LEEDS, UK—Ninety percent of rheumatologists in the United Kingdom are both interested in and enthusiastic about incorporating ultrasonography into their practices, but almost all face roadblocks such as lack of time and money, according to a new survey reported in Rheumatology.¹

"Most rheumatologists report a limited time to devote to musculoskeletal ultrasonography [MSKUS] and therefore a need to prioritize areas of importance for dedicated learning and practice," conclude researchers led by Andrew K. Brown, MBChB, MRCP, with the University of Leeds, in the UK.

Forty-eight UK rheumatologists answered questions concerning the potential role of self-performed MSKUS skills that they would be willing to learn and factors that encourage or limit the learning and practice of such skills. They also reviewed competency recommendations proposed by imaging experts concerning 142 skills in seven anatomical areas. The researchers also gathered quantitative and qualitative data regarding ultrasonography's value to their practice and rheumatologists' learning motivation.

Not enough hours in the day

Of the 48 rheumatologists surveyed, 89% said they wished to learn MSKUS. Factors affecting their learning and practice included time to achieve competency, relative added clinical value of MSKUS examination, limited training infrastructure, access to existing imaging services, and equipment funding.

"The most frequent constraint was time, not only to learn the technique and achieve the required competency standard, but also to perform each imaging examination and to maintain the necessary skill levels, particularly in the context of an already busy clinical environment in which most practitioners operated," the researchers note. "Some respondents commented that they simply did not have enough hours in the day to devote the necessary time to be safe ultrasonographers and others suggested that to do so would have to be at the expense of another clinical activity."

Value to practice assessed

The rheumatologists rated the relative value of each competency item to their practice. Overall value to practice was calculated by adding together the percentage of responses in the essential and useful categories from respondents' answers to questions concerning competency recommendations.

Respondents said that the detection of synovial fluid or effusion was the most useful MSKUS skill in a rheumatology practice. It received the highest value-to-practice score in each anatomical area. Detection of synovial thickening and identification of bone erosions were considered important, especially in the ankle, heel, hand, and wrist. The rheumatologists said that evaluation of ligament and muscle lesions and soft tissue masses were least useful. "There was a close correlation between clinical utility, learning motivation, and competency standard," the study found.

"These opinions endorse the requirement for any rheumatology MSKUS curriculum to be highly focused and relevant to the specific needs of the rheumatologist," the researchers conclude. "Consequently, any educational development process needs to consider these important factors, as they are likely to profoundly influence the future dissemination of MSKUS practiced by rheumatologists."

MSKUS also limited in the US

The new study "is comprehensive and does a good job of giving us a picture of how practicing rheumatologists in the UK feel about the role of ultrasonography," John Hardin, MD, chief scientific officer of the Arthritis Foundation, in Atlanta, Georgia, and professor of medicine at the Albert Einstein College of Medicine, in the Bronx, New York, told CIAOMed. He pointed out also that cost is a tremendous barrier in the US.

"The second barrier is how do you acquire the skills to use the machine and do the readings when we don't have any educational programs in rheumatology to train people," Dr. Hardin added. "There is also not a mechanism in place by which a rheumatologist who had acquired skills and had a machine could actually bill for the procedure and collect money."

Soon after cardiologists began using sonograms to detect heart disease in the mid-1970s, a subspeciality was born. "The division of echocardiology came out of it, and there are now people whose day job is to do cardiac ultrasounds, and they tend to do it for a whole cardiac division," Dr. Hardin said. "We may end up with a subspecialty of echo-arthritis or echorheumatology, but we are nowhere near there yet."

Reference

1. Brown AK, Roberts TE, Wakefield RJ, et al. The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists. Rheumatology. 2007;46:821-829.