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Patients undergoing recurrent CT exams: assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness

An Editorial Comment to this article was published on 30 January 2020

Abstract

Objective

To determine percent of patients without malignancy and ≤ 40 years of age with high cumulative radiation doses through recurrent CT exams and assess imaging appropriateness.

Methods

From the cohort of patients who received cumulative effective dose (CED) of ≥ 100 mSv over a 5-year period, a sub-set was identified with non-malignant disease. The top 50 clinical indications leading to multiple CTs were determined. Clinical decision support (CDS) system scores were analyzed using a widely adopted standard of 1–3 (red) as “not usually appropriate,” 4–6 (yellow) “may or may not be appropriate,” and 7–9 (green) “usually appropriate.” Clinicians reviewed patient records to assess compliance with appropriate use criteria (AUC).

Results

9.6% of patients in our series were with non-malignant conditions and 1.4% with age ≤ 40 years. CDS scores (rounded) were 2% red, 38% yellow, 27% green, and 33% unscored CTs. Clinical society guidelines for CT exams, wherever available, were followed in 87.5 to 100% of cases. AUCs were not available for several clinical indications as also referral guidelines for serial CT imaging. More than half of CT exams were unrelated to follow-up of a primary chronic disease.

Conclusions

We are faced with a situation wherein patients in age ≤ 40 years require or are thought to require many CT exams over the course of a few years but the radiation risk creates concern. There is a fair number of conditions for which AUC are not available. Suggested solutions include development of CT scanners with lesser radiation dose and further development of appropriateness criteria.

Key Points

  • We are faced with a situation wherein patients in age group 0–40 years and with non-malignant diagnosis require or are thought to require many CT exams over the course of a few years.

  • More than half of CT exams were unrelated to follow-up of a primary chronic disease.

  • Imaging guidelines and appropriateness use criteria are not available for many conditions. Wherever available, they are for initial work-up and diagnosis and there is a lack of guidance on serial CT imaging.

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Abbreviations

ACC:

American College of Cardiology

ACCM:

American College of Critical Care Medicine

ACR:

American College of Radiology

ADIS:

Advanced diagnostic imaging services

AUC:

Appropriateness use criteria

CDS:

Clinical decision support

CED:

Cumulative effective dose

CMS:

Centers for Medicare & Medicaid Services

COPD:

Chronic obstructive pulmonary disease

CT:

Computed tomography

ED:

Effective dose

IDSA:

Infectious Disease Society of America

IRB:

Institutional Review Board

MRI:

Magnetic resonance imaging

NCCN:

National Comprehensive Cancer Network

PAMA:

Protecting Access to Medicare Act

PET:

Positron emission tomography

RPDR:

Research Patient Data Registry

SNMMI:

Society of Nuclear Medicine and Molecular Imaging

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Acknowledgements

The authors sincerely acknowledge the subject matter expertise provided by Prof. Fred Mettler, Emeritus Professor, University of New Mexico and of Dr. Bob Liu, MGH for his help in dealing with IRB.

Funding

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

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Correspondence to Madan M. Rehani.

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Guarantor

The scientific guarantor of this publication is Madan Rehani.

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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 statistical analysis expertise was availed besides authors'.

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Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board waived the requirement to obtain informed consent

Study subjects or cohorts overlap

None.

This paper is continuation of the study reported in paper Rehani et al DOI: https://doi.org/10.1007/s00330-019-06523-y (reference 6). That paper had only radiation dose information and no medical /clinical information. The current paper analyses the clinical information/ diagnoses of patients and assesses imaging appropriateness.

Methodology

• Retrospective

• Observational

• Performed at one institution

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Cite this article

Rehani, M.M., Melick, E.R., Alvi, R.M. et al. Patients undergoing recurrent CT exams: assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness. Eur Radiol 30, 1839–1846 (2020). https://doi.org/10.1007/s00330-019-06551-8

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Keywords

  • Radiology
  • Referral and consultation
  • Radiation protection
  • Patient safety
  • Radiologic technology