Africa is a continent where there is a crisis in healthcare and where a significant shortage of medical professionals poses one of the most important challenges. Teleradiology and telemedicine are an innovative healthcare delivery method which can bridge the existing gap between the specialists and the patients who are currently deprived of access to healthcare. This article is a review of a retrospective study performed on cases received from the organization’s African clients who have used our teleradiology services. This provides us an insight on the patterns of utilization and acceptance in the African setting. An analysis of various disease trends is also done to get an idea on their prevalence. This analysis reveals that teleradiology can be effectively utilized for early and accurate detection of disease in Africa which in turn can lead to early and appropriate treatment, improved patient outcome, decrease in spread of infection and overall decrease in healthcare costs. However, a pre-requisite for the growth of teleradiology in these regions would be a strong telecommunications backbone.
Key words: Teleradiology, Telemedicine, Telehealth, ultrasonography
Introduction and Background
Africa faces a growing healthcare crisis. Mortality rates have been mounting quickly with negative impacts on individuals, families and the society. Chronic diseases such as Cancer, Heart disease, Stroke and infections are still prevalent. Although government and private expenditures on health care have been growing rapidly, they have not grown as quickly as health care needs, with a resulting gap between health care needs and health care delivery . Upon viewing Africa’s healthcare as a unit in 2012, the picture is still one of a generally poor population, subject to diseases that have been eradicated or brought under control on most other continents .
The challenges to better health services in Africa are well known: Africa lags behind all regions of the world, including other developing regions, on all indicators of better health. A recent report from the World Health Organization for instance shows that while Africa has 20% of the world’s sick people, it has only 4% of its healthcare workers – many of them vulnerable to the high mortality rate associated with malaria and notably the AIDS epidemic. The state of investment in healthcare infrastructure is also grossly inadequate as is the efficiency of healthcare delivery . There has been a huge shortage of physicians and radiologists in these regions leading to long report turnaround and delayed patient care. As most radiologists are based in cities, the rural regions are highly impacted. According to a KPMG report, the number of physicians per 1,000 people in 2010 in Africa is just 2.3 whereas it is 14 for the world . As per another report by WHO 2010, in Sub-Saharan Africa, 14 countries do not have a single radiologist in public service .
Telemedicine and teleradiology can be instrumental in filling the gap between needs and delivery. Telehealth is considered a major innovation at the technological, social, and cultural levels . This technology has the potential to increase access to, and quality of, health care services and to lower health system expenditures . Thus, introducing telehealth as a tool to support the delivery of health care services implies numerous changes for providers, organizations, and the health system as a whole that must be accounted for during the implementation process .
Teleradiology basically involves transfer of diagnostic images over a network for remote interpretation. The network can extend from a village to a city or even across the globe. This helps in improving patient care by reducing the time of diagnosis, enhances quality by promoting subspecialist review and also reduces healthcare costs by utilizing manpower efficiently .
Materials and methods
A retrospective study on about 4111 cases (chosen by sequential sampling) was performed by radiologists at Teleradiology Solutions to see the trends and the distribution of cases across different regions of Africa. Our teleradiology workflow in essence consists of electronic receipt of images from the client site, review of the images by our team of expert radiologists, and electronic transmission of the reports back to the client site, with additional verbal discussion on as needed basis. An electronic workflow platform named RADSpa, developed with input from our own radiologists, is used in our organization for the distribution and archival of the reporting data. This simultaneously generates a large volume of data that captures all the various quality and workflow parameters that constitute the basis for our teleradiology operations. We reviewed our database for the year 2012 to assess the following parameters:
- Location break-up: The numbers of studies reported for African clients via teleradiology were reviewed.
- Gender break-up: The cases were divided into male or female depending on the gender of the patient.
- Distribution on the modality: The primary imaging modalities referred to our centre for reporting namely X-ray (CR), CT, MR and MG were individually evaluated.
