Table 3 Description of studies

[5]

Croatia and Serbia

To investigate the need for and achievements of a comprehensive QA programme in Croatia and in Serbia from technical and radiological viewpoints.

Pre test-post test intervention study comparing image quality (IQ) in Serbia (n = 684 images) and Croatia (n = 400 images). Hospitals had either film-screen (FS) or digital (DI) systems.

IQ, patient dose and equipment performance. Intervention was corrective action based on IQ evaluations. Quantitative analysis.

The study emphasized a need for training in cooperation of all the operating mammography staff (medical physicist with radiologists and radiology technologists).

1) topics where education should be targeted: multiprofessional co-operation viewpoint 2) to improve IQ.

a) cleaning of working surfaces, screens, cassettes and processing units, change from manual to AEC, service adjustment to AEC, change of exposure parameters, introduction of daily sensitometry tests and replacement of image receptors b) incorrect positioning, contrast problems, artefacts.

a) 1, 2, 3, 4, 5 b) 1, 2, 3

[25]

Croatia

To evaluate mammographic (MG) image quality and to identify the most common. deficiencies.

N = 420 MG examinations from 84 MG units participating in the Croatian nationwide breast cancer screening program were reviewed over a 6-month period. Technical data was collected by questionnaires.

Four image quality categories were rated using the image evaluating system based on the American College of Radiology and the European Commission proposals. Quantitative analysis.

Lack of training: additional training for RTs is necessary to improve IQ and make examination more comfortable for women which could directly increase the response rate to the screening in future.

topics where education should be targeted: 2) education for RTs to improve IQ 3) patient viewpoint (to make the examination more comfortable to patients).

a) problems with viewing conditions b) problems in positioning, compression, labelling, documentation, contrast, image artefacts, different viewpoints of RTs and radiologists about IQ. There was variation in IQ by organization, equipment, staff education, working habits and motivation and by economic interests.

a) 7, 8 b) 1, 3, 8

[33]

UK

To evaluate the feasibility of training sufficient for radiographers to deliver an intervention to promote early presentation of breast cancer to all older women attending for their final routine mammogram.

Mixed methods study assessing the feasibility of training of 25 radiographers in one breast screening service at key time points during the training process.

Measures: competence and confidence of radiographers to deliver the intervention, radiographers’ perceptions and experiences both of training and delivering the intervention. Qualitative interview study.

Commitment, motivation, varying levels of staff basic education and clinical experience, informing about education, giving regular feedback about performance.

4)radiographer related factors: commitment, motivation, varying basic education 5) challenges related to organizing education: informing about education, giving feedback.

c) How to take into account the promotion of breast screening adherence in radiographer’s work.

c) 3

[26]

Turkey

To evaluate the mammography image quality in İstanbul and to survey the awareness of mammography quality.

Cross-sectional study. N = 55/50 mammography units were assessed in İstanbul. Hospitals had either film-screen (FS) or digital (DI) systems.

An American College of Radiology (ACR) accreditation phantom was used to assess image quality. 10-item questionnaire for mammographers concerning the type of mammography equipment and IQ in their unit. Quantitative analysis.

Radiographer’s lack of awareness and knowledge of mammography image quality.

2) topic where education should be targeted: education for RTs to improve IQ.

a) artefacts on the phantom because of the absence of routine cleaning and quality control following daily, monthly and yearly QA protocols, b) poor positioning, various problems in image processing, unrealistic IQ ratings by radiographers, low image quality in images taken by analogue system compared to images taken by CR and DR systems.

a) 1, 3, 10 b) 1, 4, 7

[24]

Africa, Asia and Eastern Europe

To study mammography practice from an optimisation point of view by assessing the impact of simple and immediately implementable corrective actions on image quality.

Prospective multinational study that included 54 (FS) mammography units and more than 21,000 images in 17 countries.

Images were evaluated using a three-level image quality scoring system. Following initial assessment, appropriate corrective actions were implemented and image quality was re-assessed in 24 units.

Radiographer’s lack of training.

2) topic where education should be targeted: education for RTs to improve IQ .

a) cleaning of screens, cassettes, processing units and working surfaces, damaged or scratched image receptors, or film-screen combinations that are not spectrally matched, exposure technique by using AEC, compression and tube voltage settings, viewing conditions b) issues related to film processing, inappropriate radiographic techniques.

a) 1, 2, 5, 6, 7, 8, 10

[36]

UK

To explore the experiences of women attending for diagnostic tests prior to and after diagnosis in order to inform practice.

A qualitative, exploratory and longitudinal study design. A convenience sample (n = 16) was recruited throughout the North-East of Scotland.

N = 25 semi-structured interviews with 7 participants taking part in a single interview, a further 7 and 1 participants taking part in 2 and 3 interviews. Interviews were analysed by thematic approach.

Inability of radiographers to discuss the outcomes of breast imaging with patients.

5) topic where education should be targeted: patient centeredness: psychosocial aspects, patient comfort, communication, counselling.

c) Patients experience anxiety when awaiting test results. It is necessary for imaging departments to review their result-giving policy. This should include a multi-professional, multi-departmental approach to provide a timely effective standardised and seamless result-giving service for all, which reflects the use of modern communication methods.

c) 1

[37]

UK

To study if there was variation in compression force by a practitioner over time.

Retrospective study in a regional breast screening service in the North of England.

N = 500/344 clients/1032 mammogram sets by 14 practitioners FS mammograms from 2004, 2007 and 2010 screening rounds. Measures: compression force, b MGD (mean glandular dose). Quantitative analysis.

a) Compression force and thereby breast thickness and MGD varied by screening rounds and practitioners. When the same practitioner performed breast imaging at different rounds there was less variation.

a) 8

[27]

UK

To evaluate image quality, compression and dose in Irish symptomatic breast units.

