Radiation Dose Roundtable: Progress, Potential Upsides & Remaining Challenges

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon

Managing CT radiation dose remains a critical issue for providers across the country. As studies attempt to estimate and the media too-often exaggerates the risks of radiation-induced cancers, referring physicians and patients are looking to the radiology community for answers.

Dose has become the differentiator in the CT market and a red hot topic of clinical conversations. An array of dose management software has hit the market, but there is no magic bullet to slash radiation dose. Dose reduction requires a series of incremental strategies including multiple IT tools, protocol optimization, operational changes and conversations among physicians and physicists within and among institutions. This month, Health Imaging & IT gathers leaders in the CT community for a status update. We found:

  • The top dose reduction strategy is eliminating unnecessary studies;
  • ED physicians, oft-criticized for overutilization, face particularly challenging legal constraints; and
  • Early dose tracking registries may be immature and misleading.

How has clinical understanding of radiation dose evolved in the last year?

McCollough: The heightened media focus has spread misinformation and raised anxiety among physicians and patients. However, the positive outcome of all the media attention is that it has put a spotlight on radiation dose. This has led to a focus on “right-sizing” dose for specific patients and applications, and it’s put pressure on manufacturers to spend research and development dollars to implement new technologies and other dose reduction strategies.

But bad outcomes have occurred at the clinical level. If the primary care physician accepts what is propagated in the media, the “overblown level of risk,” and makes a fundamental change in ordering patterns, patients may not get important imaging studies that could contribute to their medical care, or may get less accurate or more expensive studies.  

Multiple technologies—decision support, dose tracking and new algorithms—promise to address various elements of the dose issue.  Are we seeing wider availability and adoption of decision support systems to help cut dose?

Thrall: In some sense, the most harmful radiation is radiation from a study not indicated in the first place. No protocol optimization or dose reduction strategy even applies in this situation. This is sometimes overlooked in the rush to optimize protocols and buy new scanners with lower radiation profiles. The most dramatic way to reduce risk is to not do studies when they are not needed.

We are beginning to see substantial interest in and adoption of decision support systems. The best approach is to use a computer-based decision support system that can fit right into the workflow of a physician ordering an exam. That way, he can get feedback at the point of care on the appropriateness of the study and at the same time not be deflected from his interaction with the patient or burn up a lot of time reviewing indications.

Where do we stand as far as leveraging IT and implementing operational changes to reduce duplicate CT studies?

Thrall: The software has not been developed commercially to address the duplicate exam issue. Now it’s being done on an institution by institution basis.

At Massachusetts General Hospital, we are able to look at patients’ entire histories throughout Partners Health System, including Brigham and Women’s Hospital and our community hospitals. The physician is informed in the CPOE at the point of care if the patient has had or is scheduled to have a similar exam. This alone has eliminated 3 to 5 percent of exams.

What about new protocols to cut dose? Are there strategies that can be employed during CT scanning?

Lesser: Overall, our doses have dropped dramatically with newer scanners and new awareness of how to manage studies. With new equipment, doses are extraordinarily low. But staff has to pay a lot of attention on how the scan is set up.  Every small aspect is very important in achieving