Dose Reduction and Monitoring: Challenges and Recommendations

In the wake of the Cedars-Sinai CT overexposure scandal, California passed legislation in 2012 mandating the monitoring and reporting of CT-exam radiation dose; since then, dose-monitoring legislation has passed (or is being considered) in multiple states, and public awareness of radiation risk has been significantly heightened. Ian Judd, product manager for Sectra, says, “There’s been a lot of media attention in the United States, and in Europe as well. Due to instant access to information on the Internet, people are far more aware that radiation is a bad thing. What they haven’t been made aware of is that it’s a good thing, when used correctly.” Judd presented “Radiation Dose Monitoring & Reporting: Trends, Challenges, & Solutions” on July 31, 2013, at the annual meeting of the AHRA in Minneapolis, Minnesota. He stresses that the underlying goal of any dose-reduction and -monitoring program should be balancing image quality against patient safety: “It’s about balancing the desire to create the lowest dose for the patient and, at the same time, understanding the most appropriate modality to use to perform the diagnostic test,” he says. The number of CT, nuclear-medicine, angiography, and fluoroscopy exams has, of course, exploded over the past decade in the United States. “Many clinicians are wanting to cover their backsides, from the perspective of litigation, but also, the scanners are better and the techniques are better,” Judd says. “We’re doing more tests because we can diagnose more patients’’ conditions.” A number of ongoing studies are attempting to determine the association between radiation exposure and cancer, but the jury is still out, Judd notes. “I don’t think there are any definitive documents that cover all modalities and all techniques,” he says. “As time goes by, the physics community and the radiology community will formulate far more elegant methods of predicting the risks, but as it stands today, the best we can all do is get the dose as low as possible.” The European Approach In Europe, ionizing-radiation regulations were passed in 2000; these include regular creation and review of target dose levels, with recording and reporting of dose; clinical justification for all exposures, at multiple levels; and ongoing training of physicians and technologists. “It forces each radiology department to create and review, on a regular basis, its own dose reference levels, so you create a set of benchmarks that you measure yourself against,” Judd explains. “We also have justification at a number of levels. The first gatekeeper is the referring clinician; the request moves into the imaging department, which vets the request to see whether it agrees; and then, the radiographer, who also justifies the delivery of radiation, is the last gatekeeper.” Education also is a key component of the European requirements. “The best way to reduce patient dose is not to shave 5% off the dose delivered for each particular CT protocol; it’s to avoid doing the scan in the first place, if you don’t have to, or to avoid having to reimage patients because of faulty or erroneous technique,” Judd says. “These are ways to reduce dose fundamentally by good practice—and they are the most difficult, because you have to educate so many people in the chain.” To mimic the European approach, radiology departments will require more data, Judd says: data to establish their own dose reference levels, data on referrer and technologist compliance with new guidelines and protocols, and (eventually) data to measure the outcomes of changes made with dose reduction in mind. “Dose monitoring touches the whole range of people in the health-care chain,” he observes. Referring physicians need to improve the quality of their orders; technologists need to operate equipment according to revised protocols, as well as to standardize their techniques; medical physicists need to assess the function and safety of equipment accurately and regularly; and radiologists need to spearhead protocol improvements. Challenges Gathering radiation-dose data without the aid of an automated system is a Sisyphean undertaking, Judd says, and even with an automated system, vendors can include dose information in multiple parts of the DICOM header. “One of the difficulties with gathering data is the lack of standards,” he notes. “Whatever system you do use to collect the data needs to be robust and intelligent enough to morph and transform the data into a common structure to allow you to compare different modality vendors against one another.” Coding in the RIS is another potential problem because exam codes are based on financial information, not protocol information, he adds. Reporting also can present a challenge. Getting the data into the radiologists’ reports, closing the loop with referring physicians, and informing patients of both exam and cumulative dose is nearly impossible without automation from software, Judd says. A further difficulty lies in tracking dose beyond an individual facility or organization. “You may think your record is the total sum of all the imaging the patient has had in his life, but it’s not going to be,” Judd says. “The holy grail is to create some kind of cohesive record about the patient’s imaging.” Providing dose information to patients is rife with hazards. On this subject, Judd is not optimistic. “I think that if you provide information to patients, you also have to provide an awful lot of education to those patients, and unless you’re going to train them in radiography and physics, what are they going to make of the information?” he says. “If you scare patients, they may refuse to have scans that would actually be a net benefit to them.” Benefits and Recommendations In spite of the challenges, there are multiple benefits to radiation-dose reduction, monitoring, and management. “They are going to allow you to offer information to referring clinicians to help improve the way they have referred, and they are going to be used, within your departments, to improve the way you image, treat, and deal with patients throughout the end-to-end health-care flow,” Judd says. “They will also allow you to optimize the use of your equipment and will lead to better quality assurance and bigger improvements in how your organization is perceived.” Judd recommends that organizations appoint a designated staff member to monitor trends and regulations and to manage procedures and protocols within the institution. At the modality level, equipment should be calibrated regularly, and protocols should be reviewed and updated often. He also recommends the use of dose-tracking software. “Without automated software, you’ve got no chance,” he says. “You need a flexible solution because every imaging department is different. You need to be able to drill down easily from the helicopter view of the data directly to individual patients, clinicians, and cases.” Judd concludes by noting that mandated dose reduction is here to stay, and he recommends that organizations start early to get ahead of the curve. “You need to do it; you’re going to have to do it, so you may as well get on with it,” he says. Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.