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Clinical Observations |
1 Department of Radiology, Duke University Medical Center, Erwin Rd., Box 3808,
Durham, NC 27710.
2 Department of Radiology, Durham Veterans Administration Hospital, Durham, NC
27705.
3 Department of Medicine, Duke University Medical Center, Durham, NC
27710.
4 Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western
Australia.
Received March 24, 2005;
accepted after revision May 9, 2005.
Presented at the 2004 annual meeting of the Radiological Society of North
America, Chicago, IL.
Abstract
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CONCLUSION. Our results showed that well-trained certified technologists can perform ACBE similar in overall quality and accuracy to ACBE performed by attending physicians and residents. Training technologists to perform ACBE may help to alleviate the radiology staffing shortage in the United States.
Keywords: barium • colon • fluoroscopy • technologists
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We hypothesized that the quality of ACBEs performed by trained technologists is similar to that performed by attending staff and residents. The purpose of this study was to compare rate of detection of polyps and the quality of ACBEs performed by three groups of professionals in an academic institution: attending staff, radiology residents, and experienced gastrointestinal radiology technologists who had been trained to perform ACBEs. Our goal was to determine whether trained gastrointestinal technologists can perform satisfactory diagnostic ACBE similar to that performed by attending staff and radiology residents.
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Experience of Workers and Supervision of Residents and Technologists
All attending radiologists were board certified and had 1-30 years of
experience. The attending radiologists checked the quality of all ACBEs
performed to determine whether additional fluoroscopic images or radiographs
were needed. Radiographic or fluoroscopic evaluation was rarely repeated in
any of the three groups of subjects.
The radiology residents performed ACBE without direct in-room attending supervision. The attending radiologists reviewed the images at the end of the study. Ninety percent of the residents performing ACBE had undergone at least 4 months of fluoroscopy training and were in the fourth year of residency. The first-year residents on the fluoroscopy rotation rarely performed ACBE in this study.
The radiology technologists were trained for more than 1 year before initiation of the study. They had performed between 30 and 50 ACBEs after completion of training and before the trial began. Like the residents, the technologists performed ACBE without an attending physician in the room, and the attending physician reviewed the images before the patient left the fluoroscopy room.
Quality of Assessment
The attending radiologists interpreting each study evaluated the quality of
each ACBE on a scale of 0-4, 0 indicating excellent and 4, very poor. The five
criteria for quality assessment were feces in the lumen, feces on the mucosa,
distention, ability to assess for diverticula, and ability to assess for
polyps. This evaluation was performed for each colon segment: rectum, sigmoid,
descending, transverse, ascending, and cecum. There were therefore 30
measurements for each ACBE. The results of bowel preparation assessment were
compared among the three groups of ACBEs.
Procedure Times
The radiology technologist recorded the total procedure time for each
subject. Timing began when the patient entered the procedure room and ended
when ACBE was complete and the patient left the examination table and went to
the bathroom. Interpretation times were recorded on the case report forms by
the attending radiologists interpreting the studies.
Statistical Analysis
Sensitivity, specificity, positive predictive value, and negative
predictive value were computed and compared for all three groups performing
ACBE. Comparisons of sensitivity, specificity, positive predictive value, and
negative predictive value among the three groups were done with a chi-square
test with jackknife estimates of proportion variances. The patient was taken
to be the independent sampling observation for computation of the jackknife
estimates.
Quality of preparation, performance time, and interpretation time were compared by means of Student's t tests. A level of 0.05 was used for statistical significance. Bonferroni adjustment for multiple comparisons was applied for joint consideration of the five quality measures and comparisons among the three types of reviewers.
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The quality ratings of ACBE were similar for the three groups. There was no statistical difference in the five criteria or mean score for the three groups of studies. The mean scores ranged from 0.622 to 0.785. The quality rating for ability to detect polyps had the worst mean score with a range of 0.96-1.08 (Table 2).
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There were no significant differences in procedure times or interpretation times in comparisons of the three groups. However, the residents' subjects took more time (34.3 minutes) to complete ACBE than did those of attending physicians (29.5 minutes) and technologists (30.1 minutes) (Table 3).
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There was no difference in polyp detection among the three groups performing ACBE. In particular, studies performed by technologists had sensitivity similar to that of studies performed by residents and attending physicians. Our sensitivity of 43% for polyps 1 cm and larger was not substantially different from that in a prospective blinded investigation by Winawer et al. [16], who reported a detection rate of 48% for polyps 1 cm and larger. However, the sensitivity for detection of polyps was poorer than in other studies, not only for 6- to 9-mm polyps but also for polyps 1 cm and larger [17-22]. We suspect the differences in sensitivity relate to differences in patient selection and study design.
A limitation of this study was that the numbers of polyps found by each of the three groups performing ACBE was small. It is possible that if more polyps had been identified, differences among the three groups may have become significant. It was interesting that there was no major difference in total mean procedure times even though overall the residents took somewhat more time than the other two groups. We did not record the specific fluoroscopy times for each of the three groups, so we do not know whether there were differences in the amount of radiation used by each of the three groups performing ACBE.
Our gastrointestinal technologists were trained by one attending physician. The training consisted of two parts. The first part was observation of five to 10 barium swallows, double-contrast upper gastrointestinal studies, ACBE, and defecography. The attending physician then observed each of the three technologists performing five to 10 of each of the studies. In the second part of their training, the technologists attended 5-8 hours of lectures and read a number of articles on gastrointestinal fluoroscopy technique. The technologists also participated in revising the radiology resident manual for performing gastrointestinal radiology studies. In 2001, a didactic component was incorporated that consisted of 6 hours of lectures on gastrointestinal fluoroscopy technique and periodic meetings for review of the quality of the technologists' examinations and for discussion of problems. The initial training has been supplemented with periodic lectures and case study sessions.
In conclusion, although the sensitivity of ACBE in this study was lower than previously reported, the quality of ACBE performed by trained radiology technologists was similar to that of examinations performed by resident and attending physicians. There was no difference in sensitivity for polyp detection ABCE performed by technologists and ABCE performed by attending physicians and residents. Technologists trained in gastrointestinal fluoroscopy can help alleviate the staffing shortage in diagnostic radiology.
Acknowledgments
The authors thank David Delong for his statistical analysis of the
data.
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