National Health Committee
An Overview of
Imaging in
New Zealand
March 2015
National Health Committee – An Overview of Imaging in New Zealand
National Health Committee (NHC)
The National Health Committee (NHC) is an independent statutory body charged with prioritising new
and existing health technologies and making recommendations to the Minister of Health.
It was reformed in 2011 to establish evaluation systems that would provide the New Zealand people
and the health sector with greater value for money invested in health.
The NHC Executive is the secretariat that supports the Committee. The NHC Executive’s primary
objective is to provide the Committee with sufficient information for it to make decisions regarding
prioritisation and reprioritisation of interventions and services. They do this through a range of
evidence-based products chosen according to the nature of the decision required and timeframe within
which decisions need to be made.
The New Zealand Government has asked that all new diagnostic and treatment (non-pharmaceutical)
services, and significant expansions of existing services, are to be referred to the NHC.
In August 2011 the NHC was appointed with new Terms of Reference and a mandate to establish the
capacity to assess new and existing health technologies. Its objectives (under Section 4.2 of its Terms
of Reference – www.nhc.health.govt.nz) include contributing to improved value for money and fiscal
sustainability in the health and disability sector by:
 providing timely advice and recommendations about relative cost-effectiveness based on the best
available evidence;
 providing advice and recommendations which influence the behaviour of decision makers including
clinicians and other health professionals;
 providing advice and recommendations which are reflected in resource allocation at national,
regional and local levels; and
 contributing to tangible reductions in the use of ineffective interventions and improved targeting to
those most likely to benefit.
In order to achieve its objectives under Section 4.2 and to achieve ‘Value for Money’, the NHC has
adopted a framework of four assessment domains – Clinical Safety & Effectiveness; Economic; Societal
& Ethical; and Feasibility of Adoption – in order that assessments cover the range of potential
considerations and that the recommendations made are reasonable.
It is intended that the research questions asked will fall across these domains to ensure that when the
Committee comes to apply its decision-making criteria, it has a balanced range of information available
to it. When the NHC is setting those questions they will have the decision-making criteria in mind.
The 11 decision-making criteria will assist in the determination of the NHC work programme and in the
appraisal and prioritisation of assessments.
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National Health Committee – An Overview of Imaging in New Zealand
Contents
1
Introduction
4
2
Organisation of imaging in New Zealand
5
2.1
Volumes and costs
6
2.2
Workforce
7
2.3
Information systems
7
3
Emerging technologies
8
4
New Zealand service developments and issues
9
References
11
National Health Committee (NHC) and Executive
13
Disclaimer
13
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National Health Committee – An Overview of Imaging in New Zealand
1 Introduction
This document is intended to provide the National Health Committee (NHC) with an overview of the
current situation for diagnostic imaging in order to inform decisions about whether to undertake
further work in the area.
Diagnostic imaging services comprise a variety of modalities performed by a range of professionals.
The following are considered:
 Radiological diagnostic imaging services provided include plain X-rays, computerised tomography
(CT), magnetic resonance imaging (MRI), ultrasound and nuclear medicine imaging techniques.
These modalities provide images that are interpreted to assist in the diagnosis of disease.(1)
 Echocardiography technology uses sound waves to give structural and functional information
regarding the heart and is performed by specialist technicians and interpreted by cardiologists.
 Coronary angiography is performed by cardiologists and provides structural information relating
to the coronary arteries in the assessment of ischaemic heart disease (IHD). Angioplasty can be
performed at the same time. An equivalent approach investigating the peripheral vasculature is
performed by radiologists.
 Endoscopy − colonoscopy, sigmoidoscopy and upper gastrointestinal endoscopy are examinations
of the gastrointestinal tract that utilise a flexibly mounted video camera providing images to a
monitor screen for the diagnosis and management of a variety of gastrointestinal conditions.
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National Health Committee – An Overview of Imaging in New Zealand
2 Organisation of imaging in New Zealand
Radiological imaging services are provided by both private and public health care providers. Sources
of funding of services are through DHBs, patient expenditure and the Accident Compensation
Corporation (ACC).
