Initiatives flag patients with excess imaging dose

In a major departure for radiology, national and local programs have begun to address cancer risk from medical imaging radiation dose by monitoring medical patients' cumulative dose exposure.

NIA/Magellan Health Services, a radiology benefits manager, recently rolled out a medical radiation exposure management program that affects some 15 million lives. A program described at the 2006 RSNA meeting monitors radiation dose exposures at two hospitals in New Hampshire.

Until now, long term radiation dose monitoring has been confined largely to employees who are exposed to radiation at work sites, such as nuclear power plants. In April, however, the week-long National Council on Radiation Protection and Measurements focused attention on radiation dose exposure from medical imaging procedures. At the same time the ACR released a white paper calling for added controls on medical radiation dose, including the tracking of per-patient dose exposures from medical imaging.

The key to the NIA/Magellan program is its assignment of an approximate radiation dose related to each CPT code. Using a health plan's claims data, the company calculates a member's approximate cumulative radiation exposure for the claims period (see table).

The program is hardwired into the preauthorization process, which will be interrupted if a patient has exceeded 50 mSv of exposure within a year. Crossing the threshold will also trigger a notice to the ordering physician with an offer to discuss the case.

"Ironically, the widespread use of endoscopy, which results in a decrease in direct exposure to radiologists, is accompanied by an increase in the utilization of CT, PET, and nuclear cardiac studies," said Dr. Thomas Dehn, executive vice president and chief medical officer of NIA/Magellan. "The result appears to have been a dimming of radiologists' focus on this important issue during a time of marked increase in medical radiation exposure to the population."

After nearly two years of development and several pilot programs, Dehn cited some preliminary observations:

• Indiscriminate CT use in the emergency department is a concern.

• Standing or routine in-patient orders for daily or twice-daily monitoring of patients in special care units should be reexamined.

• Many cases are young patients with renal stones who would be better managed if the American Urological Association developed a clear and unambiguous guideline for their follow-up.

• Many cases are psychosomatic, such as panic attacks and ill-defined gastrointestinal complaints.

• Poorly managed in-office use of sinus CT by otolaryngologists is a serious safety concern, especially in adolescents.

• The burgeoning in-office performance of nuclear cardiology procedures for marginal indications is a serious safety concern.

• Indiscriminate use of contrast-enhanced CT by many radiology groups is alarming, often doubling or tripling the radiation exposure.

Anthem Blue Cross and Blue Shield of New Hampshire worked with NIA/Magellan to customize a radiation management program that rolls out this summer. Rather than focus on the amount of radiation exposure in millisieverts, the Anthem program flags patients who exceed five CT studies to the neck, chest, abdomen, or pelvis.

"The dose threshold issue carries some controversy, and we didn't want that to divert attention from what is important, which is that providers need to be aware of excessive CT studies and make decisions about patient care in those situations," said Dr. Elizabeth C. Malko, medical director of the New Hampshire Blues.

Anthem's program concentrates on patients younger than 40, whereas NIA/Magellan extends its reach to age 65. Neither program includes cancer patients, but each is open to that possibility in the future.

"Our data analysis suggests that there is a wide and worrisome variation in the manner in which cancer patients are monitored with CT and PET," Dehn said. "It's hard to disregard the risk to a 35-year-old lymphoma survivor who is receiving large doses of radiation from an extraordinary and inappropriate monitoring regime."

About the same time that NIA/Magellan was developing its program, Dr. Steven Birnbaum was doing the same for the two New Hampshire community hospitals where he is the radiology safety officer. In two years, the program has identified 41 patients exposed to 50 mSv to 100 mSv and 10 patients with exposure greater than 100 mSv.

"At first, I thought this was the tip of the iceberg. I'm now convinced this is an ice cube on top of an iceberg," Birnbaum said at the 2006 RSNA meeting. "There are so many of these patients it is mind-boggling."

Client pickup

One client of NIA/Magellan has requested a report of the members that cross the 50-mSv threshold in each of the past five years in order to evaluate the trend of increased imaging. Another client is developing a cumulative mSv system to alert requesting physicians through a trigger in patients' electronic medical records.

"A lifelong exposure history for an individual is the ideal," Dehn said. "Of course, that will require the sharing of data among insurance carriers and will require some form of governmental remedy, but I believe that it is a worthy goal."