Barriers to cardiovascular magnetic resonance across Europe: a 46-country EACVI observatory study

Abstract

Aims

Cardiovascular magnetic resonance (CMR) is established in guidelines, yet utilization remains inconsistent across Europe and beyond. This study aimed to identify barriers to CMR practice and reporting across European Society of Cardiology (ESC) member and affiliate countries.

Methods and results

This study was conducted between January and September 2025. A sequential exploratory mixed methods design was used, comprising two phases: qualitative interviews and a quantitative survey. Countries were grouped into five ESC subregions (Northern, Western, Southern, and Eastern Europe, and Central Asia/Caucasus) based on the United Nations regional classification system. Quantitative data were analysed using chi-square tests for regional differences. Qualitative responses were synthesized using thematic analysis and integrated through triangulation. Among 283 respondents from 46 countries, inadequate reimbursement (46%), insufficient training (38%), and limited scanner capacity (29%) were the main barriers. Eastern European countries reported four-fold higher training deficits than Northern and Southern Europe (56% vs. 14%, P < 0.001). Country-level analyses showed substantial heterogeneity in drivers of limited CMR access, ranging from workforce and efficiency constraints in mature systems to financial and governance restrictions. Qualitative findings enriched these results, identifying structural inefficiencies, interdepartmental barriers, and emerging adaptive strategies such as remote supervision and reading, and regional collaboration networks to support capacity building in resource-limited settings.

Conclusion

Across ESC member and affiliated countries, CMR delivery remains constrained by infrastructure, training, and reimbursement limitations. Targeted investment in standardized education, harmonized reimbursement frameworks, and collaborative service models is essential to promote equitable and sustainable access to CMR across Europe.

Graphical Abstract

Graphical Abstract.

Introduction

Cardiovascular magnetic resonance (CMR) is the reference standard for non-invasive assessment of myocardial structure and function, and has evolved into a robust diagnostic tool over the last few decades, extensively used in various clinical and research applications.^1,2 Despite the strong endorsement and increasing representation in European Society of Cardiology (ESC) guidelines, there is evidence that CMR may be still be underutilized in many parts of the world. The reasons could vary from access to scanners and prohibitive costs, to inconsistencies in CMR technology, geographic variations, heterogeneity in healthcare infrastructure, legal framework, and unstandardized training curricula.³

While our recent systematic review identified key CMR barriers globally,⁴ no study has quantified their prevalence, regional variation, or interdependencies across European healthcare systems, nor identified which barriers most strongly predict underutilization. These challenges have been observed across different health systems.⁵

Most available evidence is derived from individual countries or single-centre experiences, limiting comparability across healthcare systems. Many of the 56 current ESC countries, particularly those in Eastern Europe and Central Asia, remain underrepresented, and contextual insights are absent in settings characterized by constrained resources and fragmented governance.

The increasing prevalence of cardiovascular disease highlights the need for enhanced diagnostic tools, such as CMR and its applications, to ensure patients receive high-quality care. It is therefore evident that there is a growing need to objectively explore the barriers in practice, performance, and reporting across Europe. This is of particular importance given that CMR is widely underutilized in most parts of the world. A multistage, mixed-methods project was developed under the ‘CMR Observatory’ framework, approved by the European Association of Cardiovascular Imaging (EACVI). We used a coordinated multinational design encompassing up to 56 ESC member countries during the qualitative phase; the subsequent Survey was distributed more broadly including affiliated countries. The Survey explores barriers and facilitators to CMR practice from the perspectives of cardiologists, radiologists and imaging practitioners. Through this initiative, EACVI seeks to generate insights that can inform policy and practice, harmonize training standards, and support equitable, high-quality CMR delivery across ESC (and ESC-affiliated) countries.

Method

Study design

This study employed a sequential exploratory mixed methods design comprising two core phases: qualitative interviews and a quantitative survey. It was conducted under the EACVI CMR Observatory framework between January and September 2025 according to published criteria.⁶ Ethical approval was granted by the London School of Economics (LSE) Research Ethics Committee. Informed consent was implied through voluntary survey participation and explicitly obtained for interviews. Sample size calculations indicated 250 respondents were needed to detect 20% differences between regions with 80% power.

