Using ultrasound in primary care

Scanning at the practice avoids wasting time and money on unnecessary referrals. By Dr John Doddy.

I invested in my own ultrasound equipment in 2007 after seeing a hand-carried ultrasound system used for diagnosing muscle injuries at a sports medicine course I attended.

Having now clocked up more than 100 hours of Royal College of Radiology training, I use ultrasound to diagnose or monitor patients for conditions including screening for aortic aneurysms, gallstones, musculoskeletal injuries, breast lumps, testicular or thyroid swellings, and some antenatal scans.

At my practice in Nottingham I do opportunistic scans for acute problems and routine booked scans in a separate session after morning surgery.

Dr Doddy invested in ultrasound equipment for his practice in 2007

Advantages all round
The advantages range from patients' peace of mind and help in understanding their condition, to considerable time and cost savings in unnecessary referrals to secondary care.

Having the equipment at the practice and the training opportunities to develop the necessary skills gives GPs so many options. First, and perhaps most obviously, is musculoskeletal screening.

As an example, around 2,000 patients are referred to the shoulder clinic in Nottingham every year.

Of those, 70 per cent are querying rotator cuff injuries and many have already undergone a preliminary six-week course of physiotherapy that was ineffective. But a rotator cuff supraspinatus tear should be treated with the same urgency as a ruptured Achilles tendon.

First-line diagnosis
A community-based shoulder-screening clinic run by a GPSI and a physiotherapist could form a first line of diagnosis and potentially keep half of those patients out of hospital.

It could quickly sift out those without tears, sending patients directly to the shoulder unit when appropriate.

Another musculoskeletal care area where ultrasound could be invaluable is guiding injections.

A recent study using dye estimated that only 26.8 per cent of injections given by a GP into the glenohumeral shoulder joint actually reach their target.

A further strong candidate for use of ultrasound in primary care is screening for aortic aneurysms.

Through the ultrasound company SonoSite, which supplied my ultrasound equipment, I had specialist tuition and supervision from a vascular sonographer, scanning a complete size spectrum of patients and including some of the more difficult cases.

Of the few aneurysms we saw, I was able to compare my measurements and typically had the same results as those from the hospital, giving me confidence in my abdominal scanning skills.

Basic antenatal screening is also ideal for community- based scanning. Straightforward things like gestational dates, concerns over miscarriage, or position of the baby in the third trimester can kick-start antenatal care or quickly reassure patients without dragging them all the way to hospital.

If you ask GPs what ultrasound service they most often use it would probably be gallstones. All these areas would, with sufficient training, sit well in general practice.

My patients are delighted to be scanned at the surgery. It is easier to explain what is wrong and what treatment might achieve and they have more confidence in what I tell them.

I believe the key factors for the success of ultrasound in primary care are realising the limitations and getting appropriate training.

An ultrasound GPSI would need to attend many courses, have the correct certification to work alone on each special area, and continually reinforce what they have learnt. For instance, I am currently completing a course in musculoskeletal ultrasound, which will culminate in a postgraduate certificate recognised by the Royal College of Radiologists at level 1.

But the choice of suitable courses is growing, and ranges from a basic general course for GPs, to several in more specialist applications appropriate for primary care.

Hand-carried systems make primary care scanning even more achievable. They boot up in seconds, are perfectly sized and reasonably priced for use in a GP surgery. As an example, the SonoSite hand-carried instruments come with a five-year guarantee, there are no running or maintenance costs to take into consideration.

Depending on the specifications and machine configuration, the initial outlay is £18,000 to £25,000.

Funding a system
Under practice-based commissioning GP consortiums have funds available to spend on the development of programmes, and could easily afford a hand-carried system.

At present most of the scanning I do is not funded by the PCT, although it may be possible to develop the service into a local enhanced service.

Until a specific study is undertaken, it is difficult to estimate cost savings. However, I believe that these would be significant.

Personally, ultrasound adds an enormous boost to my work. An extra layer of expertise has the ability to reinvigorate GPs and gives them a true specialist interest qualification. With ultrasound, your knowledge of anatomy goes through the roof.

I believe every surgery in the country should have access to a non-invasive, non-harmful form of investigation like ultrasound.

  • Visit www.sonosite.com for more information about SonoSite hand-carried ultrasound systems

My ultrasound service

  • Patients with acute problems are scanned opportunistically
  • Patients with ongoing problems are seen by appointment after morning surgery
  • Scans carried out to screen for: aortic aneurysms, gallstones, musculoskeletal injuries, breast lumps, testicular or thyroid swellings, basic antenatal scans

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