The health of the population and health care cost.

The United Nations Millennium Declaration signed in September, 2000 was
aimed to combat poverty, hunger, disease, illiteracy, environmental
degradation, and discrimination against women and was to be achieved by the
year 2015 1.  Although there has been progress, many countries
have fallen short of attaining the intended goals.  In a 2012 study, 92% of women reported
experiencing some form of sexual violence in public spaces while 88% reported
experiencing some form of verbal sexual harassment 2.  Over 700 million women were married under the
age of 18, and of those some 250 million were married before the age of 15 3.  A European Union survey showed that 34% of
women with a health problem or disability were victims of violence by a
partner, compared to 19% per cent of women without a health problem or disability
4.  In 2013, the global employment-to-population
ratio was 72% for men and 47% for women 5.  Of the 585 peace agreements from 1990 to
2010, only 92 contained any reference to women 6. 

The special
issue of the Pan American Journal of Public Health on women’s health addressed
issues faced by women: maternal death, severe maternal morbidity, femicide,
physical and sexual violence, regional and ethnic inequalities, mental health,
HIV, aging, suicide, obesity, breast cancer, and alcohol use 7.  Some health challenges and diseases affect
both women and men; however, women experience pregnancy and childbirth which
can potentially carry health risks and require access to care tailored
specifically to their needs.  Moreover, women
face greater difficulties in getting the health care or protect their health
due to gender inequalities in education, income and employment 8.
 

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Radiology plays a crucial role in primary care as it is used for screening,
diagnosis and management of many diseases, however, radiology must be used appropriately
to reach its full potential in public health. 
With timely and accurate diagnosis, mortality and morbidity have the
potential to be reduced thus improving the health of the population and health
care cost.  Many Latin American and
Caribbean (LAC) countries face a number of challenges including but not limited
to a lack of quality assurance programs and standardization, shortage of
qualified human resources and a lack of functioning and updated equipment which
has led to the rendering of suboptimal services.  The article will cover 1) some of the main
health issues affecting women that can be addressed with available radiology
equipment, 2) the importance of quality assurance programs in radiology in
reducing adverse events. 

 

Quality Assurance

Around 80%-90% of diagnostic problems can easily be solved using
“basic” X-ray examinations and/or ultrasound examinations, regardless
of the type of hospital or medical setting. 
Unfortunately, two-thirds of the world’s population lack access to
radiology services and when available, both the quality and safety of the
procedures are questionable 9.   The disparity between low and high income
countries in access to nuclear medicine (NM), magnetic resonance imaging (MRI, single-photon
emission computed tomography/computed tomography (SPECT/CT), PET/CT or PET/MR
is vast with an average of 10% of countries having at least one PET scanner,
33% having at least one linear accelerator, 54% have at least one MRI unit 10.  In some countries, nearly 80% of health care
equipment is donated or funded by international donors or foreign governments,
but only 10–30% of donated equipment becomes operational 10.

For this
purpose, the use of available technologies such as conventional x-ray,
ultrasound, mammography and computer tomography is beneficial, but must be used
effectively.  Quality Assurance (QA) is
defined as planned and systematic actions that will consistently produce high
quality images with minimum exposure to the patients and workers 11.
In a high quality program both the approach to testing (quality administration
procedure) and the implementation (quality control technique) must be completed
correctly 17. QA has shown to improve the quality of care and reduction of
adverse events.  The World Health
Organization (WHO) defines adverse events as an incident resulting in harm to
patients 12.  An adverse event is a threat to patient
safety brought upon by inaccurate and untimely diagnosis, unjustified and
repeated radiation exposure, incorrect labelling of radiographic images, poor
technique in the execution of the exam, lack of knowledge, error in the
interpretation of a radiograph, including misdiagnosis or failure to diagnose,
failure to suggest an appropriate procedure, failure to communicate in a timely
and clinically appropriate manner and healthcare-associated infections 13.  Without a QA program or standardization, the
many aspect of image process is compromised; the equipment purchased may not meet
the need of the population, quality control tests will not performed, there is
a lack of proper training and supervision of allied health staff, lack of
design of imaging protocols; policies and procedures for patient management,
safety and reporting standardization.  For
proper interpretation of the image as well as a timely and accurate diagnosis,
the quality of the image must of optimal which will potentially lead to the
reduction of mortality and morbidity. 

