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A presentation at the recent Irish Cardiac Society (ICS) Annual Scientific Meeting and AGM provided a thought-provoking overview of the provision of cardiac imaging in Ireland and how this aspect of care faces multiple deficits.
Dr Caroline Daly, Cardiologist at St James’s Hospital, Dublin, told attendees that there is an “unmet need” in this field, in particular ECHO, cardiac CT and cardiac MRI, where there are “the greatest gaps in our service that we need to fill,” Dr Daly told the conference.
“We need to look at what is required in providing these services, such as the equipment — part of the problem is the initial installation cost; ECHO is obviously relatively cheap compared to CT or cardiac MRI, but nonetheless it requires a robust system of image storage, analysis and reporting software, which needs to be updated and maintained as time goes on,” said Dr Daly.
“We must also consider that the digital storage management systems involved in having a comprehensive solution for your cardiac imaging needs are costly. Furthermore, you need technical staff, and that is perhaps an issue that we are really grappling with at the moment in terms of sonographers and specialist radiographers — certainly in Dublin, it has been apparent that a relatively limited number of graduates from Kevin Street [Dublin Institute of Technology] over the last number of years have chosen cardiology as their subspecialist area of interest; they have perhaps chosen respiratory clinical measurement or urology, and that has made it difficult to create a new ‘pool’ of sonographers providing ECHO services,” according to Dr Daly.
She said that last year, some cardiac units “almost ground to a halt” because of the limited number of radiographers and the delays in having trained radiographers accredited with their respective professional bodies. “And that’s before we even get to the issue of cardiologists and the radiologists, and how they communicate with each other,” she added.
Dr Daly referred to the lack of data to accurately assess the specific gaps in ECHO services, despite the best efforts of the Irish Heart Foundation and ICS. However, she cited services in the UK as providing the best statements on what the optimal service should be.
Dr Daly told the attendees that based on a 1995 report, it was estimated that between 42,000-to-47,000 transgraphic ECHOs were required per million population in Ireland per annum, and around 2,000 per million population of transesophageal echocardiograms were required.
“With some ‘back-of-an-envelope’ calculations, I would say we are doing between — generously — one-half, and less generously one-tenth, of those numbers per million population,” Dr Daly told the attendees. “In terms of staffing levels, that report suggested we should have about 30 stenographers per million population; we certainly don’t have that in Ireland, even if you combine public and private sectors. Consultants specialising in ECHO — 10-to-13 per million population [was recommended]; again, we are nowhere near that.”
She pointed to the paradox that waiting times are actually higher in regions where there are more sonographers and higher throughputs, which reflects the differences in unmet demand.
“So you won’t have a waiting list if the referrers don’t know what the service is or what they can expect to have from it,” she said. “So paradoxically, there is such an unmet demand for ECHO in places that are under-served, if you put more ECHO technicians in and put a service in place, you will actually initially have longer waiting lists until that backlog has been dealt with.”
Other factors that influence capacity and utilisation are demographics and appropriateness of referral, she added.
At the moment, there is an ongoing national review of specialist cardiac services in Ireland, which is focusing on acute cardiac syndromes, heart failure and cardiac arrhythmias, and “it is important that we include our imaging requirements [in the review] that pertain to all of these three,” said Dr Daly. “Imaging affects all of those, be it for structural heart disease, preparation for valve implantation, dealing with rare diseases, or cardiac risk in the young, so we really need to make the case strongly to that specialist review.”
The lack of services is probably greatest in CT and MRI, she said, and Dr Daly cited NIMIS as a source of data. “There are very small numbers there; obviously, that doesn’t include the private hospitals or certain centres… but the numbers are very small
[in most of the NIMIS hospitals]
,” said Dr Daly, who also referred to NICE guidelines in 2016 that emphasised the need for cardiac CT and angiography as an initial test required for chest pain.
The SCOT-HEART study published this year also showed that early use of CT is useful in preventing myocardial infarctions by instituting earlier treatment. This leaves Ireland with “a great challenge ahead of us in providing this level of service for patients, but the data is there to show it is beneficial,” said Dr Daly.
“In Ireland, we have no dedicated cardiac MRIs in the public sector,” continued Dr Daly. “That excludes St Vincent’s and Cork, where they do have a cardiac MRI service, but the numbers in need of those services are so large that it would skew the data… we are saved slightly, in that there are active centres in the private sector and if possible, we can purchase on order a number of cardiac MRI for public patients… we have increased our numbers in St James’s Hospital but those numbers pale in comparison to what you would have if there was a dedicated magnet just doing only cardiac MRI, so we are always on the back-foot.”
Dr Daly concluded: “This is a very sobering overview of where we are with cardiac MRI services… our numbers need to be developed — and rapidly.”