treatment (clinical pathways and imaging pathways). The monitoring of image pathways is a future task. Without qualified IT personnel, optimal IT systems cannot be successful. In the complex treatment processes in hospitals high medical (radiological) quality is only possible in connection with optimal IT systems and excellent IT specialists.

[Imaging center - optimization of the imaging process]. / Imaging Center - Optimierung der diagnostischen Bildgebung im DRG-Zeitalter.

Hospitals around the world are under increasing pressure to optimize the economic efficiency of treatment processes. Imaging is responsible for a great part of the success but also of the costs of treatment. In routine work an excessive supply of imaging methods leads to an "as well as" strategy up to the limit of the capacity without critical reflection. Exams that have no predictable influence on the clinical outcome are an unjustified burden for the patient. They are useless and threaten the financial situation and existence of the hospital. In recent years the focus of process optimization was exclusively on the quality and efficiency of performed single examinations. In the future critical discussion of the effectiveness of single exams in relation to the clinical outcome will be more important. Unnecessary exams can be avoided, only if in addition to the optimization of single exams (efficiency) there is an optimization strategy for the total imaging process (efficiency and effectiveness). This requires a new definition of processes (Imaging Pathway), new structures for organization (Imaging Center) and a new kind of thinking on the part of the medical staff. Motivation has to be changed from gratification of performed exams to gratification of process quality (medical quality, service quality, economics), including the avoidance of additional (unnecessary) exams.

[Benchmarking of radiological departments--starting point for successful process optimization]. / Benchmarking radiologischer Abteilungen--Startpunkt einer erfolgreichen Prozessoptimierung.

INTRODUCTION: Continuous optimization of the process of organization and medical treatment is part of the successful management of radiological departments. The focus of this optimization can be cost units such as CT and MRI or the radiological parts of total patient treatment. Key performance indicators for process optimization are cost- effectiveness, service quality and quality of medical treatment. The potential for improvements can be seen by comparison (benchmark) with other hospitals and radiological departments. Clear definitions of key data and criteria are absolutely necessary for comparability. There is currently little information in the literature regarding the methodology and application of benchmarks especially from the perspective of radiological departments and case-based lump sums, even though benchmarking has frequently been applied to radiological departments by hospital management. AIM AND CONTENT: The aim of this article is to describe and discuss systematic benchmarking as an effective starting point for successful process optimization. This includes the description of the methodology, recommendation of key parameters and discussion of the potential for cost-effectiveness analysis. The main focus of this article is cost-effectiveness (efficiency and effectiveness) with respect to cost units and treatment processes.

Screening/health checks: can the patient only win? Whole body magnetic resonance imaging approaches to tumour screening.

One of the greatest challenges for the next decade is the fight against cancer disease. These activities must be based on three premises: Cancer prevention; Cancer diagnosis; Cancer treatment.

Assessment of patient organ dose in CT virtual colonoscopy for bowel cancer screening.

Justification and optimisation form the basic elements for the radiological protection of individuals for medical exposures. Justification includes the assessment of patient organ doses from which radiation risks are deduced. Medical radiation exposures are justified only in the case of a sufficient net benefit. For screening examinations, such as CT virtual colonoscopy, this implies that patient organ doses should be relatively low to minimise the radiation detriment. Image quality should be sufficient to maximise the potential diagnostic benefits. The Medical Exposures Directive places special attention on medical exposures as part of health screening programmes and examinations involving high individual doses to the patient, both of which apply to CT virtual colonoscopy. Technical factors were recorded for a series of patients having virtual colonoscopy on a CT scanner. In addition, the dose-length product was assessed. Patient organ doses were deduced using a CT dose calculation program. The typical effective dose was 7.5 mSv for male patients and 10.2 mSv for female patients. The effective dose is higher for female patients, as some gender-specific organs are irradiated during virtual colonoscopy. Each patient has two series of scans resulting in doses of 15 mSv for male patients and 20 mSv for female patients.

The SENTINEL project.

Health-care expenditure on radiological equipment in Europe is a growing fraction of the gross domestic product for all member states. This increase in expenditure has been driven by technical developments in equipment design, matched by the introduction of novel clinical practices, examinations and procedures. The radiation protection implications of these developments have to be assessed. The SENTINEL co-ordination action covered radiation protection, safety and related issues that arise from these technical and clinical developments. SENTINEL covered 90% of patient examinations in European Radiology, 60% of the collective dose from medical sources and approximately 50% of the collective dose to European citizens from man-made sources. The SENTINEL co-ordination actions 'main' objective was to address the safety and efficacy issues which are common to all digital diagnostic imaging systems, including nuclear medicine. High-dose procedures and sensitive groups (such as children) were covered by the project. Specifically, the co-ordination action aimed: (1) to establish both physical and clinical image quality criteria and link the two, (2) to undertake a series of dosimetry studies to establish the reference levels for new procedures and (3) to develop good practice guidelines for radiation protection in digital imaging and produce training material.

