Looking Into the Future: The Current and Future State of IR in Canada

Abstract

This review explores the priorities and future opportunities of interventional radiology in Canada.

When looking to the future state of IR in Canada, it is important to understand our past and the trajectory of IR practice in our country. Our American colleagues founded the Society of Interventional Radiology in 1973, followed closely by the Cardiovascular and Interventional Radiological Society of Europe in 1978. ¹ In contrast, the Canadian Association for Interventional Radiology (CAIR, founding name CIRA) was formed in the year 2000. Since its induction, CAIR and the interventional radiologists across Canada have been fervently closing a 20–30 year international gap with positive results.

Image-guided interventions have become an integral part of modern health care provision in Canada. The formal subspecialty designation of Interventional Radiology by the Royal College of Physician and Surgeons of Canada in 2013 was an important landmark, recognizing the unique body of knowledge and practice of interventional radiologists. Although a monumental achievement, it represented the beginning of a long journey in the growth and maturation of the specialty in Canada.

Dedicated IR residency training is now in its infancy in Canada. The transition to a clinical and interventional intensive curriculum from a diagnostic imaging core marks the second pivotal turning point in the future of IR. Although the breadth of clinical practice is variable between providing centers throughout the nation, there is no debate that “Clinical IR” is here to stay. ² The future of the specialty will be dependent on the interventionalist’s ability to provide a level of care not previously thought to be within the purview of a “radiologist.” However, lack of funding and associated infrastructure costs continue to serve as major impediments to this future state. ³ Despite decreased morbidity, improved patient safety and overall cost savings for the health care system, Canada performs the fewest IR procedures per capita amongst the G7 nations. ¹

In the following discussion, we will explore the priorities and opportunities within interventional radiology in the coming years. All futures are uncertain, but what lays before us is an opportunity to define our direction and what we need to get there.

Current State of IR in Canada

Interventional Radiology procedures were historically provided as a “hired gun” model, where the IR would meet the patient on the day of the procedure and rarely have any long-term involvement in the patient’s care. ⁴ Currently, many IRs in Canada practice clinical IR, which involves an IR clinic to evaluate patients, explain procedures and treatment options, order imaging and laboratory investigations. If the patients are candidates for interventions, the procedures are arranged, along with clinical follow-up and post-procedural laboratory and imaging investigations. In addition, many IR practices also admit patients to hospital as the most responsible physician (MRP). This progression to a more clinical practice has been rewarding and improves patient care.

IR Training

Currently, there is a mix of training programs for Vascular and Interventional Radiology in Canada. This includes traditional IR fellowships, which are non-accredited 1-year training programs with individual training objectives and various procedures reliant on the clinical services provided at the institution. This 1-year fellowship is performed after the 5-year diagnostic radiology residency.

To standardize training programs and integrate longitudinal clinical care, Interventional Radiology was awarded subspecialty status in 2013. As a result, numerous Royal College accredited Interventional Radiology Residency Programs have been developed in many of the academic centers. This new training paradigm involves standardized goals and objectives, integrated clinical training with outpatient clinics and inpatient care, increased IR rotations and electives in non-radiology specialties such as vascular surgery, hepatology, oncology, and intensive care. At the end of training, IR residents are required to pass a written examination as administered by the Royal College of Physicians and Surgeons of Canada.

IR Funding

In most Canadian hospitals, Interventional Radiology falls under the auspices and global budget of Diagnostic Radiology/Medical Imaging. The operation of a Medical Imaging Department is dictated by the global budget, as assigned by the province to the hospital, and hospital to the department. Within every Radiology department, IR is consistently the budgetary pressure point. This is due to the cost of disposable products (embolization coils, stents, balloons, etc.), IR staffing which includes medical radiation technologists (MRT) and nurses, and over-time charges related to emergency procedures. These budget overruns highlight a painful truth for IR in Canada: IR is woefully underfunded. As previously highlighted, Canada performs the least amount of IR procedures compared to our G7 counterparts. Given the ability for IR procedures to save the Canadian system health care dollars, our continued lag behind our international counterpart defies rational explanation.

There is some movement towards provincially based bundled payment systems to better manage the costs associated with different programs. For example, organizations such as Cancer Care Ontario, which fund and oversee many medical, radiation and surgical oncology treatments, developed an interventional oncology steering committee which led to bundled funding and funded indications for transarterial chemoembolization, radiofrequency ablation, microwave ablation, cryoablation, yttrium-90 radioembolization, vertebroplasty, and kyphoplasty. A similar model with CorHealth Ontario has developed bundled payments for inpatient endovascular peripheral vascular treatments and endovascular stroke therapy. The Ontario Renal Network has developed some funding models for surgical fistula creation, but there are no current reimbursement models for fistula/graft maintenance with angioplasty or stenting (including resource intense thrombolysis and thrombectomy procedures). Provincial bundled funding would help advance IR programs and procedures, as it would take pressure off individual departments and hospital global budgets. Ongoing meetings and re-evaluation of funding dollars are also required to evaluate new technology and indications based on the medical literature and increasing costs of medical devices. In the future, Canadian funding models will most likely solely support scientifically validated and economically effective interventions. Interventional Radiology could be adversely affected if validation research does not become a priority and if the global cost savings of IR treatments are not emphasized.

