By Priscilla Butler, contributing writer

July 14, 2017 -- Now more than ever, concerns about radiation exposure from imaging exams have gained visibility among patients and healthcare providers alike. CT exams -- which are increasing in utilization and are the biggest contributor to medical radiation -- are coming under increasing scrutiny due to the potential risks associated with cumulative exposure.

In most instances, however, the benefits of CT to diagnostic patient care far outweigh the risks. To enhance patient safety, radiologists and medical physicists have made a commitment that radiation doses should be as low as reasonably achievable (ALARA) -- without compromising the imaging quality required for diagnosis.

Priscilla Butler
Priscilla Butler from the American College of Radiology.

As such, the compelling question for imaging providers becomes: How can we optimize CT dose to maximize the risk-benefit ratio and deliver better patient care? To help you answer that question, here are eight actionable strategies for optimizing radiation dose while still maintaining diagnostic quality and accuracy.

Strategy 1: Educate your stakeholders about radiation safety principles

To create greater awareness among healthcare professionals and the public about dose optimization, take advantage of the wealth of resources made available by campaigns such as Image Gently (for pediatric patients) and Image Wisely. Numerous professional medical societies have come together to identify techniques and tools to help reduce radiation and promote safe, high-quality imaging. In addition, access the patient-facing radiation safety resources at

Tip 1: Check out the free radiation safety cases available on the Image Wisely website to provide radiologists, imaging technologists, and medical physicists with opportunities to expand their knowledge, reduce radiation dose to patients and staff, and earn continuing education credits.

Strategy 2: Compare your patient doses with national benchmarks to improve practice

A recent study by Kanal et al used data from the American College of Radiology (ACR) Dose Index Registry (DIR) to establish U.S. national diagnostic reference levels (DRLs) for the 10 most common adult CT exams, based on patient size. Radiologists, CT technologists, and medical physicists can access the "U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations" research to compare their patient doses with national benchmarks for like-sized patients and adjust their CT protocols. Similar data for pediatric patients are coming soon.

Tip 2: Recognize that size matters for both children and adults when it comes to optimizing dose. It is imperative to consider the relationships between patient size and DRL and achievable doses. Smaller patients do not need as high a radiation dose to obtain a diagnostic image as do much larger patients.

Strategy 3: Emphasize appropriate imaging to ensure each patient has the right exam for the clinical condition and to minimize unnecessary, potential radiation risk

To help you ensure that referring physicians and other providers are making the most appropriate imaging decisions for clinical conditions, it is imperative to consult evidence-based appropriate use criteria (AUC). Employing the ACR Appropriateness Criteria helps providers contribute to the most efficacious use of radiology. Because there is a wide range of radiation exposures associated with different diagnostic procedures, the criteria include relative radiation levels (RRLs) for most imaging examinations.

Tip 3: Starting January 1, 2018, radiologists will not receive Medicare payment for advanced imaging exams without documentation that the ordering provider consulted imaging AUC through a qualified clinical decision-support mechanism under current rules of the U.S. Centers for Medicare and Medicaid Services (CMS). Learn how to prepare now.

Strategy 4: Take a more proactive approach to radiation safety

Participating in a national data registry such as the ACR DIR gives you the information you need to compare your CT dose indices with regional and national standards and adjust your protocols to align with best practices. To help improve quality and safety, participants receive quarterly feedback reports comparing their results with aggregate results by body part and exam type. Plus, you can download your own data and generate reports and graphs from the data in real-time.

Tip 4: Check out a sample of the executive summary of a DIR feedback report, where you can see a visualization of "your facility's performance in the DIR top 10 high-volume adult CT exams." By participating in the DIR, you can use this type of report to get a snapshot of how you compare, and then drill down into individual exams to determine why averages are high for your own exams.

Strategy 5: Leverage the accreditation process to learn how to balance good quality with the right dose

ACR accreditation is a peer-reviewed, educational process that helps you ensure the highest level of image quality and safety. For example, the CT Accreditation Program includes submission of clinical and phantom images, scanning protocols, and dose measurements. The evaluation process uses maximum radiation dose estimates as pass/fail criteria for achieving accreditation. Detailed program requirements, guidelines, resources, and FAQs help you ensure quality scans using the appropriate dose.

Tip 5: The ACR provides a detailed toolkit designed to assist you in gathering and maintaining all of the documentation required for accreditation.

Strategy 6: Ensure your CT equipment meets XR-29 standards to avoid reimbursement cuts

The Protecting Access to Medicare Act (PAMA) included legislation indicating that reimbursement will be reduced for procedures performed on CT equipment that does not meet the National Electrical Manufacturers Association XR-29 Standard, also known as Smart Dose. Be sure you know what is expected, and take action to meet the standard and avoid cuts to your reimbursements.

Tip 6: To help you meet the Smart Dose requirements, access XR-29 FAQs and get the latest information about CT equipment compliance under PAMA.

Strategy 7: Communicate health benefits and potential radiation risks of imaging to patients and their referrers

Appropriate imaging is essential to quality patient healthcare, and the potential risks from examinations using ionizing radiation are extremely low. Patients and referrers frequently ask questions about the radiation exposure associated with imaging examinations and the risk of ionizing radiation. The website is an easily accessible resource that can guide discussions with patients and their healthcare providers about radiologic procedures, including specific information about radiation exposure and safety.

Tip 7: Another tool to help you communicate with patients is the Radiation Dose Chart, which summarizes approximate radiation doses from common imaging examinations.

Strategy 8: Utilize all available resources to help you optimize dose while maintaining quality

Capitalize on the wealth of tools and information available to guide you on your path to dose optimization. In addition to the resources highlighted in the eight dose optimization strategies, be sure to check out the following:

  • The ACR Radiation Safety webpage offers a vast array of resources designed to assist radiologists, medical physicists, and technologists in providing effective imaging while minimizing the potential risk during exposure to ionizing radiation.
  • The RSNA Radiation Dose Exhibit Archive -- presented by Image Wisely -- is a curated series of exhibits from the RSNA's annual meetings that deal with radiation safety and patient dose.
  • The American Association of Physicists in Medicine's Alliance for Quality Computed Tomography is a multisociety partnership that has developed reference CT protocols, which are defined as reasonable and appropriate protocols for specified diagnostic tasks.
  • The ACR DIR webpage provides a plethora of tools and tips to help you get started using the DIR, including checklists, webinars, videos, and more.
  • The ACR Practice Parameters and Technical Standards help advance the science of radiology and improve the quality of service to patients. They promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills, and techniques.

Tip 8: Continuing education to stay current about quality and safety is one of the best steps you can take in your quest to optimize radiation dose while maintaining image quality.

Priscilla Butler is senior director and medical physicist in the American College of Radiology's department of quality and safety. Butler is responsible for ACR dose-related projects including Image Wisely and serves on the steering committee of Image Gently. She also spearheads ACR physics-related activities including the ACR Digital Mammography Quality Control Manual and staffing the ACR Commission on Medical Physics.

The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of

Copyright © 2017

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