Quality Assurance in Medical Imaging may be traced back to the early
1900’s with dose monitoring and radiation protection practices, to the 1930’s
with processor monitoring, to current practices in image quality evaluation. For
many in the Medical Imaging environment governmental regulations dictate QA
processes to ensure patient safety and a minimum image quality standard, as
well as, training and education requirements for Radiologist, Physicists and
Technologists.  In addition to, or in
place of governmental regulations many professional groups provide guidelines
or accreditation programs to aid in the process and to document achievement of
quality imaging services. Examples of common programs are: the American College
of Radiology, Intersocietal Accreditation Commission furthermore, the following
organizations provide ample resource to support a quality assurance program: American
Association of Physicist in Medicine, and Radiological Society of North America
14
15
16
17.
Establishing appropriate QA practices ensures proper equipment operation for
radiation safety, image quality for viewing and ultimately accurate interpretation
and diagnosis. All modalities, Radiography, CT, MR, Nuclear Medicine and
Sonography have QA programs.   A cultural shift in which all radiology
workers and health authorities assume responsibility for the quality,
efficiency, safety improvements and behave consistently with the core values to
minimize or eliminate adverse events is essential.  For this purpose, the Pan American Health
Organization (PAHO) and partners have developed international Basic Safety
Standards (BSS) that are beneficial for the Region:
http://www.paho.org/hq/index.php?option=com_content&view=article&id=9828%3A2014-radiationprotection&catid=3316%3Apublications&Itemid=3562&lang=en 

 

ROLE OF
IMAGING MODALITIES IN WOMEN’S HEALTH:

 

Breast cancer

In the Americas, more than 408,200 women were diagnosed with breast
cancer and 92,000 women died from this disease around 46% of these deaths occur
in LAC. Mortality in high income countries is often low due to the favorable
breast cancer detection and treatment.  Despite
the improvements in breast cancer care made in the past 20 years with early screening
diagnosis and treatment, breast mortality is still high in LAC 18.  Mammography is the imaging technology of
choice since it has led to earlier diagnosis and reductions in breast cancer
mortality by 20% 19.  Early detection of breast cancer by mammography
also leads to a greater range of treatment options, including less-extensive
surgery and the use of chemotherapy with fewer serious side effects, or even,
in some cases, the option to forgo chemotherapy 20.
Approximately, 61% of breast cancers diagnosed at a localized stage has a
5-year relative survival is 99% 20.   There
is a clear correlation between the stage at diagnosis and the overall survival
or outcome.  In some countries in LAC, an
estimated 50% of detected breast cancer is in advanced stages (stage III or IV)
compared to Sweden where less than 10% of breast cancer is detected at that stage
21.
In Canada, 2%, 5 % and 8% of patients with stage I, III and stage respectfully
died, yet 49% of patients who perished were stage IV breast cancer 22.  The economic burden of breast cancer in LAC
is challenging to estimate, but costs for treating patients with stage IV
breast cancer is more likely to be around three to four times higher than for
patients with stage I breast cancer 21.
Because of the importance of mammography in accurately diagnosing breast
cancer, particularly in earlier stages, it is essential that all mammograms be
performed and interpreted with the highest possible quality standards. The
existence of a strict adherence to QA programs and quality control (QC)
measures must be practiced in order to assure the most accurate diagnoses for
all patients.  A well-organized screening
program should not only include the acquisition of mammography units, but an
environment that will permit detection of breast cancer at an earliest, most
treatable stage 19.  QA programs can minimize adverse events by
limiting the production of poor image quality, inaccurate diagnosis which has
the potential to delay the detection of breast cancer at an early, treatable stage.  PAHO Manual on Mammography Services Quality
Assurance: Baseline Standards for Latin America and the Caribbean:
http://iris.paho.org/xmlui/handle/123456789/31402 can be used as a guide for such
services.  A culture of patient safety is
crucial especially regarding the quality of the images produced and radiation
exposure.  Image quality is proportional
to the diagnostic information acquired which will play a crucial role in
patients’ treatment and outcome since early detection increases chances of
survival. 

 

Breast Sonography:

 

Although screening
mammography has been found to decrease mortality from breast cancer, it is an
imperfect tool for women with dense breast tissue as characterized by breast
density BI-RADS categories 3 and 4 23. Multiple studies have been
conducted comparing breast cancer detection of mammography versus mammography
and whole breast screening ultrasound imaging. These studies have found whole
breast ultrasound screening increased detection of small, invasive,
node-negative cancers over the use of mammography alone in women with dense
breast tissue 23 24 26 25. Additionally, the American
College of Radiology Imaging Network performed a prospective international
multicenter research study, in which it compared the findings of mammography
and hand-held, high-resolution ultrasound exams, irrespective of breast
density, in identifying breast cancers. The study concluded that the total
number of cancers identified was comparable: 58 of 111 (52.3%) for ultrasound
and 59 of 111 (53.2%) for mammography 24.

The many benefits of ultrasound,
such as its portability, cost and nonionizing radiation, allow for it to be a
readily available imaging modality in developing countries. The results of multiple
studies support the sensitivity of whole breast screening ultrasound to
identify cancer and could be a viable alternative in countries without
mammography equipment. However, image acquisition and interpretation requires a
significant amount of training and time. QA programs, imaging standards and
training should be considered prior to implementing whole-breast screening
exams 26.