Lastly, a coordinated system for replacement of interventional radiology angiography systems, ultrasound, and interventional computed tomography (CT) units is long overdue. This equipment is essential to daily operation of an IR lab. In most Canadian centers, cyclical or routine fleet replacement based on the life cycle of the technology is non-existent. Often, the equipment is used well beyond the life cycle despite published standards. ⁵ New systems are not considered until current equipment fails or becomes obsolete. Many interventional radiologists are therefore working with equipment that is not only past date and at risk for malfunction but also significantly behind current technology. A national or provincial strategy dealing with coordinated replacement of medical imaging technology (including interventional radiology systems) would address these concerns and significantly reduce the pressure on hospitals for “crisis replacement” of equipment.

The Future of IR in Canada

Future Training

As the breadth of interventional radiology expands, the current training model must adapt. There are many subdivisions within IR including body and trauma intervention, interventional oncology, stroke/neurovascular, peripheral vascular interventions, pain management, biopsy, abscess/fluid drainage, dialysis procedures, and pediatric IR. As recognition of these services increases, case volumes will also increase. This will require IRs across all centers to provide an increasing breadth of procedural and clinical care. The current 1-year training model offered by most Canadian fellowship programs may soon be insufficient in duration to allow a trainee to gain exposure and develop both the technical and nonprocedural patient care skills required. Having standardized fellowship training across all programs will allow for more well-rounded trainees which in turn will allow for the full scope of IR services to be offered across different centers, community, and academic. Future IR training programs may offer additional subspecialty training in peripheral vascular disease, interventional oncology or pediatrics, to name a few. This concept is also in practice at a few centers in the United States (US).

In the short term, Royal College accredited IR residencies (along with all Royal College residency programs) are moving towards competency based medical education (CBME), also known as Competence by Design. This paradigm shift will allow for clearer learning expectations and evaluation metrics for both learners and programs and close the gap between finishing training and transitioning into clinical practice

Future Procedures and Practice

Since the inception of IR by Seldinger and Dotter in the mid-20th century, interventional radiologists have been continuously innovative, introducing new procedures, medical devices and techniques. All aspects of IR continue to see growth, fueled from within the subspecialty and through interdisciplinary collaboration. Developments in IO include the creation of new radioembolic materials such as ¹⁶⁶Holmium microspheres ⁶ which are visible on both Xray and magnetic resonance imaging. ⁷ Percutaneous irreversible electroporation (IRE), a nonthermal ablative technique which causes apoptosis via cell membrane permeability, ⁸ is another notable innovation.

New application of existing technologies has the potential to further optimize existing IR procedures, such as with the utilization of contrast enhanced ultrasound. An excellent example of this can be seen in recently published trials investigating the implementation of sonoporation to both increase drug delivery at the cellular level ⁹ as well as to enhance tumor oxygenation to improve treatment efficacy. ¹⁰ Active research into the development and optimization of novel IR procedures abounds, providing a window into future innovation. One such trial, currently ongoing, is assessing the potential of microbubbles to improve Yttrium 90 radioembolization efficacy. ¹¹ Although this represents only a select number of new and developing procedures in a single subsection of IR, it speaks to the immense growth in the specialty as a whole.

However, access to scientifically proven, effective technology is imperative to the growth of IR in Canada, a national paradigm shift in clinical practice will also dictate future practice. In the future, coordinated patient care should parallel or surpass models currently in place in selective academic Canadian and international institutions. Specifically, multidisciplinary clinics that provide “one-stop” evaluation and treatment plans for patients will enhance and expedite patient care. Expertise will differ between institutions; however, oncology care teams treating organ-specific diseases may include interventional radiology, diagnostic imaging, medical/radiation/surgical oncology, palliative medicine, family medicine, nurse practitioners, and/or physician assistants. Multidisciplinary vascular clinics providing expertise in aortic intervention, peripheral vascular disease, and vascular malformations will also elevate disease-specific care. The role of independent health facilities in Canada remains uncertain, a pronounced difference compared to our American colleagues where office based labs (OBLs), the Canadian equivalent of Independent health facilities (IHFs), are commonplace. In the absence of IR fee-restructuring in Canada, the economic sustainability of out-of-hospital IR care is precarious and will remain dependent on diagnostic imaging fee structures.

