title: Heterogeneity in patient diagnostic pathways: an example from contrast-enhanced ultrasound diagnostic scans for focal liver lesions.
abstract: BACKGROUND
  The UK's National Institute for Health and Care Excellence (NICE) has recommended contrast-enhanced ultrasound (CEUS) for the characterisation of focal liver lesions where the results of standard unenhanced ultrasound are inconclusive. A further recommendation is for CEUS to replace other imaging modalities. However, little is currently known about the diagnostic pathways in the National Health Service (NHS) followed by patients with potential liver lesions. The aim of this study was to identify the diagnostic pathways for a number of representative hospital trusts and record the clinicians' views on patient experiences of these processes through a series of semi-structured interviews with UK clinicians (radiologists and sonographers) (N = 7). This study was undertaken in the broader context of a larger research project where the overarching research question is focused on patient preferences for CEUS and other imaging modalities, and how these impact on patient quality of life (QOL).
  
  
  RESULTS
  The results from the semi-structured interviews with UK clinicians revealed that there is a great deal of heterogeneity in diagnostic pathways followed by patients with potential liver lesions which differ both within and between hospitals. In terms of the patient experience, the clinicians believed that a combination of the more patient-friendly ultrasound process, and the fact that scan results are given to patients in 80-90% of cases on the day, as well as the problems inherent to other scan modalities (claustrophobia, anxiety) would lead to patients preferring ultrasound compared with other imaging modalities (CT or MR). However, current clinical practice means that patient choice is virtually non-existent.
  
  
  CONCLUSIONS
  The significant variation in diagnostic pathways across the NHS will require further standardisation through local agreements if contrast-enhanced ultrasound is to replace other imaging modalities in characterising focal liver lesions in line with NICE Diagnostics Guidance. The gradual development of patient choice of modalities may necessitate a change of practice in radiology processes.
authors.affiliation: York Health Economics Consortium Ltd, University of York, Market Square, Heslington York YO10 5NHUK. adam.smith@york.ac.uk.
authors.forename: Adam B
authors.initials: AB
authors.lastname: Smith
authors.forename: Alexandra
authors.initials: A
authors.lastname: Filby
authors.forename: Louise M
authors.initials: LM
authors.lastname: Carr
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D003287:Contrast Media; D003663:Decision Trees; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000473:pathology; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011788:Quality of Life; D011859:Radiography; D011795:Surveys and Questionnaires; D014463:Ultrasonography / Q000379:methods / Q000706:statistics & numerical data*
chemical_list: D003287:Contrast Media