Executive Summary - CMII 2019 - 2020

The purpose of this inventory is to document current practices and developments in the supply, distribution, technical operations, and general clinical use of advanced imaging equipment. This is the third iteration of the Canadian Medical Imaging Inventory (CMII) since we resumed the collection of this data in 2015. Previously, the Canadian Institute for Health Information (CIHI) collected data on medical imaging technologies in Canada from 2003 to 2012.

Methods

Information was collected on six imaging modalities using a web-based survey, supplemented with information from provincial and territorial validators, report peer reviewers, and literature searches. The imaging modalities were:

• CT
• MRI
• single-photon emission computed tomography (SPECT)
• PET-CT
• PET-MRI
• SPECT-CT.

The survey opened on November 27, 2019, and data collection formally closed on February 11, 2020. Data from the previous iteration of the survey were saved, and respondents were invited to update the data associated with their sites or, if there was no pre-existing entry, to complete the survey. High-level data were reviewed by pre-identified regional and provincial validators, who supplied corrections and supplementary data, which were entered in the database. Identified stakeholders and survey respondents were given the opportunity to review the report during the stakeholder feedback process.

Results

Data from 455 sites were used to inform the findings of this report. Updated or new survey responses were received for at least 244 sites. Provincial and territorial validators provided some information for nonresponding publicly funded health facilities. The majority of sites were publicly funded. Seventy-three percent of sites were urban, 24% were rural, and 2% were remote.

Computed Tomography

• A total of 549 CT units were identified in Canada, up from 484 in 2010. All provinces or territories had at least one unit. Ontario and Quebec had the most units, followed by British Columbia and Alberta. The three northern territories had one unit each.
• An estimated 5,419,821 CT examinations were performed in the most recent fiscal year in Canada, up from 4,122,158 in 2010. This is equivalent to 143.4 exams per thousand people, up from 121.9 in 2010.
• In the next 20 years, the volume of CT exams is anticipated to increase by 18%, based on population projections and current use.
• CT units operate for an average of 80.5 hours per week and 12.6 hours per day. Most operate on weekends. CT is used across disciplines, with approximately one-quarter of the time used in the field of oncology, followed by neurology, hepatobiliary exams, and respiratory exams.
• When the number of CT units per population for Canada is compared with that in other countries that report CT units to the Organisation for Economic Co-operation and Development (OECD), Canada appears in the lower quarter of the reported numbers. For the number of exams per population, Canada appears around the midpoint.
• Referring physicians use clinical decision support tools (CDSTs) for 61% of CT exams ordered at the point of care.
• One-third of CT units are five years old or less, 28% are six to 10 years old, 27% are 11 to 15 years old, and 5% are 16 to 20 years old.
• Almost half of CT units have 64 cross-sectional images or slices, and about one-quarter have 128 slices. More than three-quarters of CT units incorporate image reconstruction techniques for dose reduction, 88% are equipped with dose-management controls, and 95% record dose by exam.

Magnetic Resonance Imaging

• A total of 378 MRI units were identified in Canada, up from 281 in 2010. All provinces and one territory have at least one unit. Ontario and Quebec have the most units, followed by British Columbia and Alberta. Yukon and Prince Edward Island have single units.
• An estimated 2,330,223 MRI examinations were performed in the most recent fiscal year in Canada, up from 1,434,499 in 2010. This is equivalent to 61.6 exams per thousand people, up from 42.4 per thousand people in 2010.
• In the next 20 years, the volume of MRI exams is anticipated to increase by 20%, based on population projections and current use.
• MRI units operate for an average of 87.8 hours per week and 14.1 hours per day. More than half operate on weekends. MRI is used across disciplines, with half of all use split between neurology and musculoskeletal exams, followed by oncology and hepatobiliary exams.
• When the number of MRI units per population for Canada is compared with that in other countries that report MRI units to the OECD, Canada appears in the lower third of the reported numbers. For the number of exams per population, Canada appears around the midpoint.
• Referring physicians use CDSTs for 18% of MRI exams ordered at the point of care.
• Less than one-third of MRI units are five years old or less, 26% are six to 10 years old, 26% are 11 to 15 years old, and 10% are 16 to 20 years old.
• The majority (80%) of MRIs have field strengths of 1.5 tesla.

