RSNA: Will clinicians embrace the next generation of appropriate use?

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CHICAGO—While appropriate use criteria are key to curbing radiation exposure and ensuring beneficial CT exams, clinicians have not yet embraced them. Despite the lukewarm acceptance of appropriateness criteria, James A. Brink, MD, chair of radiology at Yale University Medical Center in New Haven, Conn., upped the ante and called for development of multidisciplinary diagnostic algorithms to standardize image utilization during a session on Nov. 27 at the 97th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA).

CT provides superior anatomic depiction and has opened the door to a host of new applications such as renal stone CT; virtual colonoscopy; CT angiography of the head, pulmonary vessels, aorta and extremities and coronary CT angiography, said Brink. These exams deliver more rapid diagnosis and enable faster, more informed decision making and treatment.

Yet, CT imaging faces a difficult dilemma. “We see the obvious benefits of CT, but the collective dose to the population is rising,” said Brink.

Appropriate utilization is essential, continued Brink, who outlined a trio of strategies for reducing dose and ensuring optimal application of CT imaging.

“Tailor the exam to the patient or application,” Brink said. The best tool is American College of Radiology (ACR) appropriateness criteria, he said. However, it’s an underused resource. “Referring physicians do not avail themselves of the criteria, and we [radiologists] do not do a good job of steering them to it.”

Brink noted the mismatch between appropriateness criteria and actual practice. CT is listed as an option in 12 percent of circumstances, yet is used with much greater frequency in practice.

Physicians should use alternate diagnostic modalities when appropriate, said Brink, providing the case of suspected appendicitis in a pregnant patient as an example. In this case, MRI or ultrasound is the most appropriate exam. However, each is associated with workflow issues for the radiologists and technologists compared with CT.

A final source of excess radiation exposure is unnecessary or repetitive studies, said Brink. The June article in New York Times on the use of “double” chest CT scans with and without contrast highlighted the issue and also showed the varying level of practice patterns in the U.S.

Brink contrasted the situation in the U.S.--haphazard application of appropriateness criteria, tremendous practice variability and varying knowledge among referring physicians--with Europe.

In 2000, the European Union enacted the European Medical Exposure Directive. The directive incorporates strict referral criteria, strict justification criteria, dose optimization requirements and dose exposure at referenced levels.

“We need to standardize practices and processes. We need multidisciplinary diagnostic algorithms that go beyond appropriateness criteria,” said Brink. The ACR is moving in this direction, said Brink, who cited an October 2010 ACR white paper on managing incidental findings as a step in that direction. He concluded, “We need buy-in from other professional societies [which will be tough], but appropriate utilization is our responsibility.”