- Distribution on the types of study: The reports of the studies were individually analyzed and broadly classified into 3 major categories (minor, normal and significant).
- Distribution of significant studies: The significant studies were further categorized on the type of disease to check the prevalence.
- Age break-up: Distribution of Studies between children and adults.
- Distribution of disease types in children: The trends of disease types in children were analyzed.
Our teleradiology reporting services have been utilized by four different regions of Africa. The distribution of the cases among these four regions is as shown in Figure 1.
Figure 2 exhibits the distribution of the cases as per the gender of the patient. The distribution of cases across the gender was almost equal with males (54%) and females (46%).
The modality break-up of the data is illustrated in Figure 3. The hierarchy from the most received images to the least is CT followed by MR, MG and then CR.
Figure 4 shows the division of cases on the type of study. The studies were broadly classified into Minor, Normal and Significant based on the reports provided by the radiologists. More than 37% of cases had significant diseases which needed timely treatment. 16% of the studies had a normal report. The remainder of the cases had minor or incidental findings. The ratio of significantly positive to normal studies exceeds 2 which are high when extrapolated over an entire population, indicating low utilization of imaging restricted mostly to those patients with significant disease. It is an indirect metric that there is a significant burden of disease that remains undetected due to inadequate imaging.
Out of the 4111 cases, we had 1199 pediatric studies. The age break-up of the total retrospective cases is shown in Figure 6.
The distribution of the type of study among these cases is demonstrated by Figure 7. Out of these cases, 105 of them fell under the category of significant studies and only 80 cases were normal.
We mainly attempted to explore the prevalence of various kinds of significant diseases across the population of Africa and evaluate if teleradiology could be an influential technology in providing superior quality healthcare to the underprivileged through this retrospective study.
The above data clearly reveals and validates that the burden of disease is huge in Africa. More than 37% of the cases had significant health diseases which could have been ignored, if not diagnosed and given timely treatment. In fact the pediatric examinations in our series show an alarming trend of more than 8% children being affected by significant diseases. As per a report by KPMG, the under-5 mortality per 1,000 live births in 2011 has been found to be 107 in Africa compared to just 57 in the world . This clearly implies that there is an extreme deficiency of health professionals in these regions. An appropriate, robust, and sustainable model for improvement in health system performance is essential in order to reverse the declining trends in health and development status and break the vicious cycle of poverty and ill-health in Africa .
Another main issue that Africa faces is that many public hospitals are dependent on aid grants. Through such grant funding the hospital is able to purchase say an MRI scanner; however the trouble is that they are unable to adequately maintain it, due to a combination of high cost of maintenance and lack of support. So when such equipment breaks down, it breaks down permanently. This is probably the biggest problem. However, World Health Organization is attempting to establish a program to train engineers to repair the equipment. The WHO developed the Basic Radiological System a few years back, which appears to be a very durable and good system. Apart from plain films, ultrasound utilization demonstrates robust growth. There is therefore significant demand for training of health professionals in ultrasonography not necessarily just radiographers or radiologists; but potentially nurses as well .
If the challenges are overcome telemedicine can provide access to scarce specialist care, improve the quality of care in rural areas and reduce the need for rural patients to travel to seek medical attention. International cross border service can alleviate the regional shortages of doctors . Telehealth can support the delivery of specialized services in a timely manner for remote populations; facilitate access to education for clinicians, and save travel costs for both patients and professionals. Moreover, as telehealth technologies become more integrated into the health care system, they will increasingly contribute to the reorganization of medical workforce supply and exert a profound influence on physician practice, especially in remote areas .
The ability to transfer digital images seamlessly around the world has globalized a previously localized medical specialty. There are few areas of medicine that could adapt to such a change so readily. Radiology is showing that it can not only cope with this transition, but can actually embrace new technology and harness it to improve speed of delivery, accuracy, reporting quality, cost-effectiveness and patient outcomes. An important factor in the success of quality teleradiology services will be maintaining open channels of communication , especially in the international setting.