Panel recommends major changes in ACR policy governing patient radiation exposure

A blue ribbon panel has recommended sweeping changes for the American College of Radiology's policies governing the tracking and physician management of radiation exposure.

Publication of the panel's 33 recommendations was timed to coincide with the announcement of revelations concerning the U.S. public's growing exposure to radiation from medical imaging. The panel, headed by Dr. Steven Amis, chair of radiology at Albert Einstein College of Medicine, proposed strategies to halt unnecessary growth in exposure.

The ACR proposal supports a standardized method for archiving individual patient radiation data documenting exposure during medical imaging. The information would be used to benchmark good medical practices and to identify patients who have accumulated high levels of radiation from frequent imaging sessions involving exposure to ionizing radiation. The information may be used to determine when alternative imaging should be recommended, the ACR said in a release.

Recommendations in the ACR White Paper on Radiation Dose in Medicine reflect findings announced this week at the annual meeting of the National Council on Radiation Protection and Measurement in Washington, DC. Speaking at the conference Monday morning, Dr. Fred A. Mettler Jr. estimated that U.S. residents will be exposed in 2007 to five times more radiation from medical imaging than from all natural sources. Mettler is professor emeritus of nuclear medicine at the University of New Mexico in Albuquerque.

The rapidly growing popularity of multislice CT is a primary source of the growth in medical radiation exposure, he said. He noted that CT utilization in the U.S. has grown from three million scans in 1980 to 60 million procedures in 2005, when one scan was performed for every five U.S. residents.

If adopted, the ACR panel's recommendations would represent a major change in the college's policy concerning the need to track the accumulation of medical imaging radiation exposure for individual patients. The report directs advice to radiologists, referring physicians, physicists, manufacturers, insurers, and government regulators. It encourages administrative practices that track radiation doses and emphasizes the need for action when the exposure to an individual patient exceeds certain radiation thresholds, Amis said.

"One of the recommendations is that there be standardization of information available for all imaging modalities that use ionizing radiation, particularly CT, where the exposure factors would be embedded in the patient information, so you would at least have an idea about what dose the patient has received externally," Amis said in an interview.

Another recommendation asks the ACR to encourage third-party payers to identify patients who have had frequent imaging exams involving ionizing radiation and to alert their physicians about the situation.

"If an insurer has authorized 10 CT exams for Mrs. Jones in the past year, you've got a clear idea that she is getting heavily radiated," Amis said. "If payers had the right mechanism in place, they could call the doctor who is ordering all these tests to ask if they are all needed."

A standardized report system could document the actual range of exposure patients receive for specific procedures. Benchmarks could then be set to establish recommended practices for radiologist performance, Amis said.

Measuring the radiation exposure will be difficult because of variations in the standards for calibrating dosage and differences in equipment performance for measuring exposure.

"We can fairly easily generate the parameters for what generates the beam, but what the effect will be to the patient's liver, pancreas, or spleen is very difficult to estimate," he said.

The Medical Imaging & Technology Alliance, the medical imaging division of the National Electrical Manufacturers Association, issued a report Friday documenting its members' efforts to curb radiation exposure. It credits equipment design innovations in the past 20 years for reducing radiation dose 20% to 75% for many imaging procedures.

With limited exceptions, the ACR has been reserved in its public positions concerning radiation exposure. It has always favored physician adherence to the ALARA principle (as low as responsibly achievable), Amis said. The policy relies on physician discretion regarding the appropriateness of medical procedures involving exposure to ionizing radiation on a procedure-to-procedure basis. Previous advisories from the college have emphasized the importance of monitoring radiation exposure for patients subjected to long fluoro-guided interventions.

