One Size Does Not Fit All

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How can radiology departments improve the overall imaging experience for patients with obesity?

More than one-third of Americans are obese and the number continues to climb. In June of 2013, the AMA classified obesity as a disease, but the condition has challenged healthcare providers for decades, with radiology departments attempting to shoulder the weight of the obesity crisis and the logistical and technical hurdles it creates.1,2 Imaging larger patients poses unique challenges when it comes to obtaining the images, the quality of the images themselves, and the accessibility, comfort, and safety of the patients.

 

Identifying Challenges

Raul N. Uppot, MD, assistant professor of radiology at Harvard Medical School, has long been interested in this issue. As a fellow at Massachusetts General Hospital, he was curious about a phrase he saw used frequently in radiology reports: “limited by body habitus.” “When writing a report on a patient, a radiologist will use this phrase if they feel the images are not of diagnostic quality or they might miss something because of it,” says Uppot. He decided to do a search on the phrase in all of the reports at his facility, in all of the various modalities, starting from when the data became available in 1998. As he suspected, there was a clear rise in the use of the phrase in radiology reports each year. He also found this correlated with graphs of rising obesity in his state of Massachusetts.3 Uppot found it troubling that so many obese patients were receiving these essentially inconclusive reports because of the insufficiencies of current imaging equipment (machines that were not powerful enough to produce diagnostic quality images in larger patients).
 
Aside from issues with image quality, Uppot observed that a few patients couldn’t even fit in machines at his facility. This, he felt, was unacceptable. “The worst thing for a patient is they take off work, they take the time and drive all the way to your facility, they wait for the appointment, just to be told they can’t have their imaging done. If you can’t even image them, how can you treat them?” Or worse, he says, they have a bad experience trying to fit into a machine that’s too small.
 

Assessing Needs

Christine Abbott, a business operations specialist at Augusta University Health in Georgia and a patient advocate on the ACR Commission on Patient- and Family-Centered Care Informatics Committee, had that experience when going in for a biennial MRI. Abbott, who suffers from multiple sclerosis, felt the MRI machine getting tighter every time. On one instance, Abbott recalls, she told the RT, “I will not fit in that.” The RT politely reassured her that she would, removed all the padding in the machine, and said, “Tell me if you get hot.” Abbott was in the machine for an hour and when it was time to get out, she found herself stuck. “I had to do a little shimmy to get out, and despite getting stuck the technician made me go back in for the second part of my imaging,” says Abbott. “It was scary and a little embarrassing and I thought to myself, ‘Never again.’”
 
Abbott’s experience is not unique and is one that Uppot has been trying to raise greater awareness of. In 2007, Uppot published a paper that provided an objective measure of the challenges radiologists face in imaging obese patients, including the inability to accommodate large patients on currently designed imaging equipment and difficulties in acquiring desired image quality.4 He began giving talks around the country to bring attention to the lack of awareness that medical personnel have about the maximum height, weight, and girth for machines at their facilities. “If you asked all the radiologists at RSNA, for example, what their machine limits were, the vast majority would not know,” says Uppot. According to him, this results in patients like Abbott being booked for machines that may not accommodate them — a problem that could be avoided by having these maximums posted on each machine in the facility and communicated to the staff scheduling the appointments. He also advocated for bigger machines — for manufacturers to build and release them, and for facilities to acquire them.
 
Uppot has observed an evolution over the last decade of more companies recognizing and capitalizing on the market for bigger machines, as well as radiologists and RTs changing protocols to be more accommodating for obese patients. Unfortunately, Uppot says, most healthcare systems — in their attitudes, equipment, and facility design — are ill-equipped to meet the needs of this epidemic.5
 
Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness in Washington, D.C., and a faculty member at Johns Hopkins Bloomberg School of Public Health, agrees that problems remain with the imaging and treatment of obese patients. “Of course, there’s technical challenges of getting good imaging results in patients that have a lot of extra body tissue, but there’s also real psychosocial issues,” says Kahan. “Whether intentional or not, heavier people often experience weight-shaming during healthcare interactions. This leads to avoiding healthcare, including imaging, for fear of further stigmatization.”
 
According to Kahan, weight stigmatization is surprisingly common. “It is often inadvertent — many providers don’t order a test or prescribe a treatment because it is assumed that heavier patients won’t be compliant with recommendations,” says Kahan. “It can also be unintentional — years ago, one of my patients was sent to a zoo for imaging, as her size could not be accommodated in traditional scanners. But intentional weight stigmatization is especially common and misunderstood. For example, many physicians believe that criticizing a patient for their weight gain or harshly commanding them to lose weight will be motivating.” However, according to Kahan, studies show that when shamed, people tend to gain more rather than lose weight.6,7 And, of course, if patients delay or forgo imaging altogether, existing health issues can worsen.
 