A previously published systematic review performed by our group provided the conceptual foundation for this study.⁴ The review informed the development of the interview guide and survey questionnaire (see supplementary materials).

Semi-structured interviews were conducted by the Heart Imagers of Tomorrow (HIT) Ambassadors. Interviewees were 19 widely recognized CMR experts with lead roles in their departments and current or previous lead roles in their National (cardiac) Imaging Societies, ensuring representation from Northern, Southern, Central, and Eastern Europe. Structured interview data were obtained from 15 ESC member countries and consisted of the following thematic sections; Part 1: Identifying and documenting barriers to performing CMR scans (general practice and experience, resource and equipment challenges, training and expertise, operational and administrative challenges, departmental preferences and multi-disciplinary collaboration); Part 2: Investigating challenges related to the reporting of CMR scan results (familiarity and expertise in reporting, accuracy and interpretation, communication and collaboration); Part 3: Gaining insights into variations in CMR scan practices (comparative practices and best practices, institutional and cultural influences); Part 4: Recommendations and insights (adopting new approaches, future direction, resources, conclusion).

Interviews were conducted predominantly in English, but also in the interviewee's own language, at the interviewee's preference. All interviews were conducted via video calls. Video/audio material was recorded and transcribed. Editing and appropriate adjustments, if required, were performed and approved by the interviewee. Transcripts were analysed qualitatively and quantitatively through reflexive thematic analysis.

Insights gained from the interviews shaped the development of a structured online survey intended to measure the prevalence and regional differences in barriers to CMR practice. The questionnaire included a variety of both closed and open-ended items, assessed multiple relevant domains including access to services, challenges, scheduling, reimbursement, training and certification of health professionals involved, departmental models, perceived barriers to utilization, and performance and CMR reporting challenges across countries and health policies (see Supplementary materials).

The survey was disseminated via EACVI communication channels, including member mailing lists, and outreach by HIT ambassadors across ESC member countries. Participation was voluntary and anonymous, and respondents could also represent ESC-affiliated countries. Responses were collected over a 12-week period (June—September 2025), with follow-up reminders issued to enhance engagement.

Data analysis

Survey data were analysed descriptively, with categorical variables presented as frequencies and percentages. Countries were grouped into five ESC subregions (Northern, Western, Southern, and Eastern Europe, and Central Asia/Caucasus) based on the United Nations regional classification system.⁷ Regional differences were evaluated using χ² tests with Fisher’s exact test applied when expected cell counts were <5. A two-sided P value <0.05 was considered statistically significant.

Multivariable logistic regression identified predictors of adequate CMR access (>3 dedicated slots/week), adjusted for country Gross Domestic Product, and hospital type. Mediation analysis explored relationships between training, reimbursement, and service delivery. A separate individual-country-level analysis was conducted for countries with at least 10 responses.

Open-ended survey responses were thematically analysed and triangulated with quantitative data using NVivo 12 (QSR International, Australia). Qualitative themes were then juxtaposed with corresponding survey results in joint displays linking each theme to relevant frequencies, regional comparisons, and regression estimates, in order to assess convergence, complementarity, or divergence. Qualitative data were used to contextualize statistically significant patterns, while quantitative data were used to test the generalizability of themes raised by interviewees. Meta-inferences drawn from this integration form the basis of the Results.

Results

Two hundred and eight three completed surveys representing 46 countries (41 ESC countries and 5 ESC-affiliated countries). Most participants (77.4%) were cardiologists, followed by radiologists 16.2% and imaging technologists or other specialists 6.4%. Respondents were geographically distributed across Western 35%, Northern 22%, Southern 18%, and Eastern Europe 15%, with an additional 5% each from Central Asia/Caucasus and other affiliated regions. A large majority of participants (∼70%) had either Level 3 or other formal CMR accreditation.

The most frequent clinical indications for CMR were cardiomyopathies, myocarditis, and coronary artery disease, followed by valvular heart disease and congenital heart disease. Half of respondents (50%) reported CMR remains underutilized for specific populations or indications, most commonly for stress perfusion CMR and ischaemia testing (45%), valvular assessment (25%), and congenital heart disease (15%).

When asked to rank the main challenges in performing CMR scans, respondents frequently cited limited scanner availability and scheduling difficulties. Severe shortages of personnel with adequate CMR training, followed by administrative or operational constraints, were common (Figure 1).