 

 Cervical Cancer

Cervical cancer is a worldwide public health concern, with the greatest
impact realized in low and middle income countries, which includes Latin America
and the Caribbean (LAC) 27.
Approximately 77,000 women die from cervical cancer and 30,000 new cases are
diagnosed each year in LAC 28.  The numbers of individuals that succumb to
cervical cancer are much higher in low and middle income countries due to the
lack of widespread screening programs as well as a higher percentage of
infections with human papilloma virus (HPV) type 16 & 18, known to have
greater cancer causing potential 2930.  Many cervical cancers in these regions are
diagnosed in the later, more advanced, stages when appropriate screening was
unavailable. High income countries have vast screening programs, finding
cervical cancers at the earliest most treatable stages resulting in fewer
deaths 31.
 The most significant risk factor for
cervical cancer is HPV infection, contracted through unsafe sexual practices 27.
Additionally, smoking, HIV infection and long term use of oral contraceptives
are contributing risk factors for cervical cancer 29.
 Without HPV infection the development of
cervical cancer is quite low. As early as 2002 an HPV vaccine has been
available to prevent HPV infection and therefore cervical cancers in the
future. As described by Clifford et al, “vaccination against HPV 16 & 18
should prevent 70% of worldwide Invasive Cervical Cancer” 30.
 When vaccination is not desired,
contraindicated or unavailable transmission prevention through education and
safe sexual practices is the key to prevention.

When preventative measures have failed it is imperative to have the
highest quality detection and   treatment
available. Without screening programs, namely the Papanicolaou (PAP) smear
examination, diagnosis is performed through clinical examination, biopsy and
histopathology. The International Federation of Gynecology and Obstetrics
(FIGO) developed a staging system that incorporates clinical, histological and
radiologic data (not including PET/MR/CT) to stage cervical cancer 31.
Medical Imaging Modalities are instrumental in the treatment planning process
and follow up of cervical cancer patients. The use of Positron Emission
Tomography (PET), Magnetic Resonance imaging (MR) and Computed Tomography (CT)
aid in the assessment of disease spread and the need for surgical intervention.
PET imaging is useful in lymph node evaluation, where MR assesses the
parametrical region well. It is recognized that both PET and MR are superior
modalities in the assessment of cervical cancer, but not readily available
imaging modalities in most of the LAC regions; therefore the use of CT is
appropriate 32.
 CT is not a valuable tool in the early
stages of cervical cancer, it is however helpful in late stage assessment, 42%
sensitive for detecting advanced disease, with a 31% sensitivity and 86%
specificity for lymph node involvement 33.
 CT also provides information on distant
metastases and roadmap for interventional procedures. According to the American
College of Radiology (ACR) appropriateness criteria MRI without and with IV
contrast is the highest rated imaging exam, second is PET/CT, with IV enhanced
CT following 33.
 It is important to note that although CT
is not the “gold standard” in cervical cancer imaging, when performed at the
highest level, CT imaging can aid in the appropriate treatment of the patient.
Treatment options range from chemoradiotherapy where available to surgery or a
combination there of. When diagnosis is performed and treatment given, “80-95%
of women with early stage disease (stages I and II) and 60% with stage III
disease can be cured” 31.

 

Postpartum hemorrhage

 

Decreasing maternal mortality rate (MMR) from preventable causes has been
a global priority beginning with the UN Millennial Developmental Goals (MDG) in
2000 and continues with the Sustainable Development Goals (SDG) established in
2016. Although substantial progress had been made under the MDG, maternal
mortality rate is still at an unacceptable level with approximately 830 women
dying each day worldwide from preventable causes related to pregnancy and
childbirth 34.
The data collected on MMR demonstrates that 99% of all preventable maternal
deaths occur in low-resource countries, with the highest risk for adolescent
girls under the age of 15 and for females who live in rural and poor
communities 34.  The disparity of health care, specifically
access to quality obstetric care and services, is directly related to maternal
outcomes 35,
36.
Ultrasound is part of routine prenatal care in developed countries, as it can
accurately date a pregnancy and identify fetal abnormalities, malpresentation,
multiple gestations, and placenta previa, which allows a physician to manage
the pregnancy properly and improve outcomes 36.  Sonography is the imaging modality of choice
for the postpartum patient who is febrile or experiencing complications such as
vaginal discharge, bleeding and pain 37,
38.
In many developing countries and especially rural communities¬, obstetric
services, including availability of ultrasound services and trained individuals
to perform the exams, are extremely limited or nonexistent, leaving women
vulnerable to poor outcomes.