Given the largest growing part of the population in the United States is people with a body mass index greater than 40 kg/m2, this is a matter of urgency.8,9 “Bottom line: obesity is a real medical condition,” Kahan says. “Obesity isn’t a choice. It’s more than just a behavioral issue; it’s driven by biology and the environment. We’re going to see more and more patients who have severe obesity, and it’s our responsibility as medical professionals to make sure we’re equipped to treat them — both in terms of availability of medical technology and by approaching them with the same care and compassion that we offer other patients.”
 

Finding Solutions

So what can radiology departments do to improve imaging for obese patients? Uppot believes physicians need more education about what to do when they encounter an obese patient. “Nobody sits down and says, ‘What happens when you cannot scan a patient?’” says Uppot. “You can’t just turn them away.”
 
Abbott believes more awareness about the machines is critical. She suggests radiology departments develop matrices for the maximum limits for machines and post this information on or near the machines themselves and distribute it to schedulers. “There should be a height/weight/girth ratio chart for every machine — what the maximum is comfortably, safely, and with padding,” Abbott says. Uppot agrees. “Every person on the team should have knowledge of maximums for the machines,” he says.
 
It would also be helpful, Abbott says, to give schedulers access to medical records so they can schedule patients for machines that will accommodate their size. “Don’t put the onus on patients to figure out if a machine will fit them or to tell the technician that they won’t fit,” Abbott says. “Some patients don’t even know to ask, and they could get stuck. Radiology practices can help reduce worry and anxiety by just scheduling the right machine to accommodate each patient.” Abbott also advises practices to have gowns available in larger sizes such as XLs or above so patients feel as comfortable as possible.
 
According to Uppot, in the age of EHRs and clinical decision support tools, the incorporation of weight limits into the ordering/scheduling process could avoid issues of patients being scheduled for procedures on equipment that they may not fit in. While many accommodations are straightforward, others may require some creativity. “Measuring girth is a challenge at some facilities,” says Uppot. “One facility I know of bought a hula hoop to determine if patients were going to be able to fit. If you cannot get a good ultrasound, use your CT. CT is the most accommodating for larger patients.”
 
Lastly, Uppot emphasizes, if you simply cannot image a patient at your facility, be prepared with information on where your patient can get the imaging done nearby: “If you are telling a patient you can’t accommodate them for imaging, your next statement should be, ‘But here’s where you can get your scan down the road.’”
 
Abbott hopes that, thanks to the efforts of healthcare providers like Uppot and Kahan, practices will have more compassion and understanding for obese patients. “There’s a certain level of condemnation and a little bit of punishment for being overweight,” she says. “It feels like, ‘You’ve made this choice to be overweight, so this is the penalty for being your size: we’re not going to accommodate you.’”
 
Kahan believes it’s unacceptable for any patient to feel marginalized. “It’s important to inform patients of the risks and challenges of imaging when they’re bigger, but this should be done in a respectful and compassionate way,” Kahan says. “I would hope that the medical field, and radiology in particular, will devote the same attention and innovation to developing solutions for imaging bigger people as they would when faced with challenges to providing quality care for any other patient group — so that we can ultimately serve patients of all shapes and sizes.”
By Cary Coryell, publications specialist, ACR Press
 
ENDNOTES
1. Centers for Disease Control and Prevention. Overweight & obesity: Adult obesity facts. August 13, 2018. Accessed January 11, 2019. Available at bit.ly/CDC_AdultObesity.
2. Frellick M. AMA declares obesity a disease. Medscape. June 19, 2013. Accessed January 11, 2019. Available at bit.ly/AMA-Obesity.
3. Uppot RN, Sahani DV, Hahn PF, Kalra MK, Saini SS, Mueller PR. Effect of obesity on image quality: fifteen-year longitudinal study for evaluation of dictated radiology reports. Radiology. 2006; 240(2):435-9. Available at bit.ly/Radiology2006_Obesity.
4. Uppot RN, Sahani DV, Hahn PF, Gervais D, Mueller PR. Impact of obesity on medical imaging and image-guided intervention. Am J Roentgenol. 2007; 188(2):433-40. Available at bit.ly/AJR2007_Obesity.
5. Ortiz VE, Ottolino RJ, Matz MW, Uppot RN, Winters B. Infrastructure design: a critical element in the care of the patient with obesity. J Patient Saf. 2018. Available at bit.ly/JPatientSaf2018_Obesity.
6. Gudzune KA, Bennett WL, Cooper LA, Bleich SN. Perceived judgment about weight can negatively influence weight loss: a cross-sectional study of overweight and obese patients. Prev Med. 2014; 62:103-7. Available at bit.ly/PrevMed2014_Obesity.
7. Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One. 2013; 8(7): e70048. Available at bit.ly/PLoSOne2013_Obesity.
8. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes. 2013;37(6):889-91. Available at bit.ly/IntJObes2013_Obesity.
9. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health. 2007;121(7):492-6. Available at bit.ly/PublicHealth2007_Obesity.

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