Technology for the continuous improvement of the quality of health care.

Since medical technology impinges on the structure, process and outcome of health care it has a profound effect on attempts to achieve improvement in this field. The present article discusses the links between medical technology and continuous quality development, with particular reference to utilization, appropriateness and cost-benefit.

Benefits of coordinated action in PACS evaluation.

PACS, a health care technology still in its developmental stage, aims to improve the management of diagnostic imaging investigations. As the technology has not been comprehensively assessed, data and facts to justify its clinical, economic and other benefits are to date insufficient. Through internationally coordinated action, it is expected to obtain a faster and more comprehensive technology assessment of PACS as well as recommendations for optimization of the system and guidelines for its rational use in various health care environments.

Big ticket health technology: is rational utilization possible?

Medical technologies that have high initial and operating costs are commonly labeled 'Big Ticket Technologies'. However, technologies with lower initial and operating costs, but which are utilized extensively in patient care, should be considered Big Ticket as well. Some of these technologies are product innovations, because they represent a new product or service. Others are process innovations because they provide an alternative way of delivering health care. Radiology and radiation oncology offer many examples of Big Ticket technologies in medicine, including CT scanners, MRI units and linear accelerators. Other examples include extracorporeal shock wave lithotripsy and resuscitation and intensive care technologies. Differences in the availability of these technologies in various countries reflects financial incentives and disincentives at work in the countries, expectation levels for health care in the countries, and the degree to which the diffusion and use of medical technologies are regulated. Evidence of the cost-effectiveness of medical technologies, and the impact of their use on health outcomes, is rapidly being added as an additional criterion for evaluation of the usefulness of medical technologies in health care.

Diagnostic imaging in small hospitals.

Diagnostic imaging in small hospitals is discussed. Four key questions are answered: (1) Are diagnostic imaging technologies necessary at this level? (2) Which technologies should be chosen and why? (3) How can they be most rationally and cost effectively used? (4) How can their total impact on health care be assessed? The paper concludes that small hospitals should have diagnostic imaging facilities and that the modalities of choice are diagnostic radiology and ultrasonography. A detailed description is given of the WHO Basic Radiological System and General Purpose Ultrasonographic equipment together with WHO recommendations for the rational use of diagnostic imaging.

[International survey of the status of dosimetry for controlling quality assurance in radiotherapy (WHO)]. / Mezhdunarodnoe issledovanie sostoianiia dozimetrii dlia kontrolia garantii kachestva luchevoi terapii (VOZ).

The results of an IAEA/WHO 14-year survey on the precision of irradiation at a preset dose (2 Gy) in radiotherapy departments in different countries have shown that nearly in 40% of cases deviations from a preset dose exceeded the tolerant rate (+/- 5%). A conclusion has been made of the necessity to develop a program of quality guarantee in radiotherapy at national and international levels.

Use of radiographic projections of knee.

A study to determine the routine radiography practice for the investigation of acute trauma cases and those with suspected arthritis of the knee was carried out by questionnaires sent to radiologists in 41 countries. The role of radiology in the investigation of chondromalacia patellae was also ascertained. Some of the reasons for the diversities of practice are discussed. The necessity for further views of the knee to supplement the two standard projections was assessed for various diagnostic entities. It became clear that if occult fractures were not to be missed, patients with knee effusions following acute trauma required additional views if a lesion was not shown by the anteroposterior (AP) and lateral views. In contrast, two views of the knee sufficed for examination of most entities affecting the knee.

World health organisation inter-laboratory comparison study in 12 countries on quality performance of nuclear medicine imaging devices.

Twelve countries participated in the WHO intercomparison for which transmission CAP (College of American Pathologists) brain and CAP liver phantoms and emission London liver phantoms were used. A total of 157 imaging devices were tested. Overall results from the phantoms revealed a wide range of targets detected. For the CAP-phantoms target detectability dropped below 50% for target sizes less than 9 mm and below 60% for target contrast less than 0.84:1. On average one false positive and six false negative results were reported using CAP-brain phantoms and one false positive and one false negative result using CAP-liver phantoms. For the London liver phantoms containing the tissue equivalent rubber abdominal simulation the target of 1 cm was never visualised. Two targets in this phantom (2 cm and 2.5 cm) were correctly identified in 34% of studies and one of these targets in 52% of studies. Equivocal and false positive results were reported in 42%. The WHO inter-comparison demonstrated the need to establish new, or to improve the existing, quality control programmes.

Radiological services throughout the world.

WHO's statistics show the doctor-to-population ratio in the Third World to have changed very little over the past decade, with radiological services among the least developed medical branches of a developing country's health care system. Data is presented on population/machine/personnel ratios, morbidity patterns, number of X-ray examinations per population and films taken, percentage of wasted film, and breakdown of types of procedures. Data collected from 89 countries show that of a total population of 1.2 billion, only 220 million have access to adequate diagnostic X-ray services. A well-structured diagnostic X-ray service at the country level should form a pyramid consisting of three levels of sophistication: (1) Basic Radiological Service (BRS), the broad base of the pyramid and available to the mass of the population requiring uncomplicated radiographic examinations; (2) General Purpose Radiological Service (GPRS), at the intermediate level, functioning as a backup service for the BRS facility and a filter station for the sophisticated department at the top; (3) Specialized Radiological Service (SRS), performing specialized radiodiagnostic procedures, and undertaking research and training. This pyramid structure does not at present exist in the majority of countries. Adequate coverage of the population cannot be achieved unless X-ray facilities are made available in places near to where the majority of the population live. The BRS comprises a technical concept and teaching/learning programme representing a solution to the present unsatisfactory situation.