Noah Takacs, BS

Continued fallout from the global shortage of iodinated contrast media (ICM) has forced hospitals and providers to triage patients, reduce imaging utilization, switch imaging modalities, and postpone imaging studies. Effective strategies to blunt the impact of the ICM shortage are urgently needed as this crisis continues to have a profound impact on patients and health-care systems.

Like many other modern-day crises, the ICM shortage originated from the COVID-19 pandemic. A large percentage of the world’s ICM supply is manufactured in Shanghai, China. Strict pandemic lockdowns led to a near total cessation of manufacturing and shipment of the contrast media out of the country, which led to widespread shortages across the world. Although the Shanghai factory returned to full operation last month, some imaging facilities may continue to have challenges with shortages until their supplies of ICM are restored to optimal levels.

Given this risk, it is prudent to develop and implement strategies that can effectively minimize the impact of the ICM shortage while maintaining high quality patient care. Multiple societies have put forward recommendations involving possible solutions, including triaging patients, using alternative imaging modalities, using alternative contrast agents, reducing overall imaging utilization, and creating central command structures.

(Editor's note: For related content, see "Lessons Learned from the Iodinated Contrast Media Shortage: A Neuroradiologist's Perspective" and "Emerging Strategies for Managing the Acute Shortage of Iodinated Contrast Media.")

One of the simplest but also most challenging of the recommended strategies involves changing what imaging tests are done and when. This can be achieved through triaging and delaying elective imaging. Triaging involves the difficult task of assigning a priority to each patient’s contrast needs. Keefe and colleagues proposed a three-category triage tier list, which includes emergent, delay for one month, and delay for three months.

 This novel strategy enables clinicians to ensure that patients with emergent needs are served quickly while also enabling health-care systems to extend their limited supplies until the crisis abates.

Another widely suggested remedy is the use of alternative imaging modalities. Possible alternatives include magnetic resonance imaging (MRI), ultrasound, and non-contrast computed tomography (CT) studies. Given the large overlap between MRI and contrast CT indications, increasing the use of MRI during this crisis has been broadly recommended.

However, there are limitations to this substitution. The primary impediments are the limited number of MRI scanners, their relatively higher cost, and the nature of the pathology. One solution to this is the use of “focused” protocols that minimize overall MRI time, which can enable each scanner to serve a larger number of patients with appropriate disease conditions.

Using alternative contrast agents is another frequently prescribed solution to this problem. Multiple alternatives, including carbon dioxide (CO2) and gadolinium, have been suggested, particularly when it comes to interventional radiology.

 Each of these substitutes has benefits and drawbacks that must be carefully considered.

Using CO2 is beneficial because it is not allergenic nor nephrotoxic and has no dose limit due to excretion by the respiratory system. However, CO2 also has risks, such as organ ischemia and emboli. It is also contraindicated for multiple conditions and procedures.

 Gadolinium is another off-label, but well studied alternative to iodinated contrast dyes. Gadolinium is advantageous since it has a low risk of nephrotoxicity. However, it is restricted by the necessity of small dosages and has limited ability to generate high quality angiographic images.

A final broad recommendation is the creation of a centralized hospital command for the allocation and distribution of iodinated contrast dye. Instead of leaving each department to handle the crisis on its own, the creation of a multidisciplinary, multispecialty, and centralized command that can effectively coordinate a hospital-wide response during this critical period is essential. This centralization of command can remove ambiguity and the burden of procurement and allocation from individual physicians and departments. This strategy can allow for more equitable and balanced distributions of limited resources.

In conclusion, although the current ICM shortage is cause for great concern, the future is promising. The Shanghai factory has reopened and other factories across the world have begun to ramp up their ICM supply to help mitigate the crisis.

 A combination of patience, effective triaging, alternative imaging, alternative contrast agents, and novel command structures will enable radiology to weather this storm and fully return to normal in the near future.

1. Reeder SB, Hess CP, Zaharchuk G, Moy L. Editorial for “Magnetic resonance imaging as an alternative to contrast-enhanced computed tomography to mitigate iodinated contrast shortages in the United States: recommendations from the International Society for Magnetic Resonance in medicine. 

 2022 Jun 2. doi: 10.1002/jmri.28282. Online ahead of print.

2. Keefe NA, Desai KR, Kohi MP, Salazar GM. Interventional radiology approach to contrast media preservation strategies. 

 2022 May 19;S1051-0443(22)00940-X. doi: 10:1016/j.jvir.2022.05.011. Online ahead of print.

3. Hicks L. Global contrast media shortage blamed on COVID lockdown in China. Medscape. Available at: 

https://www.medscape.com/viewarticle/973810

 . Published May 11, 2022. Accessed June 21, 2022.

Articles

As the iodinated contrast media shortage continues to have a significant adverse effect on radiology, these authors assess the pros and cons of emerging strategies and imaging alternatives.