Positron Emission Tomography–Computed Tomography or Positron Emission Tomography

• A total of 57 PET-CT units were identified in Canada, up from 40 in 2010. Nine provinces have at least one unit. Ontario and Quebec have the most units.
• An estimated 125,775 PET-CT examinations were performed in the most recent fiscal year in Canada. This is equivalent to 3.4 exams per thousand people.
• In the next 20 years, the volume of PET-CT exams is anticipated to increase by 16%, based on population projections and current use.
• PET-CT units operate for an average of 43.4 hours per week and 9.0 hours per day. Most PET-CT units do not operate on weekends. PET-CT is primarily used for oncology exams (79%), followed by cardiac and neurological use.
• When the number of PET-CT units per population for Canada is compared with that in other countries that report PET-CT units to the OECD, Canada appears in the lower third of the reported numbers. For the number of exams per population, Canada appears below the midpoint.
• Referring physicians use CDSTs for 26% of PET-CT exams ordered at the point of care.
• Almost one-quarter of PET-CT units are five years old or less, 28% are six to 10 years old, and 33% are 11 to 15 years old.
• Half of PET-CT units have 16 slices. The majority of units (90%) are equipped with dose-management controls, and 86% record patient radiation dose by exam.
• The most commonly used isotopes for oncology are fluorine-18–fluorodeoxyglucose (18F-FDG), followed by fluorine-18–sodium fluoride (18F-NaF).
• One-third of sites with PET-CT units have access to a local cyclotron to generate radioisotopes.

Positron Emission Tomography–Magnetic Resonance Imaging

• A total of five PET-MRI units were identified in Canada. Four are located in Ontario, and one unit is in Alberta.
• As PET-MRI is used for research purposes only, we do not have data on clinical examinations or use.

Single-Photon Emission Computed Tomography

• A total of 305 SPECT units were identified in Canada, down from 618 (including gamma cameras) in 2010. Nine provinces have at least one unit. Ontario and Quebec have the most units, followed by Alberta and British Columbia.
• Individual data for SPECT exams were not available for all provinces, so the combined exams are reported under SPECT-CT. Exam data for 2010 were not available.
• SPECT units operate for an average of 43.8 hours per week and 8.9 hours per day. A minority of units operate on weekends. SPECT is primarily used for cardiac examinations (36%), followed by oncology and musculoskeletal exams.
• Most referring physicians do not use CDSTs for SPECT exams ordered at the point of care.
• One-third of SPECT units are 11 to 15 years old, 28% are 16 to 20 years old, 17% are six to 10 years old, and 5% are five years old or less.
• Three-quarters of units have two detector heads, and one-quarter are dedicated cardiac units.

Single-Photon Emission Computed Tomography–Computed Tomography

• A total of 271 SPECT-CT units were identified in Canada, up from 98 in 2010. Ten provinces have at least one unit. Ontario and Quebec have the most units, followed by Alberta and British Columbia.
• A total of 1.2 million SPECT or SPECT-CT exams were carried out in Canada.
• In the next 20 years, the volume of SPECT and SPECT-CT exams is anticipated to increase by 13% based population projections and current use.
• SPECT-CT units operate for an average of 45.6 hours per week and 9.0 hours per day at responding sites. A minority of units operate on weekends. SPECT-CT is primarily used for cardiac examinations (33%), followed by musculoskeletal and oncology exams.
• Most referring physicians do not use CDSTs for SPECT-CT exams ordered at the point of care.
• Almost half of SPECT-CT units are five years old or less, 25% are six to 10 years old, and 24% are 11 to 15 years old.
• Almost all units have two detector heads, two-thirds are equipped with dose-management controls and 67% recorded patient radiation dose by exam. More than two-thirds incorporated image reconstruction techniques for dose reduction.

Picture Archiving and Communication Systems

• Almost one-third (30%) of sites had access to a local or institutional picture archiving and communication system (PACS) network, 30% had access to a regional network, and one-third (39%) had access to a provincial network.
• Almost all sites allow access to PACS images outside the imaging department, and two-thirds allow access to other sites within the provincial health care system.
• Sites with PACS that are geographically close may not necessarily be able to share images, if they are on separate networks with different protocols.

Appropriate Imaging

• Most imaging facilities (84%) have processes in place to determine the appropriateness of orders. Radiologist review of exam orders is the most commonly adopted process.

Limitations

• For feasibility, this iteration of the survey was restricted to six specialist imaging modalities and does not include others that are more common and widespread (e.g., conventional X-ray radiography and ultrasonography).
• As we do not have a definitive list of facilities containing the equipment, and, as the survey was voluntary, we cannot ensure that all facilities or departments containing the modalities were contacted or represented.
• For some survey questions, data were available for only a limited number of sites.