DHBs’ hospital services provide imaging services, the extent of which is covered by the Service
Coverage Schedule.(2) The description of service provision is general with the addition of some
specific requirements. Services funded by the DHB include but are not limited to diagnostic imaging
services including X-rays, ultrasound scans and mammography for diagnosis.
There is provision of imaging services to patients seen in the primary care setting as set out in the
Community Radiology (Hospitals) Service specification.(3) However the access to imaging services has
not been equitable across DHBs. In response, the Ministry of Health has developed a minimum set of
imaging modalities that must be provided to community practitioners with their evidence-based
indications defined in tandem. This is due to be finalised and will be implemented via DHB annual
plans in 2014.1 ACC is a bulk funder of radiological imaging to DHBs for the period of six weeks after
the date of an injury. Investigations are funded via the individual claimant in primary care.
The balance of provision of services between the public and private sectors varies across DHBs and
depends on local circumstances. The drivers for the public system using the private sector are:
 capacity issues at the hospital (these may be general or more specific such as lack of
sonographers)
 cost of physical assets − some equipment (e.g. MRI) is expensive to purchase.
The partnership approach between the public and private sector can operate in varied ways:
 buying of specific services
 private ownership and operation of equipment but placed at the DHB
 joint ownership.
Instead of outright purchase of new equipment, DHBs may have access to leasing agreements in the
future.
All DHBs in New Zealand provide transthoracic echocardiography, with 17 performing adult and
paediatric scans. Thirteen perform stress echo procedures and 15 trans-oesophageal services.(4)
1
Personal communication: Dr Liz McAnulty, National Clinical Leader Radiology
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National Health Committee – An Overview of Imaging in New Zealand
Coronary angiography is performed in the diagnosis of IHD, used in the management of acute
presentations and is recommended in stable patients assessed clinically as having a higher likelihood
of having IHD, particularly if angioplasty is being considered. Angiography is performed at 11 sites
across New Zealand.2 Patients assessed as low or intermediate risk initially are investigated with a CT
calcium score, or non-invasive functional modalities.(5) The assessment of patients presenting with
acute coronary syndromes with coronary angiography and of left ventricular function are used as
quality improvement indicators.(6) Provision of cardiac MRI diagnosis has been proposed by clinicians
at Nelson Marlborough DHB. An economic analysis of modalities used in the diagnosis of IHD did not
find MRI a cost-effective option.(7)
2.1 Volumes and costs
The imaging modalities of CT and MRI, colonoscopy and coronary angiography are relevant to health
targets.
For the calendar year 2012 the number of CT scans performed was 115,100 and MRI scans was
17,800.3
CT and MRI data are collected for primary care and outpatients and is currently available only for one
year. For the year 2012/13 the number of CT scans performed was 70,851 and MRI scans was
36,463.4 These radiological modalities are also a significant source of increasing costs.
The utilisation of coronary angiography and colonoscopy is also mapped by reference to domicile
population for DHBs. There were 15,503 coronary angiograms performed in 2012/13. The
standardised intervention rate by DHB had a range between 26.3/10,000 and 45.2/10,000.5 This
number of procedures equates to a cost of $30.09 million.6
There were 41,369 diagnostic colonoscopies performed in 2012/13. The standardised intervention
rate by DHB ranges between 71 and 137/10,000 population.7
2
Source: DHB Performance, National Health Board
3
Source: Analytical Services, Ministry of Health
4
Source: DHB Performance, National Health Board
5
Source: DHB Performance, National Health Board
6
Source: 2013 NHC analysis of New Zealand casemix price 2011/12 NMDS data
7
Source: DHB Performance, National Health Board
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National Health Committee – An Overview of Imaging in New Zealand
2.2 Workforce
Practising radiologists are medically qualified and fellows of the Royal Australian and New Zealand
College of Radiologists. As of June 2012 the active New Zealand workforce was 319 radiologists,
equivalent to 72 radiologists per million. The growth in radiologists is 3.9% since 2010 and 44% since
2000.(8)
Medical radiation technologist professionals provide the skills required to perform radiological
investigations and come under the Health Professionals Competence Assurance Act 2003.(9) Health
Workforce New Zealand have a focus on increasing the availability of sonographers(10) as their lack of
availability is recognised as a hindrance to service provision.
