Dose Reduction and Monitoring: Challenges and Recommendations

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Ian JuddIn 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