The health of the population and health care cost.

The United Nations Millennium Declaration signed in September, 2000 wasaimed to combat poverty, hunger, disease, illiteracy, environmentaldegradation, and discrimination against women and was to be achieved by theyear 2015 1.  Although there has been progress, many countrieshave fallen short of attaining the intended goals.  In a 2012 study, 92% of women reportedexperiencing some form of sexual violence in public spaces while 88% reportedexperiencing some form of verbal sexual harassment 2.

  Over 700 million women were married under theage of 18, and of those some 250 million were married before the age of 15 3.  A European Union survey showed that 34% ofwomen with a health problem or disability were victims of violence by apartner, compared to 19% per cent of women without a health problem or disability4.  In 2013, the global employment-to-populationratio was 72% for men and 47% for women 5.  Of the 585 peace agreements from 1990 to2010, only 92 contained any reference to women 6.  The specialissue of the Pan American Journal of Public Health on women’s health addressedissues 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 affectboth women and men; however, women experience pregnancy and childbirth whichcan potentially carry health risks and require access to care tailoredspecifically to their needs.  Moreover, womenface greater difficulties in getting the health care or protect their healthdue to gender inequalities in education, income and employment 8. 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 appropriatelyto reach its full potential in public health.

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 With timely and accurate diagnosis, mortality and morbidity have thepotential to be reduced thus improving the health of the population and healthcare cost.  Many Latin American andCaribbean (LAC) countries face a number of challenges including but not limitedto a lack of quality assurance programs and standardization, shortage ofqualified human resources and a lack of functioning and updated equipment whichhas led to the rendering of suboptimal services.  The article will cover 1) some of the mainhealth issues affecting women that can be addressed with available radiologyequipment, 2) the importance of quality assurance programs in radiology inreducing adverse events.

    Quality AssuranceAround 80%-90% of diagnostic problems can easily be solved using”basic” X-ray examinations and/or ultrasound examinations, regardlessof the type of hospital or medical setting. Unfortunately, two-thirds of the world’s population lack access toradiology services and when available, both the quality and safety of theprocedures are questionable 9.   The disparity between low and high incomecountries in access to nuclear medicine (NM), magnetic resonance imaging (MRI, single-photonemission computed tomography/computed tomography (SPECT/CT), PET/CT or PET/MRis 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 careequipment is donated or funded by international donors or foreign governments,but only 10–30% of donated equipment becomes operational 10.For thispurpose, the use of available technologies such as conventional x-ray,ultrasound, mammography and computer tomography is beneficial, but must be usedeffectively.  Quality Assurance (QA) isdefined as planned and systematic actions that will consistently produce highquality images with minimum exposure to the patients and workers 11.In a high quality program both the approach to testing (quality administrationprocedure) and the implementation (quality control technique) must be completedcorrectly 17.

QA has shown to improve the quality of care and reduction ofadverse events.  The World HealthOrganization (WHO) defines adverse events as an incident resulting in harm topatients 12.  An adverse event is a threat to patientsafety brought upon by inaccurate and untimely diagnosis, unjustified andrepeated radiation exposure, incorrect labelling of radiographic images, poortechnique in the execution of the exam, lack of knowledge, error in theinterpretation of a radiograph, including misdiagnosis or failure to diagnose,failure to suggest an appropriate procedure, failure to communicate in a timelyand clinically appropriate manner and healthcare-associated infections 13.  Without a QA program or standardization, themany aspect of image process is compromised; the equipment purchased may not meetthe need of the population, quality control tests will not performed, there isa lack of proper training and supervision of allied health staff, lack ofdesign of imaging protocols; policies and procedures for patient management,safety and reporting standardization.  Forproper 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 thereduction of mortality and morbidity.  Quality Assurance in Medical Imaging may be traced back to the early1900’s with dose monitoring and radiation protection practices, to the 1930’swith processor monitoring, to current practices in image quality evaluation. Formany in the Medical Imaging environment governmental regulations dictate QAprocesses to ensure patient safety and a minimum image quality standard, aswell as, training and education requirements for Radiologist, Physicists andTechnologists.  In addition to, or inplace of governmental regulations many professional groups provide guidelinesor accreditation programs to aid in the process and to document achievement ofquality imaging services.

Examples of common programs are: the American Collegeof Radiology, Intersocietal Accreditation Commission furthermore, the followingorganizations provide ample resource to support a quality assurance program: AmericanAssociation of Physicist in Medicine, and Radiological Society of North America14151617.Establishing appropriate QA practices ensures proper equipment operation forradiation safety, image quality for viewing and ultimately accurate interpretationand diagnosis. All modalities, Radiography, CT, MR, Nuclear Medicine andSonography have QA programs.   A cultural shift in which all radiologyworkers and health authorities assume responsibility for the quality,efficiency, safety improvements and behave consistently with the core values tominimize or eliminate adverse events is essential.  For this purpose, the Pan American HealthOrganization (PAHO) and partners have developed international Basic SafetyStandards (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 OFIMAGING MODALITIES IN WOMEN’S HEALTH:  Breast cancerIn the Americas, more than 408,200 women were diagnosed with breastcancer and 92,000 women died from this disease around 46% of these deaths occurin LAC.