There were 60.3 total full-time equivalent (FTE) cardiac sonographers at the end of 2010, with 9% of
DHB positions unfilled. The size of the workforce equates to 14 per million population, which is
higher overall than the UK rate. Of the cardiac sonographers in New Zealand, 70% are registered
with professional representative bodies in New Zealand and Australia.(4)
Gastrointestinal endoscopies are performed by physicians and surgeons and the requirements and
recognition of training are determined by the New Zealand Society of Gastroenterology.(11) A survey
in 2005 showed inadequate provision of colonoscopy in New Zealand public hospitals.(12)
2.3 Information systems
The improvement in IT services is recognised as a component of service delivery improvement for
diagnostic imaging.(13, 14) Digital storage and off-site access to images improves patient flow,
investigation reporting and reduces duplicate imaging.(13-15)
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National Health Committee – An Overview of Imaging in New Zealand
3 Emerging technologies
The miniaturisation of ultrasonography equipment is leading to broader clinical use. Point-of-care
applications have become broad but include procedural guidance, and ‘focused’ diagnostic
assessments by clinicians such as in the emergency setting and cardiology. Point-of-care use may
support quicker diagnosis and supplement or replace current modalities.(16) Training and quality
control are important to provide benefits.(16, 17) Point-of-care echocardiography may enable
improved diagnostic accuracy and reduced use of formal echocardiography.(18, 19)
The role of radiologists is developing, with interventional radiology taking an increased part of their
function. Radiologists are performing procedures, aided by imaging technologies that were
previously done by other specialists. However, procedures may be delivered in conjunction with
other specialists.
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National Health Committee – An Overview of Imaging in New Zealand
4 New Zealand service developments and issues
Radiological service capacity is limited and demands are increasing; requests for CT scans increased
by 7% year-on-year for the three DHBs in the greater Wellington region.(13) National data for the
outpatients show an increase of accepted referrals for CT scans of 9% and an increase of 8% for MRI
scans over a 12-month period up to the end of 2013.8
The limits to capacity revolve around the availability of staff and the cost of technology. The impact
of constraints may mean a modality is not locally available at all (e.g. MRI) or an alternative modality
is used. This substitution has the potential of higher radiation exposure or repeat testing with the
preferred option. Development of standardisation of prioritisation and access criteria to radiology
services is in process.(13, 15) A three-year staged programme to reduce waiting times for diagnostic
services commenced in 2011/12. From 2012/13 DHBs are required to report waiting time
information on a number of key diagnostic modalities – colonoscopy, coronary angiography, CT and
MRI.(2)
The health care service development linkages for diagnostic imaging services include diagnostic wait
indicators, faster cancer treatments and elective services.(15) The Faster Cancer Treatment
programme(20) has improved timeliness of diagnosis as a component of improved care.
Another driver to diagnostic imaging services is described as the ‘Pipeline effect’: as radiology is a
service provider to other clinicians, the appointment of new clinicians generates more requests for
imaging and new interventions can generate demand for pre- and post-procedure imaging
assessment.
Radiological imaging services can be considered as providing support to other clinical services that
endeavour to add value in terms of improved patient outcomes or overall service delivery. Radiology
services are currently pursuing a quality improvement programme.(13, 15) Also an updated community
radiology scheme is in development through Sector Capability and Implementation at the Ministry.
Audit of the positive diagnosis rate, either from the perspective of a radiological examination or by
clinical service area has been used to drive discussion of the appropriate use of modalities. If the
positive diagnostic rate is considered ‘too low’ this can lead to clinical discussion regarding best use
of modalities. However it is not straightforward to define the appropriate level. This method is at an
early stage and is not ‘business-as-usual’.9 Examples of condition/investigation overuse, though
difficult to quantify or demonstrate, are:
8
Ministry of Health
9
Personal communication, Dr Kim McAnulty, National Clinical Leader Radiology
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National Health Committee – An Overview of Imaging in New Zealand
 the follow-up of abnormal liver function tests with ultrasound
 use of CT in the context of suspected pulmonary embolism
 use of CT urogram in the context of suspected renal colic
 use of ultrasound in the investigation of abdominal pain
 use of pelvic ultrasound in the investigation of pelvic pain.
