Of the patients in our study, 219 (73 %) would have been sent to hospital for an outpatients X-ray examination if the mobile service had not been available. Although X-rays at a stationary laboratory often only take a few minutes, waiting and complicated transport logistics often result in a long period of absence from the nursing home. Figures from Oslo and Lund show that the time spent is typically between 3.5 and 5 hours (6, 10). This places a severe strain on frail, elderly individuals, and there is a risk of a negative effect on their medical condition (7, 8).
Delirium may occur, and patients with dementia are particularly susceptible (13). Patients were perceived by the doctor as being without mental impairment in only 26 (30 %) of the cases in our study. An Italian study in which mobile X-ray examinations were performed in the patients’ homes revealed significantly fewer cases of delirium than in a control group who were transported to a radiology department (11). A similar favourable effect was also reported from Lund – less confusion in patients with dementia – when scans were conducted locally in nursing homes (10).
The study confirms that mobile X-ray services make diagnostic imaging possible in situations where patients would not otherwise have been examined. Sixty of the patient examinations performed (20 %) would not have been carried out if the ambulant service had not been available. This percentage is twice as high as previously reported from Oslo (12). We have no information regarding the reasons that these patients would not have been sent, but there is reason to believe that high morbidity and frailty played a part. There were relatively more patients on long-term stays in this group. We saw that three of a total of six X-ray examinations of patients in a palliative unit would not have been carried out in the absence of a mobile service.
The study indicates that the availability of a mobile X-ray service would lead to increased use of diagnostic imaging at nursing homes. In view of the high utility value reported by nursing home doctors, we believe there is reason to maintain that this is desirable from a medical perspective.
Our respondents were also asked about the effect of the X-rays in terms of decisions to transfer patients to hospital for treatment. At the time of making the referral, they were of the view that 18 of the patients (6 %) would have been transferred directly to hospital for acute assessment or admission if the mobile X-ray service had not been available. Their view after X-rays had been taken was that they allowed hospitalisation to be avoided in 29 cases (34 %), and referral to an outpatients clinic to be avoided in 20 (23 %).
There are reports from Australia of a significant reduction in acute hospitalisations from nursing homes where mobile X-ray services are used frequently (14). Our study did not have such hard endpoints, but gives an indication of similar effects. Hospitalisation of nursing home patients may be necessary in certain cases, but this has been shown to be associated with a risk of increased morbidity and a subsequent reduction in functional status (15). Mortality in connection with hospitalisations is also very high, with the consequence that many patients end their lives in a busy hospital department instead of in their accustomed surroundings in the nursing home (5). Thus a mobile X-ray service could reduce the number of these undesirable situations.
On the other hand, there is a certain risk that a mobile X-ray service might lead to patients with complex disease pictures, who ought to be treated in hospital, remaining in municipal institutions without access to specialised diagnostic services, including sophisticated diagnostic imaging such as CT, MRI and ultrasound scans. Although our experience indicates that images acquired with a mobile X-ray apparatus are of a high diagnostic standard in the great majority of cases, in some cases better images will be achieved with a stationary laboratory. This applies, for example, to trunk photography of large patients. A mobile X-ray service also places great demands on the radiographer, who must make preparations and improvise when performing X‑rays in nursing homes.
A mobile X-ray service has clear consequences for personnel and health economics resources. The equipment is relatively costly, and the unit must be manned by a qualified radiographer. On the other hand, one avoids costly transport by ambulance or taxi, often entailing prolonged absences by accompanying nursing home personnel.
A Norwegian socioeconomic analysis from 2005 that compared the costs of stationary and mobile X-ray services for nursing home patients concluded that a mobile X-ray service turns out to be cheaper per examination than similar examinations performed at hospitals (16). A recently published prospective comparative study from southern Sweden also documents lower costs (17). However, the finances are complicated by the fact that the mobile X-ray service lies in the borderline territory between the spheres of responsibility of the municipal and the specialist health services. Furthermore, there is currently no special reimbursement scheme for mobile X-ray examinations.
In our study, it is the nursing home doctors and their subjective views on patients and treatment that are being investigated. The option of a mobile X-ray service has been very well received, with great enthusiasm, as demonstrated by the very high response rate. The nursing home doctors were well acquainted with the mobile X-ray service as a pilot project for a limited period, and aware that the results of the study could affect the decision to continue the service. This may have caused a certain positive skewing of the responses.
The weakness of the study is the lack of hard endpoints. We have no exact figures for the use of diagnostic imaging at municipal care institutions before and after the introduction of the mobile X-ray service, nor comparable figures for hospitalisations and treatment at outpatient clinics. The number of responses in the follow-up stage 2 is relatively low, and thus does not really provide a basis for a statistical analysis.
In our view, it would be particularly interesting to conduct a closer analysis of the group of patients who would not have been offered diagnostic imaging if it had not been possible to offer a mobile X-ray service. A cost-benefit analysis that includes potentially saved hospitalisations would be of great interest. Thus the study points the way for new research projects in this area.