Radiographic image interpretation by Australian radiographers: a systematic review

Introduction

The initial evaluation of plain radiographic images for potential abnormalities by radiographers has been accepted practice in the United Kingdom (UK) since the early 1980s.1, 2 In an attempt to reduce diagnostic errors in the emergency department, Berman et al.1 proposed a system by which radiographers affixed a red sticker to plain X‐ray films they believed to be abnormal. The red sticker acted as a visual cue, alerting the referrer to a potential abnormality. This simple yet effective procedure was known as the ‘red dot system’.1 The red dot system, more recently known as a ‘Radiographer Abnormality Detection System’ (RADS)3, provided a time‐efficient overlap between emergency referrers and radiographers when assessing a plain radiographic image. The lack of written documentation as to what the radiographer was flagging is a notable communication flaw with the RADS.4 To address this limitation, RADS in the UK evolved to include a brief comment accompanying an examination, describing the flagged abnormality(ies). The brief accompanying remarks, known as the ‘radiographer comment’, were officially termed the preliminary clinical evaluation (PCE) in the UK.5, 6 The role of the medical imaging professional in the United Kingdom has expanded into more advanced roles; in some cases, appropriately trained radiographers perform independent diagnostic reporting.7 The support of the Society and College of Radiographers and the Royal College of Radiologists, along with low radiologist‐to‐population ratios and intensive university‐based postgraduate radiographer training courses, has allowed this role expansion to occur in the UK.7, 8, 9 Despite the advances in radiographer image interpretation in the UK, the role of the radiographer in image evaluation within Australia has remained comparably inactive. General radiographic image interpretation by radiographers in Australia has not progressed much past the initial discussion surrounding the ‘red dot system’.10 Due to this, radiographer reporting in Australia is not a consideration at this current time, nor is it explored in this review.

Widespread implementation of radiographic image evaluation systems such as RADS is yet to be fully realised in practice. However, the Medical Radiation Practice Board of Australia (MRPBA) stipulates Australian radiographers must communicate significant clinical findings to the appropriate clinicians most preferably via a departmental protocol or instruction that standardises verbal or written communication with associated record keeping.11 The Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) is currently developing a process to examine and certify radiographers to engage in radiographic image evaluation with a written component known as a preliminary image evaluation (PIE).12 A PIE is a brief written description that acts in the same way as a ‘radiographer comment’ or PCE in that it clearly communicates significant clinical findings to the referring clinician in the absence of a definitive radiologist report.13 It should be noted that the PIE is not a substitute for the radiologist report; it provides a timely communication of the presence of a potential abnormality to the referrer in order to support patient treatment decisions when the radiologist report is unavailable. Emergency doctors, nurse practitioners and physiotherapists also play an active role in interpreting medical images in Australia.14, 15, 16 The present review focuses on radiographer image interpretation, rather than other healthcare professionals who interpret medical images, which is beyond the scope of this review.

Throughout this systematic review, the phrases ‘radiographic image interpretation’ and ‘radiographic image evaluation by radiographers’ pertain to abnormality detection systems such as RADS and commenting protocols such as PIE; they do not refer to, nor imply radiographer reporting. Image interpretation by radiographers is an internationally explored subject with inconstant definitions. Each term corresponds to a distinctive clinical practice, and to assist the reader in avoiding misinterpretation, the commonly used terms within the literature are defined in Table 1.

Research has shown that in the absence of a radiologist report, the implementation of radiographer image evaluation systems improves clinical decision‐making in emergency departments.1, 17 However, despite the MRPBA's expectation of radiographers (first published in 201311) to communicate clinically significant findings, progress has been slow. Importantly, there is a lack of understanding of the enablers and barriers to radiographer image evaluation in Australia. This review examines the literature on image evaluation by Australian radiographers, including the barriers to radiographer image evaluation systems. It aims to inform and assist the future implementation of such systems in Australia.

Methodology

Results

The search strategy produced 926 articles. After the removal of duplicates, 689 articles were screened for eligibility. Following the screening of the abstracts and titles of these 689 articles against the inclusion/exclusion criteria, 660 were further excluded. The full texts of the remaining 29 articles were then examined, and 19 studies published between 1997 and 2019 were deemed eligible for inclusion in the review. Figure 1 demonstrates a flow chart of the search strategy and the number of articles identified.

