Supply of and demand for radiologic technologist personnel in Taiwan: an analysis of 20 years

Background: Currently, nine universities and one junior college offer radiologic technologist (RT) programs (RTPs) in Taiwan. The curriculum, certificate examination, and licensing of RTs in RTPs in Taiwan are similar to those for RTPs in Japan and Korea. The present study explored the supply of and demand for RTs over the past 20 years and identified predictive indicators of trends affecting the numbers of RTs supplied and demanded. Methods: The present study involved web-based research. The analyzed data were publicly available information downloaded from the websites of relevant statistical departments in Taiwan. The study employed specific medical devices or examinations used in hospitals to determine the demand for RTs. Long-term (1999–2018) and short-term (2014–2018) trends were analyzed. The change rates were calculated using compound annual growth rate (CAGR). Pearson’s product–moment correlation coefficient or Spearman’s rank correlation coefficient was used to evaluate two groups of continuous variables. Kolmogorov–Smirnov and Shapiro–Wilk tests were used to test normally distributed data. Results: During 1999–2018, the annual numbers of students and graduates in RTPs were 2654 ± 350 and 516 ± 109, respectively, with corresponding CAGRs of 2.2% and 3.7%. During 2014–2018, the annual numbers of students and graduates in the RTPs were 2908 ± 67 and 605 ± 55, respectively, with corresponding CAGRs of −0.7% and 2.4%. During 1999–2018, the annual numbers of examinees and qualified personnel were 1228 ± 174 and 372 ± 62, respectively. The CAGRs for the number of qualified personnel were −1.5% and −4.7% during 1999–2018 and 2014–2018, respectively. The number of specific medical devices increased from 599 in 2000 to 1057 in 2018, whereas that of specific medical examinations increased from 1.7 million in 2000 to 5.3 million in 2018.


Background
In Taiwan, academic training courses for radiologic technologists (RTs) began in 1965.
Prior to 1990, only two junior colleges in Taiwan provided RT programs (RTPs). Currently, nine universities and one college offer RTPs in the form of nine bachelor's degree courses and one diploma course, respectively. The curriculum of RT training stipulates obtaining a minimum of 128 credits, including at least 58 credits from mandatory courses related to diagnosis, nuclear medicine, radiotherapy, and radiation safety. Students are expected to complete an additional 28 weeks of hospital internships [1]. After successful graduation from RTPs, students are eligible to take the certificate examination conducted by Taiwan's Ministry of Examination. A certificate is issued if a candidate's average score exceeds 60 points. When candidates become certified RTs, they can apply and register as RTs at hospitals in Taiwan. RTs have only one certificate examination and one work license. It is a single or all-in-one license and is not subdivided into multiple licenses for diagnostic radiology, nuclear medicine, radiotherapy, ultrasound, and magnetic resonance (MR). This all-in-one pattern of the curriculum and certificate examination in RTPs and licensing of RTs is similar to patterns followed in Japan and Korea [3][4][5]. RTs work mainly in the radiology, nuclear medicine, and radiotherapy departments in Taiwan. Understanding national and global health labor market forces and trends is critical for developing effective health workforce plans [6][7][8]. Excess medical staff indicates workforce wastage and reduces wages. However, an inadequate workforce supply can undermine patients' rights and indirectly affects the health of the national population [9]. The present study explored the supply and demand for RTs over the past 20 years. We also identified predictive indicators of trends affecting the numbers of RTs supplied and demanded.

Methods
The present study involved web-based research. The analyzed data were publicly available information downloaded from the websites of relevant statistical departments in Taiwan.
The numbers of students and graduates enrolled in each RTP with a bachelor's degree or diploma were obtained from Taiwan's Ministry of Education [10]. The numbers of examinees and qualified personnel who took the certificate examination were obtained from Taiwan's Ministry of Examination [11]. The certificate examination for RTs is conducted twice a year. The number of examinees and qualified personnel reported in the present study was the total of both examinations in a given year. In addition, the numbers of specific medical devices, patients undergoing specific medical examinations (diagnosis and radiation therapy), and registered RTs were obtained from Taiwan's Ministry of Health and Welfare [12]. Specific medical devices used or examinations conducted in hospitals indicated the following seven types of devices or examinations: computed tomography (CT) and magnetic resonance imaging (MRI) in the department of radiology; single photon emission computed tomography (SPECT) and position emission tomography (PET) in the department of nuclear medicine; and linear acceleration (LINAC), brachytherapy (Brachy), and proton therapy (Proton) in the department of radiation therapy [12]. Data on national population and gross domestic product (GDP) per capita were obtained from Taiwan's Ministry of Interior [13].

Statistical analysis
We analyzed long-term trends from 1999 to 2018 (or 2000 to 2018) and short-term trends from 2014 to 2018. The change rates in enrolled students, graduates, examinees, and qualified personnel were calculated using a compound annual growth rate (CAGR). The 5 numbers of specific medical devices, patients with specific medical examinations, and registered RTs as well as GDP per capita exhibited a linear distribution; hence, linear regression analysis was performed. Pearson's product-moment correlation coefficient (r) was used to evaluate two groups of continuous variables, and the correlation indicated a normal distribution. For variables that did not exhibit a normal distribution, Spearman's rank correlation coefficient (r) analysis was used. The results of Kolmogorov-Smirnov and Shapiro-Wilk tests suggested that the numbers of graduates, qualified personnel, devices, patients, and RTs as well as GDP per capita exhibited a normal distribution. SPSS v17 and Excel 2016 were used to compile and analyze the data statistically.

Results And Analysis
The numbers of students who enrolled in and graduated from the RTPs in Taiwan form 1999 to 2018 are shown in Figure 1.    In Taiwan, the GDP per capita increased from US$13,804 in 1999 to US$25,792 in 2018 [13]. GDP growth may have led to an increase in the number of specific medical devices and examinations. From 2000 to 2018, the total number of specific medical devices increased from 599 to 1057. The increase in the number of these medical devices is also reflected in the increase in the number of specific examinations.
As detailed Table 1, the examination frequency (patients per 10,000 people) in the long term, PET devices had fastest growth rate, followed by MRI devices. In the short term, the growth rate of proton devices was the fastest, whereas that of PET devices ranked second.
In the long term, the number of patients exhibited a CAGR of 6% per year, whereas in the short term, the number declined slightly to 4% per year. In 2018, a total of 2227 specific medical diagnoses and treatments were performed per 10000 people. Among them, the

Limitations
Combining the numbers of seven specific medical devices may not be a appropriate approach because each device is different and the numbers of RTs required to operate them are different. Similarly, the usefulness of combining the numbers of seven specific medical examinations is also debatable. Strictly speaking, the average number of RTs required to operate each device or conduct each examination should be consider separately and added up after weighting is applied. In the absence of relevant references, we used unweighted sums for comparison. In addition, changes in the number of RTs are also closely related to political processes [15], such as a policy changes in Taiwan's National Health Insurance system. This study did not discuss the effects of policy change.

Conclusions
Taiwanese academic institutions provide 605 graduates from RTPs each year, and among those who graduate, approximately 375 become qualified personnel. Currently, the largest number of devices/treatments for specific medical diagnoses or treatments is CT followed by LINAC. The numbers of proton devices and patients receiving proton therapy are likely to increase at the fastest rate in the next decade. The growth of GDP per capita has led to a steady increase in the demand for specific medical devices and examinations, resulting