Anecdotally the drivers for increased use of investigations and a low positive diagnostic rate are the
medico-legal environment and clinicians’ willingness to operate in a situation of perceived risk and to
accept ‘clinical uncertainty’.
In December 2012 the NHC received a referral from the Ministry of Health’s Cancer Programme
Steering Group to undertake a review of the national clinical indications for PET scanning. Regional
PET Variance Committees had been working together in this area on indications to be included in
such a review. The NHC considered at their May 2013 meeting that the use of PET was a wellmanaged part of the sector and that governance arrangements and mechanisms were already in
place to consider PET scanning indications.
A national bowel screening programme will have important impacts on colonoscopy services.
Individuals with an initial positive test will have a colonoscopy performed for definitive diagnosis.
The need for additional workforce capacity and facilities to perform colonoscopy is recognised.(21)
The need to improve access to community echocardiography for the diagnosis of asymptomatic heart
murmurs has been identified by Waikato DHB. One in six referred patients is found to have clinically
significant disease but waiting times are long and an alternative and better means has been sought
rather than all having a first specialist appointment.(22)
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National Health Committee – An Overview of Imaging in New Zealand
References
1.
Who Is a Radiologist? : The Royal Australian and New Zealand College of Radiologists; 2013
[04/12/2013]. Available from: http://www.ranzcr.edu.au/radiology/who-is-a-radiologist.
2.
Ministry of Health NZ. Nationwide Service Framework Library : 2013/14 Service Coverage Schedule
(25 July Update)
3.
Ministry of Health NZ. Nationwide Service Framework Library : Community Radiology (Hospitals).
4.
Buckley B, White S, Poppe W, Whalley G. The Cardiac Sonography Workforce in New Zealand.
Australasian Journal of Sonography in Medicine. 2013;16(2):77-85.
5.
Nice Pathways: Stable Angina: National Institute of Health and Care Excellence; [04/12/2013].
6.
Ministry of Health NZ. Diabetes and Cardiovascular Disease Quality Improvement Plan 2008.
Available from: http://www.health.govt.nz/system/files/documents/publications/diabetes-cardioquality-improvement-plan-feb08-v2.pdf.
7.
Toronto Health Economics and Technology Assessment Collaborative. The Relative CostEffectiveness of Five Non-Invasive Cardiac Imaging Technologies for Diagnosing Coronary Heart
Disease in Ontario 2010. Available from: http://lgdata.s3-website-us-east1.amazonaws.com/docs/3744/928383/TR_2010.2_theta_cardiac_imaging_report.pdf.
8.
The Royal Australian and New Zealand College of Radiologists. 2012 Radiology Workforce Census
Report: New Zealand 2013. Available from: http://www.ranzcr.edu.au/searchresult?searchword=workforce&ordering=&searchphrase=all.
9.
The New Zealand Medical Radiation Technologists Board; [04/12/2013]. Available from:
http://www.mrtboard.org.nz/what-we-do.
10.
Allied Health: Health Workforce New Zealand; [04/12/2013]. Available from:
http://healthworkforce.govt.nz/our-work/investment-relationships-and-purchasing/allied-health.
11.
Guidelines for Applying for Recognition of Endoscopy Training: The New Zealand Society of
Gastroenterology; 2011 [04/12/2013]. Available from:
http://www.nzsg.org.nz/cms2/training/endoscopy/.
12.
Yeoman A, Parry S. A Survey of Colonoscopy Capacity in New Zealand’s Public Hospitals. NZ Med J.
2007;120(1258):U2632. Epub 2007/07/27.
13.
Capital and Coast Hutt Valley and Wairarapa District Health Boards. 3 DHB Radiology: New
Directions for Radiology Services in the Greater Wellington Region. Wairarapa District Health
Board, 2013. Available from:
http://www.wairarapa.dhb.org.nz/wdhb/SubRegional/3%20DHB%20Radiology%20fact%20sheet_Q
uestions%20and%20Answers.pdf.
14.