Discussion

Over the past 21 years, many attempts have been made to (1) measure the ability of radiographers to undertake general radiograph evaluation or participate in commenting systems such as RADS and PIE and (2) explore the enablers and barriers to the implementation of these systems. Evidence from the literature reveals that radiographers display varying levels of ability to detect and describe radiographic abnormalities with performance metrics ranging from poor to excellent.19, 20, 21, 22, 23, 25, 26, 27, 33, 35 This variation is in part due to methodological differences between studies. Therefore, caution is advised when interpreting the performance results as a whole. Although the performance metrics observed for this cohort of radiographers varied considerably, one finding remained consistent: targeted radiographic image interpretation education, whether that be through self‐guided modules, or within a structured classroom environment, improves radiographers’ capacity to undertake radiographic image evaluation.23, 25, 27, 35, 36

Sixty per cent of the studies reviewed explored radiographer image interpretation performance. These studies can be further divided into two subsets of investigations: the baseline performance of radiographers’ ability to interpret radiographs19, 20, 21, 26, 33 and the effectiveness of image interpretation education.22, 23, 25, 27, 34, 35, 36 A prominent element in this review was the variation in study design, in both quality and methodology. When designing image interpretation studies, it is important to consider appropriate design of image bank contents, development and testing, as well as development of a reference standard to ensure a reliable and valid result. When testing image interpretation ability, it is essential to employ an image bank that reflects both the typical injury prevalence and the proportion of anatomy examined in the clinical setting to mitigate biases that may limit the relevance of their findings.37, 38, 39

Radiographers’ ability to describe findings in radiographs without educational intervention, known as a ‘baseline,’ is one such metric researchers can use when exploring improvement methods. The significance of such studies cannot be overstated, and the methodological approach must be accounted for when drawing conclusions from these studies. Five of the studies reviewed19, 20, 21, 26, 33 established a baseline performance metric. Four of these five studies19, 20, 21, 26 had a methodological flaw regarding participant image selection bias, whereby participants could abstain from interpreting images if they felt it was not necessary (obvious pathology or challenging cases). In practice, this can lead to radiographer non‐participation in cases considered ‘too difficult’ or ‘too easy’, resulting in a non‐reliable metric when reporting on radiographic image interpretation performance. The remaining performance study,33 which did not employ an interventional component when comparing the image interpretation ability of medical students to that of radiographers, made a considerable effort to overcome the bias detailed above.19, 20, 21, 26 The 201733 study demonstrated the potential for radiographers to aid junior doctors in radiographic image interpretation and the benefit this may have in clinical practice.

A theme identified from the literature was determining the appropriate format of an educational intervention and the effectiveness of said format on radiographers’ ability to interpret radiographs. The quality of performance studies examining the effect of education varied. Six studies explored the effect of an intervention on radiographers’ ability to interpret radiographs,22, 23, 25, 27, 35, 36 whilst one study was dedicated entirely to creating a valid and reliable test bank.34 Although the experience levels within the radiography workforce are inherently inconsistent, education was not a heavily considered variable. It would be of benefit to assess radiographers at entry to the workforce to better reflect the entry standard of the profession. It was therefore difficult to extrapolate the outcomes of studies that included radiographers with postgraduate image interpretation education to the greater Australian healthcare setting, a notable shortcoming observed in two studies.22, 25 Education alone, regardless of the method or format, improved radiographers’ ability to describe radiographic findings,23, 25, 27, 35, 36 with performance similar to that of emergency doctors.27 However, it is important to employ educational interventions that improve radiographers’ ability to retain radiographic image interpretation ability.35, 36 These interventions need to improve radiographers’ baseline ability not only in the short term but provide skill sets needed for continuous practice.35 The single randomised control trial reviewed36 showed that the performance of radiographers to interpret radiographs was far better after a condensed programme of education compared to multiple sessions over a number of weeks. The development of the reliable and valid test bank34 utilised in this randomised control trial created an opportunity to examine radiographers’ performance via a standardised approach.36 The results of the randomised control trial alone suggest departments should opt for condensed education programmes to improve image interpretation, whilst the issues of skill retention could be further measured and addressed using a validated radiographic image bank, completed at regular intervals. This could be incorporated as part of an annual skills competency.

The quality of the literature exploring the performance of radiographers in detecting and describing radiographic findings is notably higher in more recent publications. The only studies that scored the maximum mark of 15 following the critical appraisal were published between 2017 and 2019.33, 34, 36 Performance studies following 2012,25, 27, 33, 34, 35, 36 with the exception of the lowest scoring article reviewed (3/15),26 were meticulous not only in addressing bias, but in ensuring results were reliable and valid. Although studies preceding 2012 have their merits, caution is advised when citing them for the rationalisation for or against radiographic image evaluation by radiographers in Australia, due to their methodological limitations.