With procedural advancement and an increasing clinical role, interventional radiologists will have to follow the lead of our clinical colleagues in developing quality assurance (QA) and continuous quality improvement (CQI) strategies. These initiatives can be stratified into organization, clinical, procedural, and training standards. ¹² Canadian specific QI and standards of practice are essential as they reflect our unique healthcare milieu which is not represented in international guidelines.

Improvement in quality should be self-motivating. It leads to better, safer, faster, and less expensive care. ¹³ As the demands on IR departments continue to grow, efficiency in procedures will be required. Concurrently, efficiencies in procedure selection, complication avoidance, and follow-ups must be optimized. Many practices have found success in CQI initiatives targeting IVC filter follow-up/removals and formalized drainage catheter maintenance. In the future, highly performing imaging groups will include a radiology quality committee, chief quality officer, IR-specific QI/QA and participation from nurses, MRT, administrators, and potentially patients. ¹⁴

In an era of limited resources, departments that drive quality improvement and can demonstrate quality assurance are likely to be rewarded with continued and increased support. This period of data quality-driven care is an opportunity for interventional radiologists to exhibit our value to Canadian health care funders.

Future Technology

In order to appropriately facilitate procedural development, there is a need for concurrent advancement in technology. This is particularly challenging in our resource limited environment in Canada. Cornelis and Solomon ¹⁵ addressed this in a recent opinion piece stating “we are now entering a phase of IR that requires more software enhancements that can improve precision, overlay multi-modality imaging information, or provide faster, real time imaging.” Fortunately, similar to the growth in IR procedures, there have been major recent advances in IR software and technological support.

A key example of this is Automated Feeder Detection (AFD) software. Though it has yet to become widely adopted in clinical settings, recent studies have demonstrated that AFD has particularly high sensitivity for detection of “feeder” vessels supplying hepatic tumors, facilitating more accurate embolization. This technology has the potential to both shorten procedure times and improve patient outcomes. ¹⁶ In classic IR fashion, the potential utility of AFD software has been recognized and expanded into a variety of other procedures, including detection of feeding vessels in prostate artery embolization and Type II endoleaks.^17,18

One proven technology that has more widespread adoption is the use of image fusion programs. Currently adopted image fusion techniques, well-established in fields like targeted prostate biopsy, have proven their worth. ¹⁹ Studies have consistently shown image fusion technologies can improve diagnostic yield, reduce procedure time and decrease radiation dose. ²⁰

Three-Dimensional (3D) printing is another technology whose proven benefits have just scratched the surface of potential future utility. Currently utilized primarily for training and simulation in IR, 3D models have been shown to be cost-effective and provide a more effective media for learning procedural skills ²¹ and for procedural planning. A recent study by Chang et al. ²² gave several recommendations for using 3D printing, including (i) when the procedure is considered high-risk, (ii) when there are limitations in obtaining diagnostic imaging information, (iii) for procedure planning, and (iv) when the margin for error is low. Three dimensional printing of IR devices is also a burgeoning area of research, although the clinical implementation of 3D printed medical devices in IR lags behind that of surgical specialties. A recent in vitro proof of concept study by Weisman et al. ²³ demonstrated the feasibility of custom-made catheters impregnated with biologic and chemotherapeutic material and is just one example of recent progress in IR-specific 3D medical device printing. As the cost of 3D Printing continues to drop, it is likely to become more integrated into the training, planning and implementation of IR in Canada and worldwide.

Augmented reality, which allows the operator to visualize and interact simultaneously with the real world and virtual objects superimposed upon one another, is being actively studied for its utility in IR. HoloLens by Microsoft (Seattle, US) is a head-mounted display which projects clinical or technical information to aid in performance during the interventional procedure. ²⁴ Other software systems use fiducial points placed on skin prior to the procedure to allow seamless integration of real and virtual data, enabling direct guidance of interventional tools within the body. ²⁵ The benefits of such tools has been demonstrated in non-clinical trials. A recent study has demonstrated increased procedural efficiency and decreased radiation dose. ²⁶

Research and development on untethered robots and their potential utility in IR is also underway. ²⁷ Robotic technologies have the potential to improve the precision of interventionalists while telerobotics allow operators to provide care hundreds of kilometers away, improving access to interventional treatments in rural Canada and for Indigenous peoples in remote communities. ²⁸ Once this technology evolves into everyday practice, it will work towards addressing longstanding inequities in healthcare due to geography and will improve access to life-saving IR treatments, such as embolization for uncontrolled bleeding and endovascular stroke therapy. The future potential of telerobotics is remarkable.

