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Long-term experience and analysis of data on diagnostic reference levels: the good, the bad, and the ugly

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Abstract

Objectives

To analyze 11-year data of France for temporal trends in dose indices and dose optimization and draw lessons for those who are willing to work on creation and update of diagnostic reference levels (DRLs).

Methods

The data from about 3000 radiology departments leading to about 750,000 imaging exams between 2004 and 2015 was analyzed, and patterns of reductions in dose for those below and above the DRLs were estimated and correlated with technology change.

Results

Dose optimization achieved was important and significant in departments which were above or just below the DRL (p = .006) but not in those which were around half of the DRL values. The decrease in 75th percentile value of Kerma air product (KAP) for chest radiography by 27.4% between 2004 and 2015 was observed with the number of flat panel detectors increase from 6 to 43%. A good correlation between the detector type distribution and the level of patient radiation exposure is observed. Otherwise, setting DRLs for standard-sized patient excludes patients lower and higher weighted than “standard.”

Conclusions

The concept of DRL may become obsolete unless lessons drawn from the experience of users are taken into account. While establishing DRLs should be part of the regulations, setting up and updating values should be governed by bodies whose decision-making cycle is short, at the most 1 year. A local rather than national approach, taking into account body habitus and image quality, needs to be organized.

Key Points

• The technology changes faster than regulations. Requirement of DRL establishment should be part of the regulations; however, setting and updating values should be the role of professional societies.

• The concept of DRL, highlighting the 75th percentile values and dedicated to standard-sized adult, misses optimization opportunities in the majority of patients who are below the 75th percentile value and outside the range of standard-sized adult.

• The ugly aspects of the DRL concept include its non-applicability to individuals, no customization to clinical indications, and lack of consideration of image quality.

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Abbreviations

AAPM:

American Association of Physicists in Medicine

AEC:

Automatic exposure control

ALARA:

As low as reasonably achievable

AQD:

Acceptable quality dose

BSS:

Basic safety standard

CT:

Computed tomography

CTDI:

Computed tomography dose index

DLP:

Dose length product

DRL:

Diagnostic reference levels

IAEA:

International Atomic Energy Agency

ICRP:

International Commission on Radiological Protection

IRSN:

French Nuclear Safety and Radiation Protection Institute

KAP:

Kerma air product

NCRP:

National Council on Radiation Protection and Measurements

NM:

Nuclear medicine

SSDE:

Size-specific dose estimate

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Acknowledgments

The authors are thankful to Ms. Melissa Knight for language edits.

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Institut de Radioprotection et de Sûreté Nucléaire, 31 avenue de la division Leclerc, 92260, Fontenay-aux-Roses, France

    Patrice Roch, David Célier & Cécile Etard

  2. CERAP, 4 rue René Razel, Domaine Technologique de Saclay, 91400, Saclay, France

    Cécile Dessaud

  3. Massachusetts General Hospital, Boston, MA, USA

    Madan M. Rehani

Authors
  1. Patrice Roch
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  2. David Célier
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  3. Cécile Dessaud
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  4. Cécile Etard
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  5. Madan M. Rehani
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Corresponding author

Correspondence to Patrice Roch.

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Guarantor

The scientific guarantor of this publication is Patrice Roch.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because the concerned data is requested by DRLs national regulation (Order of 11th of October, 2011: https://www.legifrance.gouv.fr/eli/arrete/2011/10/24/ETSP1129093A/jo/texte).

Ethical approval

Institutional Review Board approval was not required because the concerned data is requested by DRL national regulation and the survey did not deal with human subjects, but data without link to people identity and with no impact on patient management.

Methodology

• Retrospective

• Observational

• Multicenter study

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Roch, P., Célier, D., Dessaud, C. et al. Long-term experience and analysis of data on diagnostic reference levels: the good, the bad, and the ugly. Eur Radiol 30, 1127–1136 (2020). https://doi.org/10.1007/s00330-019-06422-2

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  • DOI: https://doi.org/10.1007/s00330-019-06422-2

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