Figure 1.

Barriers to CMR service delivery as reported by respondents.

CMR infrastructure and access

Access to a CMR-capable scanner was reported by 94% of respondents. Dedicated CMR time is unavailable in 28% of the participating centres. Shared MRI scheduling with other services was common and associated with longer waiting times.

Multivariable analysis showed that centres in middle-income countries were significantly less likely to report dedicated CMR scheduling than those in high-income settings (aOR 0.19, 95% CI 0.05–0.74). Reimbursement challenges, administrative barriers, and Level 2–3 certification status were not independent predictors of access.

Training and workforce

Training-related constraints were common. Close to one-third (38%) felt their training was insufficient for interpreting complex cases. Forty two percent cited limited access to hands-on practical training. Lack of certified programmes and insufficient funding for training abroad were cited by 24.7% and 17.3% of respondents, respectively. When the analysis was restricted to participants with more than five years of CMR experience, gaps persisted: 24% reported having no formal CMR certification, and 31% continued to report insufficient training for interpreting complex cases. Preferred strategies to strengthen CMR training were fellowships at high-volume centres, which were most frequently selected (66.9%), followed by regular multidisciplinary case discussions (57.4%), onsite workshops (54.4%), and online courses or webinars (46%) (Figure 2).

Figure 2.

Training barriers, certification levels, and preferred learning modalities among respondents. (A) Reported barriers to CMR training, (B) Distribution of respondents by CMR certification level, (C) Preferred approaches to enhance CMR training.

Reimbursement and administrative factors

Inadequate reimbursement was reported by 46.2% of respondents, while 29.3% reported administrative inefficiencies. Reimbursement and administrative constraints were significantly more likely to be ranked as high-priority challenges by cardiologists than by radiologists. (χ²  P < 0.05). Institution type was associated with reimbursement barriers, which were most frequently reported in private institutions (75.0%), followed by academic (45.4%) and public hospitals 32.0% (χ²  P < 0.05).

Qualitative responses described low reimbursement levels, limited coverage for contrast agents, and restrictive referral budgets, as well as administrative barriers, including inefficient scheduling systems, competition with other magnetic resonance imaging services, and rigid booking processes. Several respondents also described radiology-led organizational structures that limited cardiology access to scanners, scheduling, and reporting authority.

Regional variation

Marked regional differences were observed. Reimbursement challenges were reported by a significantly higher proportion in Southern (58%) and Eastern Europe (56%) than in Northern Europe (24%; P = 0.002). Similarly, the lack of formal training was most pronounced in Eastern Europe, with 56% lacking formal training, compared with 14% in Northern and Southern Europe (P < 0.001). Barriers to cardiology-radiology collaboration were reported by nearly half of all respondents, with the highest proportions in Western (50%), Southern (48%), and Eastern Europe (44%), compared with 25% in Northern Europe (P = 0.02). Qualitative responses contextualized these findings, revealing recurrent themes of competition over scanner control, departmental governance, and interprofessional tension. Participants frequently described radiology-led ownership of scanners as restricting cardiologists’ scheduling and reporting autonomy, while others noted fragmented communication and a lack of shared clinical pathways. Several respondents emphasized that these challenges extended beyond workflow inefficiency. No significant regional differences were observed in the availability of dedicated CMR slots.

Free-text responses reinforced the quantitative survey findings and provided additional context. Respondents highlighted workflow and infrastructure constraints, particularly limited scanner time, lack of dedicated slots, which prolonged waiting lists. Workforce-related challenges, such as difficult-to-access structured training, mentorship and certification pathways, particularly in low-resource environments. Several respondents described departmental structures and interprofessional dynamics as key obstacles, noting that scanner ownership and governance by the radiology department often restricted cardiology-led access to imaging, scheduling, and reporting authority. Some participants also pointed to currently emerging strategies such as remote supervision, regional collaborations, and decentralized training initiatives that could address capacity limitations. A joint display summarizes the alignment between survey findings and qualitative themes (Table 1).

Table 1.