Mixed methods study in 16 mammographic units, having either film-screen (FS) or digital (DI) systems. N = 4071 patient images from 1010 patients.

Measures: dose, breast density, compression force, compression level, IQ. Quantitative, quantification of qualitative data.

a) Little lower compression force than in EU recommendations, b) MGDs with FS were higher than those with DI systems, overall they were higher in symptomatic breast units than in Irish Breast Screening service, DRLs are defined for standard sized patients which does not always apply to reality.

a) 8 b) 5

[31]

Portugal

To characterise the technology for digital mammography installed in Portugal.

Mixed methods design. The sample was radiographers (n = 118 + 59) and radiologists (n = 69).

Practice was analysed using qualitative and quantitative methods. IQ (clinical and technical), patient dose and phantoms dose, equipment performance were evaluated with qualitative and quantitative methods.

Education and training needs were identified. Radiographers acknowledged the need of dedicated education and training on digital mammography (DM), training in artifact recognition, quality control, intervention, optimisation, dosimetry and tomosynthesis. Most radiographers had received training in DM but there was variation in type, amount and the organizer of training.

topics where education should be targeted: 2) education to improve IQ: artefact recognition, quality control and dosimetry; 6) further examinations such as interventions and tomosynthesis 7) performing DM 8) pathology.

a) Implementation of the quality control program and performance; variation in exposure parameters, dose and compression force; use of cassettes and image plates that are damaged b)positioning, repeat/reject analysis should be implemented to monitor the most typical failures in practice c) high workload promotes less time to be with the patient.

a) 4, 5, 8, 10, b) 1, 6 c) 2

[32]

UK, Norway

To characterise practices of healthcare staff (radiographers and radiologists) in digital mammography.

Quantitative comparative study in UK and Norway. In each of the two centres, mammograms from 112 women aged 50–70 years were reviewed.

Four radiographers from Norway with a degree in radiography and four from the UK, holding a degree in Radiography and a Postgraduate Certificate in Mammography, were invited to participate in the study. Quantitative analysis.

Training needs for radiographers in using PGMI criteria in a uniform way.

2) topic where education should be targeted: education for RTs to improve IQ.

Use of PGMI varied between centres in both number and interpretation of the criteria employed.

b) 9

[29]

Netherlands and United States

To assess the Mean Glandular Dose (MGD) to the breast in digital mammography in conditions relevant to clinical practice.

Retrospective study. Mammographic compressions of 9188 women (the NL dataset) and 1851 women from a breast imaging centre in Pittsburgh, PA (the US dataset).

Available parameters of a set of 37,518 mammographic compressions in Denmark and 7171 compressions in USA. Quantitative analysis.

a) The forces and pressures applied in the NL dataset were significantly higher than in the US dataset. c) Factors contributing to this variation include the pain threshold of the woman, the radiographer’s sensitivity for pain expression, the uncertainty or inaccuracy in estimating the pressure on the breast, the radiographer’s opinion of what is a good compression, and local conventions.

a) 8 c) 4

[38]

Netherlands

To compare pain, projected breast area, radiation dose and image quality between flexible (FP) and rigid (RP) breast compression paddles

The study was conducted in a Dutch mammographic screening unit (288 women).

Measures: pain experience, projected breast area, radiation dose. Image quality was reviewed by 3 radiologists and 3 radiographers.

a) Pain experience showed no difference between flexible and rigid breast compression paddles. Flexible paddles do not depict clinically relevant retroglandular areas as well. Flexible paddles move breast tissue from image area at the chest wall side. Rigid paddles depict more breast tissue and show better contrast. Rigid breast compression paddles are recommended for standard mediolateral-oblique and craniocaudal views.

a) 8

[28]

UK

To characterise image quality (IQ) in mammography using technical and clinical (realistic) breast models.

Data were collected from three consecutive screening events in three breast screening sites. Data comprised 975 clients (2925 client visits, 11 700 MG images).

Measures: practitioner code, applied compression force (N), breast thickness (mm), BIRADS density category. Quantitative analysis.

a) Practitioners across three breast screening sites behave differently in the application of compression force. There was also internal variability inside screening sites in compression force and thickness.

a) 8

[34]

Portugal

To develop an e-learning course on breast imaging for radiographers and evaluate the course.

RCT target group radiographers (n = 120) and radiology students (n = 70).

Measures: efficacy, effectiveness and user satisfaction. Quantitative analysis.

E-learning group got better scores in knowledge and course satisfaction. E-learning may be some complementary solution to solve challenges in learning breast imaging.

[30]

UK

To study compression behaviours of practitioners during screening mammography.

Qualitative research with 6 focus group interviews (n = 41 practitioners) in six breast screening centres in England.

Interview focused on experiences of, the influence on behaviour of practitioners applying compression force in mammography.

a and c) viewpoints of practitioners’ use of compression during screening MG: patient empowerment, white lies, time for interactions, uncertainty of own practice, culture using compression force, power/medical dominance, compression controls, digital technology, dose audit-safety net and a numerical scale of compression force.

a) 8 c) 4

[35]

Netherlands

To compare mammography performed with and without radiolucent positioning sheets.

N = 184/179 women screened in the Dutch breast screening programme, providing written informed consent to have one additional image taken with positioning sheets.

Measures: projected breast area, image quality, pain experience and radiation dose. Quantitative analysis.

a) With positioning sheets significantly more pectoral muscle, lateral and medial breast tissue was projected (CC-views) and more and deeper depicted pectoral muscle (MLO-views). In contrast, visibility of white and darker areas was better on images without positioning sheets, radiologists were there for the better ability to detect abnormalities (MLO-views). Women experienced more pain with positioning sheets (MLO-views only)

a) 9 b) 1 c) 4