Mortality in high income countries is often low due to the favorablebreast cancer detection and treatment.  Despitethe improvements in breast cancer care made in the past 20 years with early screeningdiagnosis and treatment, breast mortality is still high in LAC 18.  Mammography is the imaging technology ofchoice since it has led to earlier diagnosis and reductions in breast cancermortality by 20% 19.

  Early detection of breast cancer by mammographyalso leads to a greater range of treatment options, including less-extensivesurgery 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 a5-year relative survival is 99% 20.   Thereis a clear correlation between the stage at diagnosis and the overall survivalor outcome.  In some countries in LAC, anestimated 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 stage21.

In Canada, 2%, 5 % and 8% of patients with stage I, III and stage respectfullydied, yet 49% of patients who perished were stage IV breast cancer 22.  The economic burden of breast cancer in LACis challenging to estimate, but costs for treating patients with stage IVbreast cancer is more likely to be around three to four times higher than forpatients with stage I breast cancer 21.Because of the importance of mammography in accurately diagnosing breastcancer, particularly in earlier stages, it is essential that all mammograms beperformed and interpreted with the highest possible quality standards. Theexistence of a strict adherence to QA programs and quality control (QC)measures must be practiced in order to assure the most accurate diagnoses forall patients.

  A well-organized screeningprogram should not only include the acquisition of mammography units, but anenvironment that will permit detection of breast cancer at an earliest, mosttreatable stage 19.  QA programs can minimize adverse events bylimiting the production of poor image quality, inaccurate diagnosis which hasthe potential to delay the detection of breast cancer at an early, treatable stage.  PAHO Manual on Mammography Services QualityAssurance: Baseline Standards for Latin America and the Caribbean:http://iris.paho.

org/xmlui/handle/123456789/31402 can be used as a guide for suchservices.  A culture of patient safety iscrucial especially regarding the quality of the images produced and radiationexposure.  Image quality is proportionalto the diagnostic information acquired which will play a crucial role inpatients’ treatment and outcome since early detection increases chances ofsurvival.   Breast Sonography: Although screeningmammography has been found to decrease mortality from breast cancer, it is animperfect tool for women with dense breast tissue as characterized by breastdensity BI-RADS categories 3 and 4 23. Multiple studies have beenconducted comparing breast cancer detection of mammography versus mammographyand whole breast screening ultrasound imaging.

These studies have found wholebreast ultrasound screening increased detection of small, invasive,node-negative cancers over the use of mammography alone in women with densebreast tissue 23 24 26 25. Additionally, the AmericanCollege of Radiology Imaging Network performed a prospective internationalmulticenter research study, in which it compared the findings of mammographyand hand-held, high-resolution ultrasound exams, irrespective of breastdensity, in identifying breast cancers. The study concluded that the totalnumber of cancers identified was comparable: 58 of 111 (52.

3%) for ultrasoundand 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 areadily available imaging modality in developing countries. The results of multiplestudies support the sensitivity of whole breast screening ultrasound toidentify cancer and could be a viable alternative in countries withoutmammography equipment. However, image acquisition and interpretation requires asignificant amount of training and time. QA programs, imaging standards andtraining should be considered prior to implementing whole-breast screeningexams 26.

  Cervical CancerCervical cancer is a worldwide public health concern, with the greatestimpact realized in low and middle income countries, which includes Latin Americaand the Caribbean (LAC) 27.Approximately 77,000 women die from cervical cancer and 30,000 new cases arediagnosed each year in LAC 28.  The numbers of individuals that succumb tocervical cancer are much higher in low and middle income countries due to thelack of widespread screening programs as well as a higher percentage ofinfections with human papilloma virus (HPV) type 16 & 18, known to havegreater cancer causing potential 2930.  Many cervical cancers in these regions arediagnosed in the later, more advanced, stages when appropriate screening wasunavailable. High income countries have vast screening programs, findingcervical cancers at the earliest most treatable stages resulting in fewerdeaths 31. The most significant risk factor forcervical cancer is HPV infection, contracted through unsafe sexual practices 27.

Additionally, smoking, HIV infection and long term use of oral contraceptivesare contributing risk factors for cervical cancer 29. Without HPV infection the development ofcervical cancer is quite low. As early as 2002 an HPV vaccine has beenavailable to prevent HPV infection and therefore cervical cancers in thefuture.

As described by Clifford et al, “vaccination against HPV 16 & 18should prevent 70% of worldwide Invasive Cervical Cancer” 30. When vaccination is not desired,contraindicated or unavailable transmission prevention through education andsafe sexual practices is the key to prevention. When preventative measures have failed it is imperative to have thehighest quality detection and   treatmentavailable. Without screening programs, namely the Papanicolaou (PAP) smearexamination, diagnosis is performed through clinical examination, biopsy andhistopathology. The International Federation of Gynecology and Obstetrics(FIGO) developed a staging system that incorporates clinical, histological andradiologic data (not including PET/MR/CT) to stage cervical cancer 31.Medical Imaging Modalities are instrumental in the treatment planning processand follow up of cervical cancer patients. The use of Positron EmissionTomography (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 theparametrical region well.

