the role of imaging in primary health care

7/31/2019 The Role of Imaging in Primary Health Care

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A CRITICAL EVALUATION


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*Provision of quality and safe health servicesthat meet the needs of the people through a

network of health facilities organized to

function on the basis of increasing levels of

sophistication.

*Each level of care is expected to provide a

package of well defined services provided by

appropriately trained health professionals.

Diploma Radiography (Diagnostic) - 2012


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*Mission clinics

*Rural health clinics

*Various organisation staff clinics

*Ante- natal and post- natal clinics

*Family planning clinics

*Others



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*Environmental Health technician

*Two nurses

*Community based distributor

*Midwives

*Village health workers



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*



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**There is about 50% staffing in all rural health clinics.

*Only less than 46% of rural households have access to a village health

worker.*Village health workers are no longer receiving supplies.

*Only fewer midwives available as a result of lack of trained professionalswho are supposed to train midwives (issues of brain-drain).

*The current staffing status of 2 nurses per clinic is no longer adequate due

to increased workload.

*Few Environmental Health Technicians with the vacancy rate reaching 50%.

*The 2007-2008 drastic economic decline rendered rural health clinicsdysfunctional thereby losing credibility in the social circles. This is stillcausing patients to by-pass them thereby impairing the referral system.-75%

of patients attended to by Central Hospitals are self referring.*Large distances that patients/ expectant mothers have to travel to reach

rural health clinics ( No transport or ambulances)

*Poor connectivity and communication systems.



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District Hospitals

Mission Hospitals that have been designated as

District Hospitals

Various missionary, private, and company

facilities may also provide the same emergencyand general health services as district hospitals.

(The government intends that each District

Hospital serve a catchment area of 140 000

people)


*


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*Nurses

* Doctors (this is the lowest level where patients can be treated

by doctors)

*For specialty health services, or more difficult health issues than

the district health staff can treat, district facilities may referpatients to the tertiary facilities.

*District hospitals are administered by a hospital and district

health committee.

*DHOs supervise the district hospitals, and in turn are supervisedby the PMD.



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SHC Facility No. of Facilities


*


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*Most District hospitals are facing challenges that involvedilapidation of infrastructure and lack of fund to revamp the

situation.

* Shortage of doctors and nurses (a result of brain drain).

*Shortages of pharmaceuticals.

* Shortage of equipment especially in the Imaging Department.

* Lack of technological advancement leading to generally slow

processes.

*Recent shortages of Anti-retroviral drugs.


*


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* This consists of 7 Provincial hospitals which are situated in

every Province with the exception of Harare and Bulawayo.

*Provincial hospitals receive referral patients from district

hospitals and tend to have specialists on staff to deal with

more difficult health issues. However, various unique and

difficult cases are referred to the six central hospitals thatreceive patients from all provinces of Zimbabwe.

*Tertiary care is also available at some private clinics/hospitals

located in Zimbabwes largest cities, though many of the

private clinics tend to be too expensive for most Zimbabweans.Health Personnel Involved

*Specialist Doctors.


*


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**Quaternary/central care consists of six central

hospitals in Bulawayo, Harare, and Chitungwiza.*There are currently 6 of these and they have the mostadvanced equipment, staff, and pharmaceuticals fordealing with the most severe cases.

*The central hospitals have the largest staff ofconsultant specialists and clinicians and act as thehighest level for health referrals.

*Central hospitals report directly to the MOHCW.Similar to tertiary care facilities, Zimbabweans withhigh incomes tend to forego quaternary care in favorof treatment outside of the country.


*


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Challenges* Disregard of the referral chain- despite this, and disappointingly, the

central hospitals are in most ways unable to cater for the needs of

these patients since the standard has also gone down.

*Brain drain of health professionals.



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The Role

ofImaging

in

Primary Health Care


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*Background & Statistics

Historically; of the myriad of global health care efforts, very fewinvolved radiologists or radiographers.

The role of diagnostic imaging in global health has been under-

represented, likely due to the perception that radiology requires

expensive imaging equipment, not available/accessible in

developing countries. However, as the gap between technology and production costs

closes, the role of radiology in global health work has grown.

Simple diagnostic X-ray installations have a valuable role to play

(orthopaedics, congenital and infectious diseases).

Modern technology, new modalities and diagnostic techniques

are making it more and more feasible and cheaper to produce

quality radiographs and other forms of diagnostic images.



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*Background Contd.

Statistics indicate that less than 1 third of the word populationhave accesses to diagnostic x-ray radiography, let alone othermodalities.

In Africa, the statistics indicate that there is 1 machine for morethan 50 000 people. As compared to developed countries (


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X-ray - 1895 (Wilhelm Conrad Roentgen)*First Chest X-Ray 1896 (F H Williams, Using AgBr coated plates)

*Collimator 1903 (E.A.O. Pasche)

*Gamma Rays - Baqurel

*Grid, Vacuum Hot-Cathode Tube

1913 (Gustav Bucky, William D.Coolidge)

*Tomography 1930-1931

*CT - 1972 (Godfrey N. Hounsfield)

*Improvements in X-ray (digital, fluoroscopy), CT. PET, Angiography(dual modalities, 3D reconstructions). DSR

*Developments in MRI, Ultra Sound

*Health Concerns: Radiation Protection


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* Imaging In Primary Health-Care

*Some clinical conditions in primary care are common and appear to

be easily diagnosed clinically requiring no more therapy than

reassurance and proprietary OTC medicines available in pharmacies.

*However, some conditions may be diagnosed or strongly suggested

clinically but require imaging to confirm the diagnosis and to assess

the extent of the changes.

