Consequences of outsourcing referrals for radiological examinations

Abstract: Background: Demands for ever more effective healthcare and care accessibility for all patients continue to increase the workload in diagnostic radiology departments. Along with rapid developments in imaging technology which affect its day-to-day clinical use, these are three important factors for which outsourcing might be a potential solution. Outsourcing radiological examinations increases the need for cooperation between different healthcare units. Outsourcing a radiological examination is accompanied by administrative work. Examinations performed externally change the work flow and create a multifaceted environment that can be reviewed both qualitatively and quantitatively. The impact of outsourcing magnetic resonance (MR) and computed tomography (CT) examinations to external units in a zero-based budgeting healthcare system is unknown. This impact can be studied both from the perspective of healthcare work flow as well as from that of the patient experience. Aims: The overall aim of this thesis was to describe the outsourcing of radiological examinations such as MR and CT scans from a university hospital in terms of costs, quality, time efficiency, and both the patient’s and referring physician’s perspectives, and also to investigate the differences when CT examinations are outsourced from a university hospital as part of a contract compared to conditions prior to the contract between the hospital and external radiology unit. Material and Methods: In Study I, consecutive outsourced MR examinations requested by the Department of Oncology during the first quarters of 2005 and 2006 were selected for investigation. Examinations performed by the University Hospital’s Radiology Department (Group A, n = 97) were compared to matched examinations outsourced to external private units (Group B, n = 97). In Study II, structured interviews (oral questionnaires) were held with one group of patients (n = 160) referred for MR examinations. In Study III, qualitative interviews were held with 10 referring physicians from orthopedic and oncology clinics representing clinics with large volumes of radiological referrals. In Study IV, 264 elective CT examinations were randomly selected from four different groups of patients referred from the Departments of Hematology and Oncology during two time periods: one time period had no detailed plan for cooperation (OSnC) and one represented contract-based outsourcing (OsC). Within these time periods, examinations performed inhouse (Group HI13; IN14) and outsourced (Group OSnC; OsC) were compared. Results: In Study Ι, the time from writing a referral to obtaining the report was significantly longer in Group A (in-house) than in Group B (outsourced). For referrals without a preferred timeframe, the waiting time was shorter for outsourced examinations than those not outsourced. No significant difference in the number of examinations requiring additional imaging was observed between the two groups. Fewer examinations in Group A needed additional work for reinterpretation of images than in Group B (14% vs. 28%). The average cost for an MR examination in Group A was calculated to be €616.80, and €510.80 in Group B. In Study II, 69% of the patients stated that they could neither choose nor influence the location to which their examination was referred. Aspects that influenced the patients’ choice of radiology department were: short waiting time 79% (127/160), ease of travelling to the radiology department 68% (110 /160), and short distance to their home or work 58% (93/160). For 40% (60/160) of the patients, a short time in the waiting room was related to a positive response regarding returning for a further MR examination. In study III, all the referring physicians agreed that the quality of outsourced examinations was frequently inferior to that of examinations performed in the University Hospital’s Radiology Department and that requests for additional reinterpretation work led to higher costs for their clinics. In Study IV, during 2013, management time for CT examinations which needed no reinterpretation was longer in the outsourced group than in the in-house group, with a statistical significance of 0.002. CT examinations in Group OsC (contract-based outsourcing) were associated with shorter overall processing time, shorter patient waiting time and lower costs compared to group OsC (without a detailed plan for cooperation). Conclusion: - Outsourcing magnetic resonance examinations is one potential solution for reducing patient waiting time. - Outsourced examinations more frequently need reassessment at the University Hospital than examinations that are not outsourced. - If patients were informed about outsourcing and could also choose where to have their examination, the key factors contributing to patient satisfaction could be met even when MR examinations are outsourced. - When considering outsourcing, the needs of the patients, of the referring physicians and of the radiology departments must all be considered, to optimize patient care. - For better planning of radiological services, radiology departments must consider the referring physicians’ needs and develop a suitable contract for organizing the practice of outsourcing. - Using a contract for outsourcing CT examinations may be an effective way of reducing patient waiting time. - Outsourcing based on a well-founded contract can be cost-effective, compared with outsourcing without a detailed plan for cooperation.