CT Dose Reduction in Practice
Dose reduction initiatives are big priorities these days. In fact, a just-completed survey of Health Imaging & IT readers on strategies to manage CT radiation exposure shows that 95 percent of organizations have implemented a dose reduction initiative in the last 24 months. Fifty-four readers participated in the survey.Although dose reduction initiatives are widespread, progress is uneven. Some institutions tout lofty dose reductions, stretching as high as 50 percent or more, and credit an array of factors including dose reduction software, educational programs, updated clinical protocols and application of appropriate use criteria.

 Indeed, a concerted initiative can prove fruitful. “We have achieved overall dose reduction through uniform CT protocols over Northern California,” offered one respondent. “We have [developed] order entry educational bullets, recommendations, guidelines and Spectralink phone consultation with specialists. We have overcome the challenges of CT tech compliance with protocols through rigorous education, auditing and monitoring. I have given multiple grand rounds, noon conferences and department lectures to clinicians and specialists regarding CT radiation dose and risk. Our enterprise has an active Imaging Utilization Committee which provides feedback to clinicians and specialists regarding their appropriateness of imaging and guidelines for appropriate imaging.”

Meanwhile, others hover near the starting line and contend with apathy and resistance within the radiology department and across the enterprise. Why? CT dose reduction practices represent capital expense without capital gain, which means radiology departments in cash-strapped enterprises may run into administrative and/or budget hurdles as they attempt to implement programs or invest in technologies that can trim dose.

The essential ingredient: Referring physicians

Referring physician education emerged as a recurring need. In many cases, a dose reduction champion represents the secret to success.

“I have been working with our children’s center to educate them on all imaging modalities to decrease the number of inappropriate exams orders,” shares Debra Farnham, medical imaging manager at Enloe Medical Center in Chico, Calif.

Others expressed frustration with the profligate ordering patterns of emergency department (ED) physicians. Respondents cited ED physicians who order CT scans on patients with prior negative studies in a short time frame and continue to rely on CT as the primary exam.

The issue, however, isn’t limited to the ED. One respondent reported, “There is pushback from physicians who are used to ordering certain studies per protocols developed by their subspecialty.”

Protocols: The framework for dose management

Standard protocols offer a template for CT imaging. However, with scores of CT protocols and variations, developing and managing protocols is a complex process, as evidenced by Medicare Hospital Care data released earlier this summer showing a handful of hospitals performing a high number of excess chest CT scans without and with contrast on Medicare patients. But focusing on protocols does make a difference.

The ideal strategy may be teamwork as more organizations are turning to cross-enterprise collaboration and partnering with regional hospitals to develop protocols for all facilities.

Take for example Ashland Community Hospital in Oregon. In 2009, the radiology department leveraged the expertise of its radiology group, Medford Radiological Associates. The radiology practice developed and applied updated protocols for Ashland Community Hospital and other local medical centers, which helped it slash its rate of chest CT studies without and with contrast from 40 percent in 2008 to less than 3 percent in 2011, explains Rob Hibner, director of radiology.  

Unfinished business

Facilities and departments that have tapped into iterative reconstruction technologies are proving that the method works and realizing dose reductions in the 25 to 50 percent range, but others are struggling to find the funds to invest in the software.
Ultimately, dose management is an ongoing initiative that requires continued focus on the part of providers and vendors. As the emphasis turns to dose reporting, respondents noted that non-standard dose reporting methods among vendors present another hurdle.