JAMA editorial calls for gov't regulation of CT

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The U.S. can best address CT overutilization and issues of quality control and training through national legislation, according to an editorial published in the July edition of the Journal of the American Medical Association.

Average radiation dose has doubled over the past 30 years, and medical imaging contributes half of the dose to the U.S. population, stated editorial authors David J. Brenner, PhD, of the Center for Radiological Research at Columbia University Medical Center in New York City, and Hedvig Hricak, MD, of the radiology department at Memorial Sloan-Kettering Cancer Center in New York City.

CT imaging accounts for the lion’s share of the increase in radiation exposure, with the U.S. performing nearly 80 million CT scans each year and the figure increasing approximately 10 percent annually. However, sources include other radiographic imaging and nuclear medicines scans with newer modalities of PET/CT and SPECT/CT likely to fuel further dose increases, said the authors.

While acknowledging the benefits of CT and the small individual risks of radiation carcinogenesis, the authors advocated for an optimal public benefit/risk balance. “Regardless of the actual magnitude, these population risks would undoubtedly be reduced if radiation doses were optimized for each procedure and if medically unnecessary imaging were minimized,” wrote Brenner and Hricak.

Current medical radiation regulation is an ineffective patchwork of state control and voluntary accreditation. The exception is mammography; the 1992 Mammography Quality Standards Act produced significant improvements in mammography quality control and provides a model for regulation, posed the authors.

Barriers and solutions
Achieving an optimal benefit/risk balance hinges on several issues, specifically quality control, training and overutilization, said Brenner and Hricak.

Recent incidents of radiation overdoses during CT studies and 10-fold variability in dose from facility to facility suggest uneven quality control, and voluntary standards developed by the FDA, the American College of Radiology and the Radiological Society of North America have not been ineffective at improving quality control but may not suffice, wrote the authors.

The editorial also pointed to ‘very limited’ radiological training in medical school curricula and the lack of mechanisms to ensure practitioners understand new imaging modalities. Legislation could mandate continuous education for clinicians, radiologists, physicists and techs, noted Brenner.

The final, and most vexing, problem is overutilization. “There is convincing evidence that a substantial fraction of the approximately 80 million CT scans currently performed each year in the United States are performed without good medical justification,” wrote Brenner and Hricak. Studies that compare actual CT use patterns with clinical decision guidelines suggest 20-40 percent of scans could be avoided if guidelines were followed, according the editorial.

Legal and economic pressures as well as patient preferences, however, make it difficult to reduce the number of CT scans that aren’t clinically justified, noted Brenner. Incorporating CT decision guidelines into CPOE has increased use of guidelines, and universal provision of guidelines coupled with regular audits could reduce clinically unjustified scans, stated the authors.

While suggesting mandatory access to and consideration of guidelines, the authors shied away from ‘cookbook medicine’ with mandatory protocols. Complementary initiatives such as tort reform and payment system reform also should be considered as part of a comprehensive approach to quality control and overutilization, summed the authors.