Mobile Solutions Aid Radiologists Serving Rural America

Imagine if an imaging appointment in the nearest big city with an academic medical center required a full day of travel or an expensive boat or plane trip. Now imagine the strain on your monthly budget due to these travel costs plus the medical expenses, especially if you do not have health insurance.

For approximately 60 million people who live in rural areas of the U.S., these types of scenarios happen every day.

With barely a tenth of physicians practicing in rural locations, according to the National Organization of State Offices of Rural Health, it can be easy for patients to skip routine imaging screenings, like mammograms, or put off more intensive imaging appointments that require travel to larger facilities.

While physician shortages in rural areas are not specific to radiology, they do bring unique challenges for radiologists who want their patients to have routine screenings and keep important appointments.

Some radiologists are turning to mobile solutions to reach patients in far-flung areas across the U.S.

Lack of Health Insurance a Deterrent for Rural Patients

For the past 15 years, the University of Virginia, Charlottesville, VA, has operated a mobile mammography unit that brings comprehensive screening services to women at workplaces and community locations throughout Virginia.

Along with proximity, one of the biggest challenges facing patients in these rural locations is the lack of health insurance, according to Jennifer Harvey, MD, professor of radiology and medical imaging and division head, breast imaging, at the University of Virginia.

Dr. Harvey knows how prohibitive the lack of insurance can be when it comes to radiology services, especially mammography.

“Many rural residents have jobs that do not offer benefits or find that health insurance is unaffordable,” Dr. Harvey said. “Often, women put their family’s health needs above their own. As a university, we knew we could travel to these areas and provide women with the screenings that they need.”

Offering screenings free of charge, the mobile mammography unit provides 3-D tomosynthesis mammography and ultrasound, and travels 25 percent of the time to rural locations, usually three to four hours away from the university. The unit typically spends at least 48 hours in one area of the state, traveling between nearby cities. During its stay, 20-25 women are seen each day.

All images are uploaded to the university where Dr. Harvey and her team review them, sending results and additional information back to the unit. Dr. Harvey and her team are studying the remote use of diagnostic mammography and ultrasound in these rural areas to evaluate whether this improves compliance after an abnormal mammogram.

Should a patient require a consultation with a university radiologist, Dr. Harvey said, they can do so during a teleconference on board the mammography truck.

“Much like an in-person meeting when there is something suspicious on an image, the patients can talk with a radiologist to ask questions and get information to help them make an informed decision,” Dr. Harvey said.

If there is a need for a patient to come into the hospital for additional services, that is discussed at that time as well.

“For many rural patients, taking the time out of their day to even visit the mobile unit is difficult. If there is something abnormal on their scan, it can be challenging for women to travel to a larger medical facility, especially those who cannot afford to take a day off from work or don’t have the gas money to get there and back,” Dr. Harvey said. “We work with the patient’s schedule and even provide gas cards to help get patients to the necessary appointments.”

Because it is challenging for patients in rural locations to travel into the city, the university is currently looking into additional types of medical services — radiologic and other — that could be provided via the mobile van.

“We have been a steady presence in these communities for so long that we are trying to identify other health resources that are scarce in these rural areas that we might be able to provide,” Dr. Harvey said.

Weather a Factor in Reaching Patients in Difficult Locales

Lack of health insurance does not play as big a role for people living on Nantucket, an island 30 miles off the east coast of Massachusetts. It is the potential for bad weather that can wreak havoc on medical care.

“Nantucket can have significant weather issues,” said Anand M. Prabhakar, MD, assistant professor of radiology at Massachusetts General Hospital (MGH) in Boston. “Fog and wind are major concerns that have affected the ability of medical personnel to travel to the island and/or remove patients from the island.”

Dr. Prabhakar leads the diagnostic imaging operations at Nantucket Cottage Hospital, a 19-bed hospital on the island.

Once a week, he and a rotating group of MGH radiologists fly on a nine-seat plane over the Atlantic Ocean to the island. No radiologists live on the island, so Dr. Prabhakar travels there to provide fluoroscopy and select minimally invasive interventional procedures.

In addition to his travel to the island, Dr. Prabhakar and his colleagues at MGH provide teleradiology reading and interpretation for the Nantucket Cottage Hospital 24 hours a day, seven days a week, when not onsite.

If a patient needs to be transferred off the island to MGH, it is conditional on the weather. At times, the Coast Guard is called in to assist during particularly foul weather. However, most transfers take place without incident.

These transfers are what interested Dr. Prabhakar to field a study, published in the American Journal of Emergency Medicine in 2016, to investigate the role that imaging played in transfers off the island.

He and his co-authors found that less than one in 30 emergency department patients at Nantucket Cottage Hospital required transfer for a higher level of care. Cardiac etiologies were the most common reason for transfer to MGH. However, imaging only played a role in transfers for noncardiac-related events.

“Most patients were managed without needing services available at the higher care facility,” Dr. Prabhakar said. “While cardiac indications were the most common cause for transfer in the study, imaging did not play a major role in these transfers. Potential next steps would be to study whether or not imaging (such as coronary CTA) could reduce potentially unnecessary cardiac transfers.”

“No matter when or how we get to the island, time is well-spent there with the amazing team of physicians at the hospital and the appreciative Nantucket community, who have welcomed the imaging staff from MGH,” Dr. Prabhakar said.