[Tumor search with diffusion-weighted imaging--first experience]. / Tumorsuche mittels kernspintomografischer Diffusionsbildgebung--Erste Erfahrungen.

PURPOSE: Assessment of fat-suppressing diffusion imaging as a tool for tumor search in primary oncological staging and follow-up after treatment. MATERIALS AND METHODS: The DWIBS sequence (DWIBS: Diffusion-Weighted Whole-Body Imaging with Background Body Signal Suppression) developed by Taro Takahara et al. was implemented in oncological MRI protocols. After measurement of 8 volunteers with a whole-body protocol, 47 whole-body scans were performed on 38 oncological patients. 70 exams were performed on 62 tumor patients with organ-specific protocols using parallel imaging. A total of 64 patients showed neoplastic lesions in the non-diffusion sequences. These lesions were evaluated in terms of visibility and signal intensity in DWIBS imaging. Non-malignant changes which showed high signal intensity in diffusion imaging were recorded in all examinations. RESULTS: 113 of the 125 DWIBS examinations were judged as technically good. Diffusion imaging showed bright signal in the malignant lesions of 58 of the 64 patients. The tumors of 6 patients showed only moderately bright signal or were not discernible at all. Although partly performed with free breathing of the patients and limited spatial resolution of the sequence, lesions with sizes close to voxel-size were able to be visualized. Some of the patients were seen in follow-up examinations and showed signal decrease of their lesions in case of therapy response and signal increase in recurrent disease. CONCLUSION: Introduction of diffusion-weighted imaging provides a new independent parameter in oncological scanning. DWIBS meets the requirements of a fast, robust technique. Homogeneous fat suppression allows the use of maximum intensity projections which may visualize the spread of the disease at first glance. Most of the tumor entities examined in this study showed a bright signal in DWI. Exceptions were some osteoplastic metastases and hemorrhaged lesions. Although sensitive, visual evaluation of signal intensity alone showed limited specificity. Detection of lesions in physiological hyperintense structures may be difficult. DWIBS imaging seems to be a sensitive tool in the search for lymphomas and gastrointestinal tumors.

[Digital radiography und fluoroscopy. Basics of technology, imaging properties and applications]. / Digitale Radiographie und Fluoroskopie Technische Grundlagen, Abbildungseigenschaften und Anwendungen.

For 110 years, x-rays and special x-ray films have been used in medical diagnostics. New developments in the field of x-ray techniques, and especially new computer applications, have led to new imaging techniques which have substantially expanded the spectrum of radiological examinations. In spite of significant technological and medical advances in the field of MRI and multidetector-CT, radiographic images of the lungs, skeleton and organs still comprise up to 80% of the routine radiological workload. The increasing availability of digital detectors has led to the continual replacement of conventional film/screen systems. The inclusion of digital mammography was delayed due to the higher requirements for spatial resolution. For about 2 years, dynamic flat panel detectors have started to replace the image intensifier which has been used in fluoroscopy for 40 years.

Image quality and dose management in digital radiography: a new paradigm for optimisation.

The advent of digital imaging in radiology, combined with the explosive growth of technology, has dramatically improved imaging techniques. This has led to the expansion of diagnostic capabilities, both in terms of the number of procedures and their scope. Throughout the world, film/screen radiography systems are being rapidly replaced with digital systems. Many progressive medical institutions have acquired, or are considering the purchase of computed radiography systems with storage phosphor plates or direct digital radiography systems with flat panel detectors. However, unknown to some users, these devices offer a new paradigm of opportunity and challenges. Images can be obtained at a lower dose owing to the higher detective quantum efficiency (DQE). These fundamental differences in comparison to conventional film/screens necessitate the development of new strategies for dose and quality optimizations. A set of referral criteria based upon three dose levels is proposed.

Relevant training issues for introduction of digital radiology: results of a survey.

Council Directive 97/43/Euratom establishes the need for adequate training of radiology staff. The transition to digital radiology implies changes in various imaging aspects, which are not sufficiently covered by current institutional training programmes. This work aimed to assess how professionals, experienced in digital imaging, acquired their expertise and hence, what form institutional training should take. Within DIMOND III, a survey on training and resources was performed among radiology professionals. A lack of institutional education for digital radiology was found. In the transition to digital radiology, 30-35% train on the job and another 23-28% receive training from digital equipment vendors. A general agreement exists on the need for new quality criteria and strategies for dose management. Issues relevant for conventional/digital transition are only sparsely covered in EC training programmes. Based on these results, a set of training issues was produced, to be included in future European guidelines.