Future Staffing Considerations

As volumes increase, procedural wait-times, IR suite turnover times and length of hospital stay become important quality of care and budgetary considerations, ones that are closely tied to staffing of the IR suite. The IR team consists of nurses, MRTs, interventionalists, and administrative staff. As IR continues to grow, so will the need for highly qualified multidisciplinary angiography teams. The SIR position statement on staffing guidelines recommends a 1:3 nurse-to-bed ratio in the pre/post procedure areas in addition to at least one individual to scrub and assist the physician, one nurse to administer sedation, and one MRT. ²⁹ In high acuity and complex cases more nonphysician staff members are needed. Designated on-call and backup-call teams will further increase staffing demands. The addition of nurse practitioners and physician assistants to IR practice will also be essential in elevating patient care and clinical continuity in both inpatient and elective outpatient care.

Along with this will be the need for expanded facilities and access to resources including both in-hospital patient care facilities, outpatient clinics and minor procedures spaces. Anesthesiology involvement will also be important. Technological advances will continue to allow more advanced interventions to be performed on medically complex patient populations which will necessitate access to anesthesiology. The expertise provided by anesthesiology significantly improves periprocedural patient care. ³⁰ A review of the National Anesthesia Clinical Outcomes Registry data showed that within non-operating room anesthesia locations, cardiology and radiology locations had increased complication rates. ³¹ In a 2014 survey of active SIR members, 74% agreed that institutional guidelines to mandate staffing and anesthesia support based on case and patient complexity would improve patient care at their institutions. ³² Further, only 56% of respondents agreed that anesthesia services were readily available after hours and on weekends. With increasing patient and procedural complexity, anesthesiology availability in the IR suite in Canada will be important for optimal patient care, safety, and comfort, along with reducing medical complications.

Future Funding Models and Evolving Relationship With Diagnostic Imaging

Paramount to IR affirming itself as an independent specialty is the need for fee schedule restructuring in Canada. Currently, in most Canadian provinces, IR billing codes are substantially lower than those of diagnostic imaging despite the expertise required, risk involved, procedural times and patient complexity. Ongoing disparities in fee structure can serve to disincentivize entry into the field and dictate hiring practices. It can also propagate practice dynamics which disempower interventional radiologists, who based on current fee schedules, will often generate significantly lower billings in combined group practices.

Additionally, some provinces do not have a dedicated fee code for interventional radiology consults which include both history and physical examination. Dedicated province-wide fee codes for pre- and post-procedure consults are necessary for fair reimbursement of longitudinal care, akin to our other specialist colleagues. In parallel, diagnostic radiology should embrace and support an IR clinical practice with dedicated time, staffing and infrastructure. Interventional Radiology is often the “face” of the radiology practice, and a robust clinical IR practice offers many advantages to diagnostic radiology, including improving patient care, hospital relations, and relationships with non-radiology physicians and imaging volumes.

As in all partnerships, the relationship between DI and IR will continue to evolve. Practice models will vary by province, city, and institution; however, by definition the practice of IR is embedded within the practice of diagnostic imaging. General and specialized imaging expertise is a core competency and complete divergence of these specialties is not possible nor desirable. Rather, the discipline-specific attributes of IR merit its sub-specialty status and the resource allocation that follows. In some future practices, IR shall remain as a division under “Medical Imaging.” In others, future practice may manifest as a separate department whereby IR works parallel but separate to DI. Irrespective of center-specific models, over the next 10–20 years, the concept of “Clinical IR” will have long become the standard of practice for IR physicians across Canada and not just the ideal model for which we continue to advocate. In addition to medical device innovation, the future IR practice will harness healthcare analytic technology. Research and data collection with clinical outcome and an economic focus will drive adoption of IR treatments in an economically pressured health care environment. Angio-teleradiology services will parallel current diagnostic teleradiology practices, enabling access to IR nationwide, including remote-access communities where IR care is currently limited.

Conclusion

When predicting the future, uncertainty is inherent to the task. However, we can be certain that the demand for interventional radiology will continue to increase. There will be many more innovations which will significantly impact patient care by decreasing morbidity and mortality. Interventional Radiologyprocedures will allow patients to return to their respective jobs and activities more quickly, improving their quality of life. Interventional Radiology staffing including physicians, technologists, nurses, and ancillary staff will increase. Concurrently, Interventional Radiology budgets will need to reflect the cost of angiography suites, devices, and health care worker salaries. Existing archaic budget models will need to change to accommodate these factors. Interventional Radiology fee codes and consult codes also need to reflect and compensate the current non-billable work many IRs are performing, allowing clinical IR to thrive. In the interim, it will be up to the individual and collective body of interventional and diagnostic radiologists to continue to promote and advocate for our patients, and improve access to IR in Canada.