Bigger, faster, stronger

A new breed of MRI scanner is coming your way;
does Canada have the dough and the know-how to keep up?

By Owen Dyer

The magnetic resonance imaging (MRI) scanner has been one of the most successful medical inventions of recent decades. It provides detailed images without radiation and new uses and techniques are being discovered all the time.

At the recent Radiological Society of North America Annual Meeting in Chicago, papers were presented about emerging research related to MRIs. One suggested that MRIs can detect people likely to develop Alzheimer's disease decades before they show symptoms, and can diagnose multiple sclerosis at an earlier stage than has previously been possible. Another reported on new, superfast MRI scanners that can scan a stroke patient in three minutes instead of 20. Such a machine could supplant the fast but fuzzy CT scanner in diagnosing stroke. Another special MRI technique called diffusion tensor imaging has been used to track brain changes associated with early onset schizophrenia.

But is Canada well placed to exploit these advances? For years, this country's shortage of diagnostic imagers has been notorious. The general public is acutely aware of the problem, and in 2002 a survey found that reducing wait times for diagnostic services was the public's number-one spending priority for the extra health dollars promised by Ottawa. (For more on waiting times, see Practice makes perfect on page 1.)

DISMAL RATING
That same year the Kirby Senate Committee on Health Care Reform offered this grim assessment: "Canada ranks 21st of 28 OECD [Organisation for Economic Co-operation and Development] countries in the availability of CT scanners, 19th of 22 in availability of lithotriptors and 19th of 27 in availability of MRIs. Its only acceptable ranking is in the availability of radiation equipment, where it ranks 6th out of 17. Data also show that this technology gap is widening. For example, the availability of MRIs in Canada worsened between 1986 and 1995 relative to other OECD countries. Information provided to the Committee indicated that between 30% and 63% of imaging technology currently used in Canada is outdated."

BANKROLL THE ISSUE
Provincial premiers scrambled to address the issue and in 2001 arrived at the First Ministers' Accord on Health Care Renewal, which set up a Diagnostic and Medical Equipment Fund (DMEF) with a sizable federal contribution from which provinces could draw when buying high-tech equipment.

The fund got off to a rocky start, with a spate of newspaper stories in 2002 about DMEF monies being used to buy icemakers and lawn mowers. But with the issue of diagnostic imaging still high on the voters' agenda, ministers got together again in 2003 to beef up the fund and set rules about its use and abuse. The DMEF coffers now hold $1.5 billion.

The Canadian Institute for Health Information (CIHI) has been given the task of measuring the impact of the drive to improve diagnostic services. Their first report on the issue suggests that sometimes throwing money at a problem actually works pretty well.

By January 2003, Canada had a total of 147 MRI scanners, compared to 30 in 1993, an increase of nearly 400%. The volume of outpatient MRI scans funded through the Ontario Health Insurance Plan rose by nearly 500% in nine years, from about 25,000 scans in 1992 to about 146,000 in 2001.

CIHI found that to date, 98% of the spending on hospital MRIs has come from provincial governments. Although neither CIHI nor anyone else actually knows how much is being spent on imaging nationally, it seems that most of the federal money remains unspent. Which is just as well, because all the money spent so far has not bought Canada parity with other developed countries.

Canada's MRI machines are now, on average, newer than those in Europe. But according to the latest figures, from 2001, Canada remains below the OECD average for both MRI and CT scanners. In the case of MRIs, Canada has 4.2 per million people, compared to the OECD average of 5.4 per million. Japan leads the field with a whopping 23.2 MRIs per million people, while Mexico brings up the rear with just 0.3 per million.

How this translates into waiting times is less clear. The latest data suggests that the average Canadian's wait for MRI, CT or angiography was about three weeks, but 5% waited 26 weeks or more.

GETTING THE MANPOWER
It's clear that more machines do not automatically translate into more scans. Manitoba, for example, had in 2001 only half as many MRIs per million population as England, yet actually performed more scans. Alberta had 7.3 MRI scanners per million people as of January 2003, the highest figure in the country, but the provincial government is worried about finding people to run them.

Getting trained staff is likely to be the biggest hurdle to reducing wait times. Globally, no medical speciality is more understaffed than diagnostic imaging and the problem is only going to get worse.

For example, the proportion of medical radiation technologists under the age of 35 in Canada is decreasing, from 47% in 1991 to 31% in 2001.

The supply of medical imaging professionals in Canada has generally held steady in recent years relative to population growth, which is more than most developed countries can boast. The numbers of Canadian diagnostic radiologists and nuclear medicine physicians, for example, increased by about 6-7% between 1996 and 2001. But the number of imaging machines more than doubled over the same period. As CIHI President Richard Alvarez points out, "Imaging equipment is of little value without skilled professionals to provide and support imaging services."