[High resolution contrast-enhanced 3D MR-angiography of renal arteries using parallel imaging (SENSE)]. / Hochauflösende Kontrastmittel-gestützte 3D-MR-Angiographie (MRA) der Nierenarterien mit paralleler Bildgebung (SENSE).

PURPOSE: To compare three dimensional contrast enhanced MR angiography with parallel imaging technique (sensitivity encoding) to standard MR angiography technique. MATERIAL AND METHODS: CE-3D MRA of renal arteries was performed in 22 patients (23 examinations) on a 1.5 T MR- scanner (Gyroscan Intera, Philips, Netherlands). For contrast enhanced MRA a single dose of Gd-DTPA (0.1 mmol/kg b.w.) was administered. Group I: The following standard 3D gradient echo (GE) sequence was performed in 9 of the 22 patients: TR: 4.3 ms, TE: 1.5 ms, flip angle: 40, 40 slices, scan duration: 19 seconds. A spatial resolution of 1.96 x 1.76 x 3.0 mm (3) (1.76 x 1.76 x 1.5 mm (3) interpolated) was obtained. Group II: 14 examinations were acquired in 13 patients: TR, TE and flip angle were equal compared to the first protocol. The k-space lines were acquired with CENTRA (contrast-enhanced time robust angiography) and parallel imaging technique (SENSE). 60 slices were acquired, scan duration was 24 seconds. The spatial resolution of this sequence was 1.19 x 1.08 x 2.0 mm (3) (0,84 x 0,84 x 1,0 mm (3) interpolated). Original images and calculated maximum intensity projection (MIP) images were analysed by two radiologists. Image quality and the visibility of renal arteries were rated on a four-point scale. RESULTS: In the first group the image quality was rated "good" in 8/9 patients. The renal arteries were detected in all cases and rated "good". The anterior and posterior segments were rated "good" in only 5/9 and the lobar arteries were detectable only in 3 of 9 cases. The interlobar arteries could not be seen in these patients. In the second group the image quality was rated excellent in 5 examinations and good in 9 of 14 examinations. The rating for the renal arteries was excellent in all examinations (14/14). The results of the anterior and posterior segment were as followed: excellent 5/14, good 7/14, insufficient 2/14; the lobar arteries: good 6/14, insufficient 6/14 and not detectable 2/14. Interlobar arteries could be seen in 7/14 examinations, but the quality was insufficient. In 7/14 the interlobar arteries could not be detected. CONCLUSION: The use of parallel imaging technique improves image quality and the delineation of small vessels in renal MRA.

Is a combination of Tc-SPECT or perfusion weighted magnetic resonance imaging with spinal tap test helpful in the diagnosis of normal pressure hydrocephalus?

OBJECTIVE: The aim of this study was to evaluate the combination of spinal tap test (STT) with cerebral perfusion measurement assessed either by Tc-bicisate-SPECT (Tc-SPECT) or perfusion weighted MRI (pwMRI), or both, for a better preoperative selection of promising candidates for shunt operations in suspected idiopathic normal pressure hydrocephalus. METHODS: 27 consecutive patients were examined with a standard clinical protocol (assessed by the Homburg Hydrocephalus Scale (HHS)) as well as with 99m Tc-bicisate-SPECT (n=27) or additionally by pwMRI (n=12) before and after STT. The results of these examinations were compared preoperatively for each patient and correlated with postoperative clinical outcome after shunt surgery. RESULTS: Nine patients showed both, a clinical improvement, and increased cerebral perfusion after STT. They underwent shunt surgery with good to excellent results. In another nine patients increasing cerebral perfusion was detected although they did not show a clear clinical improvement after STT. Six of them also received a shunt operation with good to excellent outcome. Three patients of the last group could have an operation. Nine patients did not show any clinical improvement or any kind of increasing cerebral perfusion after STT. Therefore, they did not undergo surgery. The results of SPECT and pwMRI correlated in 92 % of the patients (11 of 12). CONCLUSION: It is concluded that a combination of clinical assessment with SPECT or pwMRI is helpful in the preoperative selection of patients for shunting procedures with suspected NPH syndrome. This combination is a minimal invasive and objective test modality that is superior to STT alone. Further studies are necessary for a comparison of the described imaging techniques with different diagnostic tests in this difficult field of cerebral disease.

[Image quality and exposure dose in digital projection radiography]. / Bildqualität und Dosis in der Digitalen Projektionsradiographie.