*These are then treated appropriately and follow up examinations

may be required to confirm or assess the degree of resolution.

*Sometimes the primary care clinician may be treating a patient with

a confirmed diagnosis but resolution is slow or has failed and imaging

is required to exclude or define complications.*Finally, imaging may be undertaken for more complex cases that

require specialist referral but prior investigations is undertaken to

ensure that the referral is to the correct specialist and that the

consultation is productive.Diploma Radiography (Diagnostic) - 2012


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* Primary Health-Care Radiography*A primary care radiological facility involves a complete X-ray system that

will provide basic radiography at all public health centres and hospitals.

*This allows trauma conditions and pathologies to be diagnosed moreaccurately e.g. accurate diagnosis is made between simple pneumonia andtuberculosis, as compared to using a simple stethoscope.

* In some countries the access to diagnostic imaging services is limited tobasic conventional examinations.

* Ideally, the types of investigation available to primary care clinicians shouldbe based on relevance to the clinical problem and patient management andnot only on the cost or complexity of the imaging procedure.

*Developments in CT, MRI and US have resulted in these modalities also beingused extensively and should be essential services to be provided in PrimaryCare.

*There should obviously be competent radiology personnel and physiciansable to image and interpret the radiographs.

* If interpreting is done by junior doctors there is risk of adopting false-positive results in many cases. (Zimbabwe situation)


*


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*PathologiesOf the diversity of pathologies that are prevalent at primary level, the

majority can be diagnosed with radiological imaging.

However, because patients have limited access to health care, many

diseases are imaged in advanced stages.

A brief list of conditions that can be usefully examined by primary care

radiology are as follows:

*Trauma: All limbs fractures, spinal injuries, skull injuries, ribs

*Chest: Pneumonia and all acute lung infections

*Tuberculosis, Tuberculosis pericarditis and all chronic lung infections

*Pneumothorax (traumatic and spontaneous)

*Pleural effusions

*Effusions due to cardiac failure

*Lung infections (fungal, abscesses)

*Asthma and emphysema

*Carcinoma of the lung Diploma Radiography (Diagnostic) - 2012


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*Pathologies Contd.Abdomen

*Acute obstruction,

*Renal or bladder infections and calcifications

*Liver abscess

*Splenic abscesses

*Chronic pancreatitis, calcification

Other

*Congenital

*Arthritis

*Dietary deficiency (e.g. rickets)



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*Diagnostic Yield

*The diagnostic yield of radiographic imaging depends much on thepathological/medical condition of the patient and the modality used.

*Plain film X-ray images are very useful and economic in many

skeletal conditions (especially trauma)

*Other symptomatic conditions (chest, abdomen) can be assessedfairly effectively with plain film radiography.

*However, many conditions require core complex and more expensive

modalities in order to come up with accurate diagnosis.

*For example, research has revealed that routine chest radiographyhas low diagnostic yield in asymptomatic primary care patients.



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*Diagnostic Yield Contd.

*Nevertheless, chest radiology is one of the most widely useddiagnostic imaging techniques.

*It has been reported to change patient management by the GP in 60%

of patients.

*This has substantially reduced the number of referrals and initiatedor changed therapy.

*It has also been shown to be cost effective.

*Joint disease is also an important reason for consultation in primary

health practice.

*Although clinical history and examination can assist in the diagnosis

of osteoarthritis radiographic demonstration may be required and

the x-ray features have been shown to affect management regardless

of the clinical picture.



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* Screening, Invasive Procedures & New Technologies

*Radiological imaging has made it possible for certain conditions to be

to be assessed more comprehensively and with much accuracy andcertainty e.g. alimentary canal (barium contrast procedures),tumour development, size etc.

*Fluoroscopy has also made it possible for many sensitive surgicaloperations to be done more efficiently with improved outcomes.

*It has played a key role in orthopaedic insertion, removal andmonitoring of intramedullary rods, plates, screws, fistula, foreignbodies.

*Likewise, Ultra Sound has played a critical role in obstetrics.

*Some conditions managed by primary care physicians are acute andrequire rapid investigation.

*The technological advances in radiological imaging (mobileradiography, digital radiography etc.) has allowed timelyintervention in such scenarios.



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*Medical Imaging In Zimbabwe

Trends and current status

*The public health sector has a well established medical imagingsystem that is available in all district, provincial and central

hospitals.

*However, most of the equipment is either obsolete or non-functional

due to the shortage of spare parts.

*Because of the need for specialist services, most facilities are

centralized in Harare and Bulawayo. (MRI, CT, PET etc.)

*Government has increased training of imaging professionals at

Parirenyatwa, UZ and NUST.

*X-ray operators were also trained in provincial hospitals.

*However, the public health sector has no single radiologist since

these are trained outside the country.



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*Trends & Current Status Contd.

*Due to the shortage of radiologist in the healthcare system, most ofthe interpretation of radiographic images is being done by junior

doctors and this is negatively impacting on outcomes.

*On-going research on the red-dot system is being done (to assist

doctors in interpreting radiographs)

*In line with their objective to strengthen imaging services, the

government has also made commitments to scale up training and

retention of radiology staff and specialists

*They also look forward to revamp the facilities in BYO, Harare,

provincial and districts hospitals.


*R f


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*References:

*Madzorera H Dr. 2009: The National Health Strategy for Zimbabwe.Ministry of Health & Child Welfare. Harare

*Palmer P, 1978: Radiology and Primary Care. WHO. New York

*Tigges S, Roberts DL, Vydareny KH, Schulman DA. 2004: Routine chestradiography in a primary care setting. National Library of MedicineNational Institutes of Health. Atlanta


the role of imaging in primary health care

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