Integrated findings of the survey and qualitative data

Quantitative domain survey	Key quantitative finding n = 279	Qualitative findings	Summary quote
Infrastructure and scanner access	71% reported lack of dedicated CMR slots; 32% indicated long waiting times for elective cases	Workflow bottlenecks limited scanner access and competing scheduling priorities reduce availability for cardiac cases	‘Our scanner time is shared with neuro and oncology, leaving almost no cardiac slots.’ Southern Europe
Training and certification	34% lacked CMR certification; 38% rated training as insufficient	Training gaps and limited mentorship; lack of structured fellowships; few accredited centres	‘To become competent, one must go abroad; local exposure is too limited.’ Central Asia
Reimbursement and administrative processes	46% identified inadequate or absent reimbursement; 29% cited complex authorization procedures	Administrative and reimbursement hurdles; unclear funding routes; variable national reimbursements	‘There is no re-imbursement for CMR in non-university hospitals or outpatient-settings;’ Western Europe
Departmental model and governance	58% worked in radiology-led and 30% in cardiology-led departments; 12% in hybrid models	Interprofessional dynamics and departmental control shapes access to scanners and reporting rights	‘Well, I have to leave my home country -Italy due to the fact that Radiologists would not allow Cardiologists to practice CMR.’ Southern Europe

Country-specific quantitative data triangulated with qualitative findings

Italy (n = 34): Despite 71% having dedicated CMR slots and 65% level 2–3 CMR certification, severe reimbursement constraints with 79% reporting inadequate funding, and interdepartmental barriers (62%) (Figure 3). Qualitative responses highlighted constrained scanner scheduling within radiology-led workflows and uneven access to CMR training, with expertise concentrated in academic centres. Respondents frequently described dependence on radiology for scanner access and reporting authority, contributing to operational limitations despite high clinical demand.

Figure 3.

Country-specific distribution of barriers to CMR practice in high response countries (at least 10 responses).

Sweden (n = 23): Swedish respondents demonstrated established infrastructure (70% dedicated slots) but lower certification rates (35% level 2–3); among those with more than 5-year experience, 53% lacked formal certification. Only 26% reported reimbursement barriers and 22% collaboration challenges, suggesting a mature but workforce-constrained system. Qualitative comments emphasized optimization challenges rather than access, focusing on workforce sustainability, reporting workload, and maintaining expertise in smaller centres. Regional collaboration and remote expert support were described as strategies to sustain service quality.

United Kingdom (n = 22): 82% of respondents reported having dedicated CMR slots and 72% had level 2–3 CMR certification. Despite strong infrastructure, administrative inefficiencies affected 58% of services, while reimbursement (21%) and collaboration (37%) posed moderate barriers. Qualitative responses centred on workforce pressure, reporting burden, and increasing clinical demand. Participants emphasized efficiency constraints within an otherwise well-developed system and expressed interest in workflow redesign and AI-supported reporting.

Germany (n = 21): Germany exhibited paradoxical findings. Excellent certification (89% level 3) and good infrastructure (64% dedicated slots), but severe collaboration and reimbursement challenges (83%), despite modest administrative (38%) barriers. This suggests interprofessional tensions despite technical competence. Qualitative responses centred on reimbursement, dedicated slots, training, and staffing issues. Inadequate reimbursement was cited as a principal barrier to CMR expansion, limiting scanner access, staffing, and programme development. Training opportunities were described as available but limited, often requiring individual initiative. Workflow constraints were mentioned in relation to reporting workload and staff availability.

France (n = 19): French centres showed good infrastructure (72% dedicated slots), but concerning certification gaps (33% level 2–3). Notably, only 31% of participants reported more than five years of CMR experience. While administrative and reimbursement affected only 22% and 17% of participants, respectively, interdepartmental collaboration barriers were modestly present (44%). Qualitative responses described marked regional heterogeneity, with strong centres alongside areas with limited access to mentorship and training. Respondents noted that reimbursements do not adequately reflect the time and expertise required for advanced or complex CMR studies. As a result, institutions tend to favour shorter, standard protocols over more comprehensive examinations. Respondents noted the need for a clearer national protocol.

Spain (n = 15): 72% of Spanish respondents reported access to dedicated CMR slots, but critical training deficits (only 31% certified); among those with more than 5 years of experience, 50% did not hold formal certification. Combined with reimbursement/administrative barriers (26%) and collaboration challenges (38% indicate systemic underinvestment. Qualitative responses emphasized funding constraints, restricted protected scanner time, and reliance on informal training pathways. Respondents noted that these factors limited the expansion of CMR services, particularly outside tertiary centres.

