In 2010, the California state legislature passed SB 1237, mandating that health care providers collect and record CT dose information as part of patients’ medical records beginning July 1, 2012. In response, the University of California Center for Health Quality and Innovation funded the US DOSE grant, empowering a working group of radiologists, technologists, and medical physicists to develop standardized CT protocols for the entire UC system—and, potentially, beyond.
“Simplifying what we do will empower the technologists to maximize their capabilities while minimizing dose, so I think the information will be taken to heart. Data has been our strongest weapon in this particular fight.”
—Rebecca Smith-Bindman, MD
“The broad goal is to organize the reasons patients go for imaging across the different UC sites, and, when they come in with particular clinical questions, to ensure they get the same kind of evaluation,” says Rebecca Smith-Bindman, MD. Smith-Bindman is a professor of radiology and biomedical imaging at UC San Francisco, as well as the DOSE grant’s principal investigator. “How should we ideally image patients who come in with suspected pulmonary embolism? Can we reach a consensus about what we’re trying to get from these diagnostic studies, and how we can do that with the lowest dose?”
Smith-Bindman explains that deciding on the best possible protocols for a wide array of clinical indications requires the buy-in of both health system leaders and stakeholders such as radiologists, technologists, and medical physicists. “It’s a pretty large table,” she says. “It includes clinicians, the chairs of radiology, and the CMOs, who have a lot of concerns about these issues in terms of patient safety. I’ve invited physicians from each institution, we have technologists and radiologists involved, and we’re working closely with the CMOs and deans of each institution. Our goal is to get this done to meet everyone’s needs.”
Machine settings and average dose for protocols are compared across the UC sites, and dose acquisition software is leveraged to pull data from the sites’ PACS platforms. The data are then utilized to generate protocols that meet as low as reasonably achievable (ALARA) dose standards, and these protocols will be disseminated across the health system’s five sites.
CT utilization also is monitored by ordering physician, performing technologist, and system, enabling the health system to give feedback to its caregivers. “We’re hoping to encourage people to see that if they are an outlier, then they need a good reason for using a higher dose,” Smith-Bindman says. “We’re working with the department chairs and CMOs to see if we can encourage systematic thinking and systems-based approaches to fixing the problem.”
The UC DOSE grant will fund the project for three years; it recently hit the six-month mark. Smith-Bindman notes that the ambitious scope of the project is not without its challenges; for instance, she says, the nomenclature of dose protocols across the five UC sites alone is inconsistent. “We’re categorizing all the protocols by the names they’ve been given at the individual institutions and on the individual machines, and often those names make no sense,” she says. “One challenge is giving them a nomenclature that makes sense, and then to organize the protocols according to the clinical question that the patient needs answered.”
Spreading the Knowledge
As protocols are optimized through comparisons of site dose data, every two weeks, the results are reported in a conference call. A planned 2013 meeting will provide more than 100 educational sessions on dose reduction, as well as an opportunity for attendees to upload their protocols and benchmark them against others. “We’re going to use the richness of our data to encourage people to try to standardize,” Smith-Bindman says. “You’ll be able to see that your protocol has four times the dosage of someone else’s, where before you wouldn’t have had the necessary information to get a handle on how you’re doing.”
Down the road, Smith-Bindman hopes the UC system can disseminate its newly organized and optimized set of CT dose protocols to other institutions as well. The health system also has entered into talks with vendors about offering a standardized set of low-dose protocols pre-programmed on their CT systems. “My hope is to make these widely available to everyone in the country who wants to use them,” she says. “To