Case Study: Large New Zealand Public Health Board Relies on Intelerad Solutions for Effective,
Efficient Workload Sharing 2012. Available from: http://www.intelerad.com/casestudies/cdhb/pdf/CDHB_CaseStudy.pdf.
15.
Central Region Regional Services Plan 2013-14. 2013. Available from:
http://www.centraltas.co.nz/RegionalWorkProgramme/RegionalServicesPlan/tabid/157/Default.as
px.
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National Health Committee – An Overview of Imaging in New Zealand
16.
Moore CL, Copel JA. Point-of-Care Ultrasonography. New England Journal of Medicine.
2011;364(8):749-57. doi: doi:10.1056/NEJMra0909487.
17.
Sicari R, Galderisi M, Voigt J-U, Habib G, Zamorano JL, Lancellotti P, et al. The Use of Pocket-Size
Imaging Devices: A Position Statement of the European Association of Echocardiography. European
Journal of Echocardiography. 2011;12(2):85-7. doi: 10.1093/ejechocard/jeq184.
18.
Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, Toste J, Cobos MA, et al. Usefulness of a New
Miniaturized Echocardiographic System in Outpatient Cardiology Consultations as an Extension of
Physical Examination. Journal of the American Society of Echocardiography. 2011;24(2):117-24.
doi: http://dx.doi.org/10.1016/j.echo.2010.09.017.
19.
Platz E, Solomon SD. Point-of-Care Echocardiography in the Accountable Care Organization Era.
Circ Cardiovasc Imaging. 2012;5(5):676-82. Epub 2012/09/20. doi:
10.1161/circimaging.112.973578.
20.
Ministry of Health NZ. Faster Cancer Treatment Programme [04/12/2013]. Available from:
http://www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancertreatment-programme/cancer-pathway.
21.
Ministry of Health NZ. Costs and Bowel Screening Programme Development [04/12/2013].
Available from: http://www.health.govt.nz/our-work/diseases-and-conditions/cancerprogramme/bowel-cancer-programme/costs-and-bowel-screening-programme-development.
22.
Medical Services Unit Waikato Hospital. Primary Care Access to Echocardiography for Investigation
of Asymptomatic Heart Murmurs. 2013.
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National Health Committee – An Overview of Imaging in New Zealand
National Health Committee (NHC) and Executive
The National Health Committee (NHC) is an independent statutory body which provides advice to the
New Zealand Minister of Health. It was reformed in 2011 to establish evaluation systems that would
provide the New Zealand people and health sector with greater value for the money invested in
health. The NHC Executive are the secretariat that supports the Committee. The NHC Executive’s
primary objective is to provide the Committee with sufficient information for them to make
recommendations regarding prioritisation and reprioritisation of interventions. They do this through
a range of evidence-based reports tailored to the nature of the decision required and timeframe
within which decisions need to be made.
Citation: National Health Committee. 2015. An Overview of Imaging in New Zealand.
Wellington: National Health Committee.
Published in March 2015 by the National Health Committee
PO Box 5013, Wellington, New Zealand
ISBN 978-0-478-42860-5 (online)
HP 5953
This document is available on the National Health Committee’s website:
http://www.nhc.health.govt.nz/
Disclaimer
The information provided in this report is intended to provide general information to clinicians,
health and disability service providers and the public, and is not intended to address specific
circumstances of any particular individual or entity. All reasonable measures have been taken to
ensure the quality and accuracy of the information provided. If you find any information that you
believe may be inaccurate, please email to NHC_Info@nhc.govt.nz.
The National Health Committee is an independent committee established by the Minister of Health.
The information in this report is the work of the National Health Committee and does not necessarily
represent the views of the Ministry of Health.
The National Health Committee makes no warranty, expressed or implied, nor assumes any legal
liability or responsibility for the accuracy, correctness, completeness or use of any information
provided. Nothing contained in this report shall be relied on as a promise or representation by the
New Zealand government or the National Health Committee.
The contents of this report should not be construed as legal or professional advice and specific advice
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information in this report.
Any reference to any specific commercial product, process, or service by trade name, trademark,
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Zealand government or the National Health Committee.
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