Netherlands (n = 12): The Netherlands demonstrated balanced development with strong infrastructure (83% dedicated slots), good certification (67%), with minimal barriers (25% reimbursement, 33% collaboration), representing an optimized system. Qualitative responses focused on managing high-volume services, standardizing protocols, and optimizing workflow efficiency, rather than addressing foundational access or training gaps.

Switzerland (n = 10): Swiss respondents reported exceptional infrastructure (90% dedicated slots), Barriers across other domains were minimal. Qualitative responses emphasized maintaining high technical standards, quality assurance, and alignment of training and practice, with no emphasis on access-related constraints.

Portugal (n = 10) Portugal presents a paradox. Universal level 3 certification (100%), yet severe reimbursement constraints (60%) and limited infrastructure (50% dedicated slots), indicating highly trained professionals operating in resource-limited settings. Qualitative responses highlighted funding and reimbursement constraints. Several respondents referenced reimbursement as a limiting factor for CMR utilization.

Discussion

The first pan-European mixed-methods analysis reveals that more than one quarter of CMR services operate without dedicated scanner slots. Reimbursement limitations, training gaps, and departmental governance challenges emerged as recurring themes shaping how services are organized and experienced across countries. These findings reveal a recurring yet heterogeneous pattern across Europe, with particularly pronounced difficulties in Eastern and Southern regions. Interview data reinforced these themes, describing structural inefficiencies and limited local training opportunities, while also highlighting emerging adaptive practices such as remote supervision and simplified protocols.

The results align with prior evidence summarized in our CMR barriers review, in which scanner scarcity, high costs, and insufficient structured training were identified as central constraints.⁴ Our data confirm that these remain unresolved. Only 72% of centres have dedicated CMR slots, and our analysis demonstrates that this is directly associated with service volume (χ², P = 0.004). The dependence on shared magnetic resonance imaging systems continues to limit scheduling flexibility and patient access. Cost and reimbursement issues were equally persistent; 46% of participants reported financial obstacles, comparable to findings from North American surveys documenting low reimbursement per scan.⁸ Such variation highlights the influence of policy frameworks on imaging availability.

Training deficits remain another major limiting factor. One-fifth of surveyed cardiologists had no formal CMR certification, and over one-third reported inadequate training.³ It should be noted that the Society for Cardiovascular Magnetic Resonance (SCMR), EACVI, and affiliated National Societies, particularly over the last 5 years, have developed national and international training opportunities, including online and face-to-face courses, structured online training programmes, alongside frameworks defining levels of CMR competence and institutional credentialing requirements. Despite these, many centres still face challenges in fulfilling these standards.^9–11 EACVI’s core syllabus outlines essential competence levels and recommended training components that provide a benchmark for standardized education, yet its uptake appears fragmented.¹² Across Europe, fellowship opportunities remain concentrated in a few academic hubs, perpetuating inequity across regions and countries.¹³ Earlier national reports from Portugal and the UK also noted limited hands-on exposure during training.^13,14

Organizational structure strongly shaped access to CMR. The majority of respondents practised in radiology-led departments, which is consistent with reports that 70% of European CMR examinations are performed under radiology governance.¹⁵ Departmental separation can restrict cardiologists’ scanner access and limit interdisciplinary training. Similar challenges have been reported internationally, where legal frameworks sometimes prevent cardiologists from independently conducting or reporting CMR.¹⁶ However, integrated or cardiology-led models can succeed when supported by collaborative governance. EACVI position statements have emphasized that competent multimodality imagers trained in cardiology can safely lead CMR services and enhance clinical integration.¹⁶

Marked regional disparities were evident. Eastern European respondents reported the lowest levels of formal training and the most severe reimbursement barriers, reflecting limited infrastructure and fewer magnetic resonance imaging units per population.¹⁵ Northern European countries demonstrated stronger funding support and established training networks, while Southern Europe exhibited intermediate characteristics with persistent financial restrictions despite higher training exposure. Country-specific patterns revealed that barriers to CMR implementation differ markedly in their underlying drivers. Some systems demonstrated mature infrastructure but remained constrained by workforce sustainability and organizational efficiency, whereas others showed high professional expertise operating within restrictive financial or governance environments. Several countries exhibited strong technical capacity alongside persistent interdepartmental challenges, suggesting that scanner ownership and reporting authority continue to influence service delivery. In contrast, a smaller group of nations appeared to have progressed beyond access limitations, with attention shifting towards optimization, protocol standardization, and management of increasing demand. These patterns align with existing evidence of unequal distribution of advanced imaging resources across Europe and emphasize that targeted, region-specific interventions are required.^3,4

