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Contrast Media: American College of Radiology Recommendations


Experts discuss discuss the American College of Radiology recommendations regarding the use of contrast media and their guidance related to the use of generics during supply shortages.

Joseph Cavallo, MD, MBA: I’m going to start by throwing out some of the major points of emphasis from the ACR when they put out recommendations for the usage of contrast media during that supply shortage. Two of the major points were utilizing alternative agents, which includes generics, if available. The second one was identifying multiple vendors for supply. Then later in their document, they wanted to prioritize agents where high-volume vials were available because a lot of the lower-volume vials contributed to excessive waste or inefficient usage of a limited supply. I’d just like to hear a little about your experience with the contrast shortage and how you think the additional supply chain resiliency may be affected by these generic agents.

Dushyant Sahani, MD: That is such a great question and a nice segue into how contrast media are important but also are in a finite amount. If you rely on only 1 supplier, there can be challenges. The lessons I learned when there was a contract crisis is we are so dependent on our suppliers [being] well staffed, well resourced, and diversified in terms of their ability to provide or meet our needs. Second, I learned how important imaging techniques [are] and [the] value of contrast media. There was such an emphasis at the highest level in the health system to this crisis because our referring provider knows radiology is a gateway for facilitating care across the health system…whether it’s inpatient care, acute care, or outpatient elective care.

One thing we had to do [was], first of all, create a partnership with our stakeholders and with our vendors or contrast supplier. That partnership is extremely valuable. We can have expectations in terms of what supplies [we will get, as well as] the timeline for that. I think that was essential. We also prioritized contracts you used based on patient’s risk, so we created a tiered system, [determining] who could get contrast media and where we can differ the use of contrast media to clinical judgment. We moved to using more of a noncontrast exam or MRI [magnetic resonance imaging] when it was appropriate.

Then it comes down to how we effectively use contrast media that was made available. One [way was by making] sure each site had enough volume of contrast media to meet the projections of CT [computed tomography] exam volume, prioritizing acute care first. Oncology was the other one, and inpatient care—these are areas we want to make sure are well resourced with contrast media. We created a framework of a team structure with good communication and sharing. [We] created a color-coded dashboard [that showed] where we [were regarding] our contrast media supplies. If we had 7 days [or more], or less than 3 days of contrast media, we gave a color of green, yellow, or red, depending on that. Then we acted on those urgencies based on the status of contrast media volumes at different sites. The third thing we did is made sure to optimize our protocols by exploiting some of the offerings of new technology [such as] multi-energy CT or a spectral CT, where you can substantially reduce contrast by amplifying the iodine signal through some image recounts. That allowed us to drop either dose per patient by 30 to 50 ml. Higher drops were seen in those with indication for city and geographies. Finally, we used an imaging bulk pack for contrast media. We had power injectors in our system that enabled us to use the imaging bulk pack, [so] we could reduce waste and have a higher throughput in those patients. It was a very complex challenge, but we learned a lot of things. The lessons I learned are: You need to be proactive in terms of checking your supplies, you need to be diversified where your supplies are coming from, and you need to have a great relationship with your vendors. Those relationships really are on display when you need their assistance…. [I also learned to give] autonomy to your team to make those decisions, [and have] great communication. Those were some of the lessons.

Now, what does it mean? The lessons we learned from that is you cannot take things for granted. You need to be prepared, and that’s where generic contrast media can fill that unmet need if you have those challenges. We are talking about challenges in the United States, where some of the supply is still prioritized. But if you look at disparities that exist in rest of the world, those challenges are much more severe than they were. I agree with what ACR has proposed. It was also common sense to ensure that we have various options available so we don’t compromise our care delivery.

Joseph Cavallo, MD, MBA: Those are great points. [Because] we were a victim of our own success, we needed to lean operations. And, just in time, inventory management is really good at cutting costs and avoiding unnecessary expenditures in times of normal operation. As we found out, they do not have a lot of flexibility in a time of disturbance, like we saw with the acute iodinated contrast shortage. Very good points, and a lot of stuff that people learned as an industry and as individual institutions.

Transcript is AI-generated and edited for clarity and readability.

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