Exploring potential barriers when implementing a new clinical initiative is imperative,40 yet the barriers and enablers of systems such as PIE have been sparsely explored within Australia over the last 20 years. The common barriers to development of radiographer image evaluation were a perception of a lack of education and both radiographer and radiology perception and support.3, 24, 28, 29, 30, 31, 32 Education acts as both a barrier and an enabler, suggesting the development of systems such as PIE hinge on addressing access to education at a national level. Tailored training and educational interventions, in line with the current literature,36 and provision of relevant continuous professional development (CPD) resources to better assist radiographers maintain performance, are required. The use of Internet‐based learning tools similar to the eLearning systems in the UK41 may be worthy of consideration.

The literature also suggests that the identified barrier around lack of radiologist and fellow radiographer support may stem from the inconsistent use of terminology for radiographer image interpretation in the literature. Such terminological inconsistencies could have raised concern amongst radiologists in terms of radiographers providing a diagnostic report. The definition used in the early research is cloudy, particularly regarding the terms ‘reporting’ and ‘commenting’. The language used in the Cook et al. workplace trial of radiographer reporting22 suggested radiographers were providing a diagnostic report in the ‘trial’ setting; however, the experimental design is that of a second ‘radiological impression’ compared to the radiologist report. The use of the term reporting as an interchangeable term to commenting is also evident in another study where informal, verbal comments are referred to as ‘verbal plain film reporting’.24 These findings suggest that a universal term that clearly defines the accurate meaning of radiographer commenting be adopted. A recent paper ‘describing the strategies that Australian rural radiographers use for communication of their radiographic opinion to the referring doctor’ provides a better context of radiographic image interpretation,32 whereby a comment is notably different to a diagnostic report (a role held exclusively by radiologists in Australia). In 2018, the Royal Australian and New Zealand College of Radiologists (RANZCR) issued a position statement titled ‘Image Interpretation by Radiographers – Not the Right Solution’, 42 formally opposing the implementation of radiographer image evaluation systems such as PIE in any such setting within Australia. This opposition may have been influenced by employing an inadequate search strategy that may have utilised the inconsistencies in terminology observed in the texts. Interestingly, the position statement did not make reference to, or explore any of the 19 studies covered in this review. Drawing from opinion pieces and studies conducted overseas, the statement demonstrates an ill‐informed understanding of the terms utilised in the research and the purpose of PIE.

It is likely that the interprofessional barrier could be overcome with a less aggressive tone in conjunction with a clear, universal definition of ‘radiographer commenting’/ PIE. Furthermore, future studies should aim to assess the performance of a PIE system in clinical practice. Results of these types of studies may alleviate the concerns held by the RANZCR.

Two studies31, 32 reported that radiographers have concerns regarding the potential medico‐legal ramifications of radiographer image evaluation system such as the PIE. However, it is noteworthy to consider that medical litigation may arise in all steps of the medical imaging pathway, from poor‐quality imaging to an inaccurate communication of findings.43, 44 For example, two recent coroners’ findings45, 46 found radiographers could have played a more active role in the medical imaging team by communicating the findings to the referring clinician, potentially avoiding the deaths of two patients. The MRPBA ‘professional capabilities for medical radiation practice’11 statement clearly states that radiographers must convey information to the referrer when an unexpected or urgent finding is noted. Furthermore, it could be interpreted that a radiographer who does not participate in a PIE system or similar may be in breach of their professional registration.

There are several strengths and limitations of this review that are worthy of consideration. The review conducted was comprehensive and provides major insights into performance of radiographer image evaluation and barriers and enablers to its implementation. A further strength is the thorough methodological approach to the review, including a balanced and transparent approach to study selection and quality evaluation. This approach mitigated selection bias and ensured only quality studies were included in the review. The McMaster critical appraisal tool utilised has limitations due to the fact it was mildly modified and was not retested for reliability and validity. Another limitation was that the majority of studies reviewed relied on voluntary cohorts for assessment of radiographer performance. This voluntary bias may affect the validity of the results and should be taken into consideration when interpreting the findings of this review. The substantial variation in study designs is of importance and warrants consideration. The methodological variations across studies limited the ability to pool data for analysis.

Conclusion

Findings from this review indicate that Australian radiographers can undertake radiographic abnormality detection and PIE; however, educational and clinical support barriers limit the implementation of radiographer image evaluation systems. Access to targeted educational resources and a clear definition of radiographers’ image evaluation role may drive a wider acceptance of radiographer image evaluation in Australia. Moving forward, the literature will benefit from well‐designed projects that assess radiographers’ image evaluation performance in the clinical setting.

J Med Radiat Sci 66(2019) 269–283