It is recognized that both PET and MR are superiormodalities in the assessment of cervical cancer, but not readily availableimaging modalities in most of the LAC regions; therefore the use of CT isappropriate 32. CT is not a valuable tool in the earlystages 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 distantmetastases and roadmap for interventional procedures.

According to the AmericanCollege of Radiology (ACR) appropriateness criteria MRI without and with IVcontrast is the highest rated imaging exam, second is PET/CT, with IV enhancedCT following 33. It is important to note that although CTis not the “gold standard” in cervical cancer imaging, when performed at thehighest level, CT imaging can aid in the appropriate treatment of the patient.Treatment options range from chemoradiotherapy where available to surgery or acombination 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 IIIdisease can be cured” 31. Postpartum hemorrhage Decreasing maternal mortality rate (MMR) from preventable causes has beena global priority beginning with the UN Millennial Developmental Goals (MDG) in2000 and continues with the Sustainable Development Goals (SDG) established in2016. Although substantial progress had been made under the MDG, maternalmortality rate is still at an unacceptable level with approximately 830 womendying each day worldwide from preventable causes related to pregnancy andchildbirth 34.

The data collected on MMR demonstrates that 99% of all preventable maternaldeaths occur in low-resource countries, with the highest risk for adolescentgirls under the age of 15 and for females who live in rural and poorcommunities 34.  The disparity of health care, specificallyaccess to quality obstetric care and services, is directly related to maternaloutcomes 35,36.Ultrasound is part of routine prenatal care in developed countries, as it canaccurately date a pregnancy and identify fetal abnormalities, malpresentation,multiple gestations, and placenta previa, which allows a physician to managethe pregnancy properly and improve outcomes 36.

  Sonography is the imaging modality of choicefor the postpartum patient who is febrile or experiencing complications such asvaginal discharge, bleeding and pain 37,38.In many developing countries and especially rural communities¬, obstetricservices, including availability of ultrasound services and trained individualsto perform the exams, are extremely limited or nonexistent, leaving womenvulnerable to poor outcomes. Hemorrhageis the leading cause of maternal death in LAC at 23.1%, with the greatestproportion (57%) of deaths in the postpartum period 35,39.

Postpartum hemorrhage (PPH) is divided into primary PPH (defined as 24 hoursafter delivery) and secondary PPH (defined as more than 24 hours after deliveryto 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 oflabor are strategies to address primary PPH associated with uterine atony 39.  Sonographyof the postpartum uterus can be used to identify other causes of PPH such asretained products of conception, AV malformations, endometritis, abscess, woundcellulitis, and surgical complications like hematoma, pseudoaneurysms, oruterine scar dehiscence 38.

Imaging studies are used to identify the source of bleeding and to helpdetermine if surgical intervention is warranted 38.Interpretation of sonographic studies of the postpartum uterus can becomplicated as there is significant overlap between pathologic and normalphysiologic changes of the uterus. However, utilizing sonography to evaluate symptomaticpatients can facilitate early intervention and treatment and lead to a decreasein MMR 38,42.

 AdditionalDiseases Affecting Women   Additional diseases orconditions within NCDs and respiratory diseases are included in the table.  In the Americas, one in three women hasexperienced intimate partner violence or sexual violence by a non-partnerduring her lifetime 43.  Womenwho are victims of violence are more likely to experience acute or immediatephysical injuries, such as abrasions, lacerations, burns and bites, as well as fracturesand acquired immune deficiency syndrome (AIDS) related death.  In addition, they will experience unwantedpregnancies, abortions, pregnancy complications/miscarriage and vaginalbleeding or infections to name a few 44.Tuberculosis claims the lives of 23 000 every year in the Americas and TBmortality among women is associated with literacy, basic sanitation, drinkingwater coverage, and nutritional status 45.

   CVDs,including heart attacks and strokes, continue to be the leading cause of deathin almost all countries, accounting for 1.63 million deaths (37.5 percent)annually.  Women are more likely to beobese in the Americas with 27.4 percent compared to 21.

7percent of men.  Subsequently, women have higher rates ofheart 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 publichealth to improve the health and wellbeing of the population, or prevent thedeterioration of their health. To assist countries in LAC, a holistic approachmust be utilized in public health with the inclusion of quality radiologyservices.   Acquisition of equipment, improving imagequality and interpretation are one part of what constitute radiologyservices.  Standardization is anothervery important component that cannot be ignored.  Without standardization, the services offeredare suboptimal thus a threat to patient safety and will minimize the influenceto radiology in public health.

  Patientsafety is an essential principle of health care and adverse events must bereduced to establish an effective system. There are no shortcuts to patient safety and quality of care; radiologyplays a crucial role in reducing the morbidity and mortality.  History has shown women facing constant barriersin society, yet an educated and healthy woman will have a positive impact in acommunity.  With inadequate rendering ofradiology services, the patient becomes a victim not only of the disease butthe services that fail to provide proper management.  The role of radiology in women’s healthcannot be underestimated or ignored; however, the services must be of qualityto yield positive outcomes.

Radiology must establish itself in public healthand women’s health.