Written evidence from the British Society of Interventional Radiology
Key Points:
1. Interventional Radiologists carry out minimally invasive therapies using small incisions of 1-2 mm, under local sedo-analgesia, usually as day case procedures.
2. Interventional Radiology procedures sometimes compliment orreplace more invasive open surgical procedures often at overall reduced costs.
3. There may be higher 'up front costs' in setting up services, which over time will result in an overall cost saving to the NHS.
4. The elective day time work helps support sufficient numbers of trained IR's to also provide emergency out of ours care, particularly haemorrhage control.
5. There is an urgent need to invest in more interventional radiologists and develop the local infra-structure in the majority of hospitals which in time will help reduce the overall costs of treatments in the NHS.
Interventional radiologists are medical doctors who are trained in imaging but have undergone additional specialist training in interventional radiology. Interventional Radiology (IR) has become a vital part of modern medicine providing essential high quality patient focussed care and delivering safe and effective treatments often at reduced costs. IR procedures increasingly replace open surgical procedures as they are less invasive, reduce morbidity and mortality and allow more rapid patient recovery and hospital discharge. Over 90% of procedures are undertaken through incisions of around 2–3 mm, and most procedures are performed under local anaesthesia and/or sedoanalgesia, allowing same-day discharge from hospital. IR plays a vital role in both elective and emergency treatment particularly for haemorrhage control in trauma and gastro-intestinal haemorrhage where embolisation can be life saving. Although imaging remains at the heart of IR training, IR practice is fundamentally different from diagnostic imaging. The skill sets and training requirements for IR's are significantly different from those of diagnostic radiologists and in 2010 interventional radiology became a subspecialty with a modified curriculum to produce more appropriately trained IR's .
In addition to replacing or enhancing many surgical procedures the service delivered by a dedicated IR team also enables development of new treatments to patients with chronic and often life threatening conditions. Although there are high costs in equipping, staffing, and training for the provision of a 24/7 IR service, once in place, the service offers significant savings compared to standard surgical therapy, by reducing in patient bed and ITU utilization.(1) So that although there may be significant costs in setting up an IR service, the overall costs of the procedures over time is less with a resultant overall saving to the NHS.
As patients and clinicians become more aware of how IR can improve patient care, the demand on IR services has grown exponentially over the last decade. Consequently the specialty has grown to support a wide range of patient treatments (2-28) which has stretched the capabilities of many hospitals to provide a high quality sustainable service, particularly 24/7. Examples of such procedures under specialised commissioning include fibroid embolization where woman traditionally have undergone hysterectomy can now be treated with embolization techniques using small tubes 1mm in size, with a short overnight stay or even as a day case. This is quicker and cheaper than open hysterectomy and patients can return to work far more quickly resulting a huge saving to the NHS and overall economy. In a US study (29). The mean total costs per patient in the fibroid embolisation group were significantly lower than those in the hysterectomy group ($11,626 vs $18,563; mean difference, -$6,936 [-37%], 95% CI: -$9,548, $4,281). The direct medical in-hospital costs were significantly lower in the embolisation group: $6,688 vs $8,313 (mean difference, -$1,624 [-20%], 95% CI: -$2,605, -$586). The costs related to absence from work differed significantly between the treatment strategies in favor of embolisation (mean difference, -$5,453; 95% CI: -$7,718, -$3,107). The costs of absence from work accounted for 79% of the difference in total costs. The cost effectiveness of embolisation over surgery has also been supported by the HOPEFUL , UK based trial (30) However the provision of this service is patchy due to lack of adequate investment in local provision and referral pathways. For this reason the RCR and BSIR have strongly supported retention of best practice tariffs or uterine fibroid embolization to encourage their development throughout Enland. Overall the demands on the service have far outstripped the resources currently available, so threatening the future viability of good quality services in many units. The lack of adequate resources and/or a 24/7 IR service, can make equitable access to IR services difficult and jeopardize patient safety in terms of denying access to often lifesaving minimally invasive treatments. It is vital for patient care that IR units have the correct infra-structure to support the wide range of interventional radiology procedures for optimal patient safety.
An IR unit requires highly trained and experienced interventional radiologists. There is also a fundamental requirement for well trained allied health staff including nurses and radiographers. Units also need modern imaging equipment ranging from ultrasound, CT, MR and digital subtraction angiographic facilities. A modern IR service is called upon to provide a wide range of procedures and some hospitals may not be able to provide the full range of current IR treatments, depending on local clinical services . Some procedures are uncommon and/ or extremely complex, and so it may not be pragmatic or appropriate for all units provide them. In the UK guidance on optimising training opportunities for low-volume procedures has been published . (31-32)
For smaller units a formal network with a neighbouring unit should be developed to share resources with possible transfer of patients and or staff . An example would be the shared provision of a 24/7 IR service to ensure a reasonable on- call rota (27).
There are a few procedures which account for the vast majority of out of hours emergency procedures and these include arterial embolisation for haemorrhage and drainage of obstructed infected systems e.g. nephrostomy for obstructed kidneys. Hospital units which admit acute medical and surgical patients should have access to these IR techniques, either on-site or by formal arrangement to transfer the patient to other sites. Where transfer of patients and or staff is agreed it is vital that there are clear agreed, written pathways between all parties, and that these pathways are understood by local managerial as well as clinical colleagues. These can be mutually beneficial to all the network hospitals, staffed with minimal cost implications for the units involved .Specialist IR training through the CIRSE IR curriculum ensures that all recently qualified IR consultants are able to carry out these core procedures. More complex or less commonly performed procedures may require inter-hospital transfer.
Simulation of emergencies such as in trauma can be invaluable in maintaining team readiness and addressing issues that may arise ( 33) . In addition to having sufficient IR’s larger centres or networked centres are more likely to have the infra-structure support, and a greater range of procedures to help maintain competency of the whole team. Centralisation for trauma and vascular disease has resulted in moving specialist IR into major centres has resulted in improved delivery of acute emergency trauma and vascular services with IR's better organised and supported and improved infra-structure to support 24/7 emergency care for these groups of patients. However this has been at the expense of reduced local support and cover for IR locally and there is a urgent need to increase the numbers of IR's who can provide cover for these smaller peripheral units while maintaining competencies by carrying out the wide range of procedures in the central units.
3 May 2016
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