Iodinated Contrast Media Shortage: Practical Solutions and Applications in Radiology

The prompt and accurate results of an imaging study can be the difference between life and death. Yet the number of practicing radiologists in the United States is likely insufficient to meet the growing demand. This shortage is also projected to worsen, and according to the Association of American Medical Colleges (AAMC), the U.S. is projected to have a shortage of 17,000 to 42,000 radiologists, pathologists, and psychiatrists by 2033.

 On average, the number of imaging studies increases by a rate of up to five percent per year, but the number of radiology residency positions only increases by two percent.

This shortage has a dramatic impact on patient care. A shortage of radiologists leads to increased turnaround times for study results to be generated, which can negatively impact patient outcomes. One recent study found that radiology imaging delays are an independent predictor of length of hospital stay.

 Another recent study found it took more than three hours to generate a report from an average CT study with the radiologist being the bottleneck 42 percent of the time.

 This delay in clinically pertinent information can have a significant impact on patients. These delays needlessly burden health systems, patients, and insurers, and could be resolved by improved imaging coverage. Although the situation might appear dire, there are many potential solutions.

The first and most immediate solution would be an increase in the number of radiology residency positions.

 The number of positions is largely determined by Medicare, and there have only been marginal increases over the years in radiology. In 2006, there were 1,011 radiology residency positions. In 2020, there were 1,113 radiology residency positions. However, this slow increase has begun to change as Congress passed a graduate medical education (GME) expansion in 2020, which added 1,000 new residency spots, many of which are likely to be radiology positions.

Increasing medical student awareness of the specialty is another promising way to combat the shortage.

 Medical students often have little exposure to the radiology specialty, and a recent study found that only 35 percent had completed a radiology rotation by graduation.

 This could be remedied by promoting radiology as a core rotation in medical school as well as increasing the amount of radiology material that is covered during the preclinical curriculum. One study found that adding just 2.5 hours of radiology lectures to the first year of medical school significantly increased student interest in radiology, and increased the likelihood of students completing a radiology rotation later in the curriculum.

 This is a promising solution since more medical students interested in and matching into radiology could potentially reduce the impact of the radiologist shortage.

Another solution to this workforce challenge is achieving improvements in radiologist efficiency.

 Many studies have investigated potential methods by which radiologists can increase efficiency. Promising solutions include decreasing distraction and integrating the utilization of artificial intelligence (AI) in practice.

 Interruptions due to phone calls, emails, and consent forms can hinder a radiologist’s workflow, potentially leading to decreased performance and less informed consultations.

Reductions of these distractions through the use of reading room coordinators and enhanced communication workflows are often pursued as solutions for improving efficiency. Additionally, AI enables radiologists to perform their roles with greater efficiency. Although unlikely to replace the role of the radiologist, AI can be used to help with measuring lesions, comparing studies, and triaging scans that are at an increased risk of being urgent. One study found that AI could be used to select which chest X-rays were more likely to be abnormal, and then prioritized those for interpretation by radiologists.

 This method was able to decrease the average delay in interpretation of abnormal scans from 11.2 days to 2.7 days.

Although current trends in the number of practicing radiologists may seem concerning, the future is bright. There are many effective solutions to this problem, all of which are simultaneously being pursued. Many medical schools are integrating more radiology material into the curriculum, radiology residency positions are being expanded, and radiologists are becoming more efficient each year. These trends are promising for the future of the field and with sufficient action, the shortage can be addressed and possibly reversed.

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https://www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf

 . Published June 2020. Accessed January 20, 2022.

2. Smith-Bindman R, Kwan ML, Marlow EC, et al. Trends in use of medical imaging in US healthcare systems and in Ontario, Canada, 2000-2016. 

3. Courane S, Conway R, Creagh D, et al. Radiology imaging delays as independent predictors of length of hospital stays for emergency medical admissions. 

4. Perotte R, Lewin G, Tambe U, et al. Improving emergency department flow: reducing turnaround time for emergent CT scans. 

 2018 Dec 5;2018:897-906. eCollection 2018.

5. Prezzia C, Vorona G, Greenspan R, et al. Fourth-year medical student opinions and basic knowledge regarding the field of radiology. 

6. Branstetter B, Humphrey A, Schumann J. The long-term impact of preclinical education on medical students’ opinions about radiology. 

7. Dargan R. Artificial intelligence boost efficiency and quality in radiology practice. Radiological Society of North America (RSNA). Available at: 

https://www.rsna.org/news/2019/march/artificial-intelligence-boosts-efficiency

 . Published March 18, 2019. Accessed January 20, 2022.

8. Lee MH, Schemmel AJ, Pooler BD. Radiology workflow dynamics: how workflow patterns impact radiologist perceptions of workplace satisfaction. 

While current projections suggest a shortage of radiologists in the future, promising developments with radiology residency positions, medical student awareness of the field and AI-aided efficiencies could be game changers. 

Noah Takacs, BS

Articles

Iodinated Contrast Media Shortage: Practical Solutions and Applications in Radiology

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