Selected recommendations of ACR Blue Ribbon Panel on Radiation Dose in Medicine:

MEASUREMENT

• develop national database for radiation dose indices to address actual range of exposure for x-ray examinations

RADIOLOGISTS

• ask American Board of Radiology to require at least one self-assessment module on patient safety, including radiation dose, in 10-year maintenance of certification requirements

• support maximum radiation dose estimate pass/fail criteria in ACR CT accreditation program

• urge college to include in its practice guidelines and technical standards additional consideration for radiosensitive populations such as children and pregnant and potentially pregnant women

• encourage radiology practices to record all fluoroscopy times, compare them with benchmarks, and evaluate outlines as part of ongoing quality assurance programs

• endorse ACR policies that encourage radiology practices to define surveillance mechanism to identify patients with high cumulative radiation doses due to repeated imaging

REFERRING PHYSICIANS

• ask ACR to convince Liaison Committee on Medical Education and American Association of Medical Colleges about need for standard methods and learning materials to introduce medical students to radiation exposure in medical imaging

• recommend that ACR work with American Medical Association to ensure wide dissemination and enactment of its Council Report on Diagnostic Radiation Exposure

• urge lobbying to persuade Council of Medical Specialty Societies to address issue of radiation exposure during medical imaging with its member societies

• support adding relative radiation dose levels to the ACR Appropriateness Criteria and ensure that criteria can be integrated into physician order entry systems for real-time guidance in ordering imaging examinations

• call for ACR-sponsored summit meeting with leaders from emergency medicine to discuss developing consensus guidelines for imaging common conditions for which CT may be overutilized

TECHNOLOGISTS

• encourage radiology practices to provide in-service training on radiation safety issues for their technologists on regular basis

• ask ACR to phase in requirement that at least one technologist per accredited CT site hold American Registry of Radiology Technologists advanced registry in CT and at least one technologist per accredited nuclear medicine site hold advanced registry in nuclear medicine or certification by Nuclear Medicine Technology Certification Board

PATIENTS

• recommend that ACR collaborate with RSNA to install patient safety link on RadiologyInfo homepage and regularly review and update information on website regarding risks and benefits of imaging procedures

• request patient safety link on ACRIN homepage that will lead patients to information on risks and benefits associated with participation in current ACRIN research protocols

• emphasize importance of ACR's work with patient advocacy organizations to more effectively communicate potential radiation risks and health benefits of imaging procedures

MEDICAL PHYSICISTS

• urge ACR to work with the American Association of Physicists in Medicine to develop credentialing program for nonradiologists physicians who use fluoroscopy

• advocate development of better teaching methods for medical physicists in support of AAPM-RSNA initiative on physician education for radiology residents

VENDORS

• support collaborations with National Electrical Manufacturers Association to encourage vendors to ensure that application specialists are familiar with imaging protocols that emphasize ALARA standards for new equipment

• stress importance of ACR's work with NEMA to encourage vendors to adopt standardized approach describing exposure indices for computed radiography and digital radiography

• emphasize ACR's ongoing initiative with NEMA to encourage vendors to standardize digital equipment using ionizing radiation so that it automatically captures compete dose information for each examination

REGULATORY AGENCIES, ACCREDITING BODIES, AND THIRD-PARTY PAYERS

• ask ACR to consult with FDA and U.S. Nuclear Regulatory Commission on how it can better support their efforts to minimize unnecessary radiation exposure

• support continued work with Conference of Radiation Control Program Directors task force to develop suggested state regulation for radiation controls

• urge ACR to encourage Joint Commission to apply existing credentialing and privileging standards to nonradiologist physicians who want to use fluoroscopy

• recommend that ACR encourage third-party payers to develop methods to identify patients who have frequent imaging examinations using ionizing radiation and to provide feedback regarding these patients to their referring physicians

For more information from the Diagnostic Imaging archives:

Soaring CT stirs appropriateness concerns

Soaring CT use may prompt need for long-term dose monitoring

Protocols for pregnant patient increase safety

CT screening for lung cancer stirs safety, ethics concerns

Study finds measurable cancer risk from CT angiography scans

CT spurs concern over thyroid cancer