Hemorrhage
is the leading cause of maternal death in LAC at 23.1%, with the greatest
proportion (57%) of deaths in the postpartum period 35,
39.
Postpartum hemorrhage (PPH) is divided into primary PPH (defined as 24 hours
after delivery) and secondary PPH (defined as more than 24 hours after delivery
to six weeks postpartum) as well as four general classifications of causes:
tone, trauma, tissue and thrombin 40,
41.
Primary PPH due to uterine atony makes up 70% of all PPH cases 44.
Utilization of uterotonic drugs and active management of the third stage of
labor are strategies to address primary PPH associated with uterine atony 39. 

Sonography
of the postpartum uterus can be used to identify other causes of PPH such as
retained products of conception, AV malformations, endometritis, abscess, wound
cellulitis, and surgical complications like hematoma, pseudoaneurysms, or
uterine scar dehiscence 38.
Imaging studies are used to identify the source of bleeding and to help
determine if surgical intervention is warranted 38.
Interpretation of sonographic studies of the postpartum uterus can be
complicated as there is significant overlap between pathologic and normal
physiologic changes of the uterus. However, utilizing sonography to evaluate symptomatic
patients can facilitate early intervention and treatment and lead to a decrease
in MMR 38,42.

 

Additional
Diseases Affecting Women  

Additional diseases or
conditions within NCDs and respiratory diseases are included in the table.  In the Americas, one in three women has
experienced intimate partner violence or sexual violence by a non-partner
during her lifetime 43.  Women
who are victims of violence are more likely to experience acute or immediate
physical injuries, such as abrasions, lacerations, burns and bites, as well as fractures
and acquired immune deficiency syndrome (AIDS) related death.  In addition, they will experience unwanted
pregnancies, abortions, pregnancy complications/miscarriage and vaginal
bleeding or infections to name a few 44.

Tuberculosis claims the lives of 23 000 every year in the Americas and TB
mortality among women is associated with literacy, basic sanitation, drinking
water coverage, and nutritional status 45.   

CVDs,
including heart attacks and strokes, continue to be the leading cause of death
in almost all countries, accounting for 1.63 million deaths (37.5 percent)
annually.  Women are more likely to be
obese in the Americas with 27.4 percent compared to 21.7percent of men.  Subsequently, women have higher rates of
heart attack complications and more associated deaths 4810. 

 

 
DISEASES
 

 
ULTRASOUND

 
COMPUTED TOMOGRAPHY

 
CONVENTIONAL X-RAY
 

Injuries/ Violence

Sonograms of extremities to identify hematomas,
DVT, and AVM
Sonogram of thorax or abdomen to look for free
fluid

CT provides high quality imaging of
musculoskeletal injuries such as fracture/ dislocation. Injury to soft tissue
organs such as liver and kidney are also assessed with CT. Head trauma,
hematomas, contusions, hemorrhage are effectively diagnosed with CT.

X-ray of affected anatomy to assess fractures
and/or foreign bodies

 
TB

Ultrasound of the chest can detect pleural and
pericardial effusion, localize area for drainage 50, locate subpleural nodules
and lung consolidations 51

CT is beneficial in the assessment of
patients with lymphadenopathy, pleural effusions, and cavitation.

Chest x-ray may be sufficient for diagnosis in the
appropriate clinical setting in primary pulmonary tuberculosis

 
 
CVDs

Ultrasound evaluation including Doppler waveforms
of the blood vessels can identify plaque, or hemodynamically significant
stenosis and/or occlusion.
Ultrasound exam of the heart is used to identify
structural and functional abnormalities of the valves, chambers and muscles.

CT demonstrates calcified vessel in the body as
well as heart (calcium scoring). Additionally, imaging of arterial stenosis,
dissection or aneurysm can be accomplished with CT angiography imaging.

Chest x-ray will show fluid in or around your
lungs.  Enlarged heart Blood vessel
problems, such as an aortic aneurysm. Calcium build-up in the heart or blood
vessels.
 

 

Conclusion:

Radiology is used for screening,
diagnosis and management of many diseases which are important requirements in public
health to improve the health and wellbeing of the population, or prevent the
deterioration of their health. To assist countries in LAC, a holistic approach
must be utilized in public health with the inclusion of quality radiology
services.   Acquisition of equipment, improving image
quality and interpretation are one part of what constitute radiology
services.  Standardization is another
very important component that cannot be ignored.  Without standardization, the services offered
are suboptimal thus a threat to patient safety and will minimize the influence
to radiology in public health.  Patient
safety is an essential principle of health care and adverse events must be
reduced to establish an effective system. 
There are no shortcuts to patient safety and quality of care; radiology
plays a crucial role in reducing the morbidity and mortality.  History has shown women facing constant barriers
in society, yet an educated and healthy woman will have a positive impact in a
community.  With inadequate rendering of
radiology services, the patient becomes a victim not only of the disease but
the services that fail to provide proper management.  The role of radiology in women’s health
cannot be underestimated or ignored; however, the services must be of quality
to yield positive outcomes. Radiology must establish itself in public health
and women’s health.