PURPOSE: Comparison of the imaging capabilities of storage phosphor (computed) radiography and flat plate radiography with conventional film-screen radiography to find new strategies for quality and dose management, i. e., optimizing imaging quality and dose depending on the imaging method and clinical situation. MATERIALS AND METHODS: Images of a CDRAD-phantom, hand-phantom, abdomen-phantom and chest-phantom obtained with different exposure voltages (50 kV, 73 kV, 109 kV) and different speeds (200, 400, 800, 1600) were processed with various digital systems (flat plate detector: Digital Diagnost [Philips]; storage phosphors: ADC-70 [Agfa], ADC-Solo [Agfa], FCR XG 1 [Fuji]) and a conventional film-screen system (HT100G/ Ortho Regular [Agfa]). RESULTS: The evaluation of CDRAD images found the flat plate detector system to have the highest contrast detectability for all dose levels, followed by the FCR XG 1, ADC-Solo and ADC-70 systems. Comparison of the organ-phantom images found the flat plate detector system to be equal to film-screen radiography and especially to storage phosphor systems even for low exposure doses. CONCLUSIONS: Flat plate radiography systems demonstrate the highest potential for high image quality when reducing the exposure dose. Depending on the system generation, the storage phosphor systems also show an improved image quality, but the possibility of a dose reduction is limited in comparison with the flat plate detector system.

[Influence of tandem optics and television tube of modern digital fluoroscopy equipment on image quality]. / Einfluss von Tandemoptik und Fernsehaufnahmeröhre moderner Durchleuchtungsanlagen auf die Bildqualität.

The influence of the tandem optics and the TV-tube to the image quality of 1k- and 2k-radiographs of a modern fluoroscopy equipment should be assessed on the basis of objective parameters and clinical requirements. Radiographs of different phantoms with 1k- and 2k-image matrix, different illumination point corrections (IPC) and signal gray levels were taken, examined and evaluated, in order to determine the objective image parameters and the clinical relevancy of these parameters. On the one hand, the digital images data could be used directly for evaluation; on the other hand, the radiographs could be visually evaluated by experienced radiologists within the framework of a blind study. The IPC is controlled by the aperture of the iris diaphragm and the insertion of a neutral gray filter in the tandem optics. The larger the aperture of the iris diaphragm (at constant image receiver dose) the higher were gradation, signal to noise ratio (SNR) and image homogeneity. Furthermore, the larger the aperture, the lower was the square wave response function (SWRF). The insertion of a gray filter in the tandem optics decreases gradation, SNR and homogeneity, and improves the SWRF.

[MR angiography of pelvic and leg vessels with automatic table movement technique ("Mobi-Trak")--clinical experience with 450 studies]. / MR-Angiographie der Becken-Beingefässe mit automatischer Tischverschiebung ("MobiTrak")--Klinische Erfahrung mit 450 Untersuchungen.

PURPOSE: By a retrospective clinical evaluation of 450 MR angiograms of the lower extremity arteries the question was posed of whether MR angiography can replace i.a. DSA. MATERIAL AND METHODS: Image quality of 450 MR angiograms was graded by 4 radiologists; in 102 patients who underwent radiological intervention a comparison between MR angiogram and i.a. DSA was done. Additionally, MR angiography was compared with the results of surgical intervention in 106 cases. RESULTS: 6% of 450 examinations showed a significant limitation of diagnostic information. 5 examinations (1%) had to be redone by i.a. DSA. In all cases the diagnosis from MRA was proven by the results of the following i.a. DSA or surgical procedure. CONCLUSION: The retrospective clinical evaluation of 450 examinations demonstrated that MR angiography of the lower extremity arteries can replace i.a. DSA in routine use.

[Examination of the image quality from digital fluoroscopy equipment with 1k- and 2k-image matrix]. / Untersuchungen zur Bildqualität von Durchleuchtungsanlagen mit 1k- und 2k-Bildmatrix.

PURPOSE: The image quality of 1k- and 2k-radiographs from digital fluoroscopy equipments (Sireskop SX and Polystar SX--Siemens) are characterized by comparison with each other to evaluate the relevance of this technique in clinical routine. MATERIAL AND METHODS: We examined fabricated and evaluated images with 1k- and 2k-image matrix from several high and low contrast phantoms and from skeleton phantoms. On the one hand, the digital image values can be used directly for the evaluation, on the other hand the comparing evaluation by experienced radiologists resulted from a visual consideration in a blind study. RESULTS: The quality difference of the 1k- and 2k-images depends mainly on the distance of the investigated sector of the object to the image intensifier and on the scattering of the radiation in the object positioned between the investigated sector and the image intensifier. The nearer the investigated object is located to the intensifier and the smaller the radiation is scattered in the object, the more the image quality of a radiograph with a 2k-matrix is increasing in comparison to an image with 1k-matrix. The higher the tube voltage, the smaller are the differences. CONCLUSION: The image quality enhancement because of the more sensitive sampling of the Saticon target in the 2k-matrix is limited by the opening of the iris positioned in the light distributor. Therefore the image quality differences of medical 1k- and 2k-radiographs in many cases are small.