Qualitative findings highlighted these structural gaps but also revealed emerging adaptive strategies. Respondents described using tele supervision, remote reading, and regional collaboration networks to extend training and service delivery where local expertise was limited.¹⁷ Such digital and cooperative models help connect lower-volume centres with experienced mentors, fostering capacity building even in resource-constrained settings.^17,18 The growing use of AI-assisted interpretation may further streamline workflows and reduce reliance on specialist manpower.^19,20

Suggested aspirational changes to the current system

We propose evidence-based interventions for EACVI committees to consider developing:

• a) Harmonizing reimbursement: Establish the median and range of current CMR reimbursement to recommend a minimum price per scan through EACVI advocacy.

• b) Expanding structured education: Support and incentivize accreditation of new EACVI-accredited level 3 centres in underserved regions within 5 years, possibly supported by improved remote supervision.⁹

• c) Mutual recognition of certification and accreditation: Develop pan-European CMR certification and accreditation with mutual recognition across countries by 2030, reducing current credentialling time.

• d) Collaborative service models: Promote formal cardiology-radiology partnerships with defined scanner access (min 40% cardiology allocation) and joint governance structures.

The breadth of responses across 46 countries provides an unprecedented pan-ESC member and affiliated countries overview. Nonetheless, our study acknowledges certain limitations: voluntary survey participation may favour responses from active imaging centres, and the absence of responses from some countries limits generalizability. Country-level interpretations in settings with smaller response numbers should be viewed with caution, as these findings may not fully reflect broader national practice patterns. Self-reported data may introduce bias, and the survey’s English-language administration may have limited participation. Despite these caveats, the consistency between quantitative and qualitative findings and their alignment with external literature reinforce the robustness of the conclusions.

Conclusion

CMR utilization across ESC member and affiliated countries remains constrained by limited scanner access, uneven training opportunities, suboptimal reimbursement, and fragmented governance. The degree of each barrier varies regionally, reflecting systemic disparities in resources and health policy. Strategic investment in infrastructure, equitable reimbursement, standardized education, and collaborative service models is essential to ensure sustainable expansion of CMR. Co-ordinated efforts led by EACVI, leveraging innovation and cross-regional mentorship, will be critical to achieving equitable access to high-quality CMR and realizing its full diagnostic potential across Europe.

Supplementary data

Supplementary data are available at European Heart Journal - Imaging Methods and Practice online.

Author contributions

Manos Androulakis (Conceptualization, Methodology, Project administration, Writing—review & editing [equal], Investigation [lead]), Tesfamariam Aklilu Betemariam (Conceptualization, Investigation, Methodology, Project administration, Writing—review & editing [equal], Data curation, Formal analysis, Writing—original draft [lead]), Mark R Dweck (Writing—review & editing [supporting]), Rocco Friebel (Conceptualization, Data curation, Formal analysis, Investigation, Project administration, Writing—original draft, Writing—review & editing [equal], Methodology [lead]), and Steffen E Petersen (Conceptualization, Project administration, Writing—review & editing [lead], Data curation, Formal analysis, Investigation, Methodology, Writing—original draft [equal])

Funding

None declared.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

Lead author biography

Dr Emmanuel Androulakis Consultant Cardiologist specializing in Cardiovascular Magnetic Resonance, Multi-Modality Imaging, Inherited Cardiac Conditions, Preventive and Sports Cardiology. Working collaboratively across European Societies (EACVI and EAPC), leading and promoting international, impactful cardiology projects. Dedicated researcher focusing on advanced CMR applications in inherited cardiac conditions and heart failure using advanced LGE quantification, fibrosis texture analysis, parametric mapping, and artificial intelligence. Resilient educator and teacher organizing and national and international courses and teaching events, tutor, and section lead in 2 MSc programmes and an International Medical School curriculum.