Results of more than 11,000 scans with weightbearing CT - Impact on costs, radiation exposure, and procedure time.

BACKGROUND: Weightbearing CT (WBCT) has been proven to more precisely measure bone position than conventional weightbearing radiographic series (R) and conventional CT (CT). The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness. METHODS: All patients who obtained a WBCT as part of standard of care from July 1, 2013 until March 15, 2019 were included in the study. Image acquisition time (T), radiation dose (RD) per patient, and cost-effectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group). RESULTS: 11,009 WBCT scans were obtained from 4987 patients (4,987 scans (45%) before treatment; 6,022 scans (55%) at follow-up). On a yearly average, 1,957 WBCTs (bilateral scans) and an additional 10.6 CTs (bilateral feet and ankles) were obtained (WBCT group). In 2012, 1,850 Rs (bilateral feet, dorsoplantar and lateral, metatarsal head skyline view) and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for the WBCT/RCT groups (mean difference of .5uSv; a decrease of 10% for the WBCT group; p<.01). Yearly mean T was 114/493h in total (3.3/16.0min per patient) for WBCT/RCT groups (mean difference of 379h; a 77% decrease for the WBCT group; p<.01). Yearly cost-effectiveness was a mean profit of 43,959/-723 Euros for WBCT/RCT groups. CONCLUSIONS: 11,009 WBCT scans from 4,987 patients over a period of 5.6 years at a foot and ankle department resulted in 10% decreased RD, 77% decreased T, and increased financial profit (51 Euros per patient) for the institution.

Reduced Imaging Radiation Exposure and Costs Associated with Anti-Tumor Necrosis Factor Therapy in Crohn's Disease.

BACKGROUND: Radiation exposure from diagnostic imaging may increase cancer risk of Crohn's disease (CD) patients, who are already at increased risk of certain cancers. AIM: To compare imaging radiation exposure and associated costs in CD patients during the year pre- and post-initiation of anti-tumor necrosis factor (anti-TNF) agents or corticosteroids. METHODS: Adults were identified from a large US claims database between 1/1/2005 and 12/31/2009 with ≥ 1 abdominal imaging scan and 12 months of enrollment before and after initiating therapy with anti-TNF or corticosteroids. Imaging utilization, radiation exposure, and healthcare costs pre- and post-initiation were examined. RESULTS: Anti-TNF-treated patients had significantly fewer imaging examinations the year prior to initiation than corticosteroid-treated patients. Cumulative radiation doses before initiation were significantly higher for corticosteroid patients compared to anti-TNF patients (22.3 vs. 17.7 millisieverts, P = 0.0083). After therapy initiation, anti-TNF-treated patients had significantly fewer imaging examinations (2.9 vs. 5.2, P < 0.0001) and less radiation exposure (7.4 vs. 15.4 millisieverts, P <0.0001) than corticosteroid-treated patients in the follow-up period. Reductions in imaging costs adjusted for 1000 patient-years after initiation of therapy were - $275,090 and - $121,960 (P = 0.0359) for anti-TNF versus corticosteroid patients, respectively. CONCLUSIONS: This analysis demonstrated that patients treated with anti-TNF agents have fewer imaging examinations, less radiation exposure, and lower healthcare costs associated with imaging than patients treated with corticosteroids. These benefits do not account for additional long-term benefits that may be gained from reduced radiation exposure.

Outcomes and costs associated with two different lead-extraction approaches: a single-centre study.

AIMS: We sought to compare outcomes and costs of a stepwise approach to transvenous lead extraction (TLE) involving laser-assisted sheaths or mechanical polypropylene sheaths, with/without crossover. METHODS AND RESULTS: We prospectively included patients who underwent TLE (between August 2013 and December 2014) as part of a stepwise approach involving simple traction, lead snaring, and sheath-assisted dissection; all of these patients underwent a first-line polypropylene-sheath-extraction approach (Group A). The comparison group (Group B) was consecutive patients who had undergone TLE before August 2013, during which laser-assisted sheath extraction was the first-line approach. The number of patients in Group B was adjusted to match the number who eventually needed sheaths in Group A. Procedural data, outcomes, and costs were compared between groups (comparison of approaches) and in patients who needed sheath-assisted extraction (comparison of techniques). Overall, 521 leads were extracted (131 patients in Group A, 104 in Group B). Radiological and clinical success rates were similar; crossover from polypropylene to laser sheaths was needed in 10 patients in Group A (vs. none in Group B). Radiological (P< 0.001) and clinical (P= 0.01) success rates were higher and were achieved with a lower radiation exposure (P= 0.03) with laser sheaths in patients (60 in each group) who needed sheath-assisted extraction. Complication rates were similar in both groups (P= 0.66) but two deaths occurred in Group B. The laser approach had higher material cost (P= 0.002). CONCLUSIONS: Although laser-assisted TLE was more effective than polypropylene sheath-assisted TLE, the latter was associated with fewer complications and was more cost-effective.

The association between socioeconomic status and reactions to radiation exposure: a cross-sectional study after the Fukushima Daiichi nuclear power station accident.

Risk perception and individual reactions to risk are not necessarily comparable, and socioeconomic status may affect individual reactions to risk. This study aimed to investigate the association between socioeconomic status and reactions to radiation exposure risk. This cross-sectional study, based on a self-reported online survey was conducted between 3 March and 21 March 2012, one year after the accident at Fukushima Daiichi nuclear power station. We used feelings of anxiety and risk-averse behavior concerning radiation exposure as dependent variables, and equivalent income and educational attainment as independent variables. Multiple logistic regression analysis was applied to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) with adjustment for possible confounders. Among 10 000 participants, 23.0% felt anxious and 12.0% engaged in risk-averse behavior for radiation exposure. Participants with a higher socioeconomic status tended not to feel anxious but undertook risk-averse behavior. Participants in the highest quartile income category did not report feeling anxious but showed prevalent undertaking of risk-averse behavior for radiation exposure compared to the lowest income category (for anxiety, aOR, 0.77; 95% CI, 0.64-0.93, for risk-averse behavior, aOR, 1.33; 95% CI, 1.04-1.69). University or graduate-school graduates were associated with greater risk-averse behavior compared to junior high school or high school graduates (aOR, 1.49; 95% CI, 1.29-1.73). Socioeconomic status may affect reactions to radiation exposure risk. Risk communication strategies should consider the socioeconomic status of those affected.

Overuse of CT and MRI in paediatric emergency departments.

The aim of this review is to survey CT and MRI overuse in the paediatric emergency department (ED) population. CT is one of the most important modalities employed in the ED. Not surprisingly, its high accuracy, rapid acquisition and availability have resulted in overuse. An obvious limitation of CT is ionizing radiation; in addition there are economic implications to overuse. Studies from the last two decades have shown increase in paediatric ED CT utilization in the first decade, reaching a plateau forming around 2008, followed by a decrease in the last decade. This decrease occurred in conjunction with campaigns raising awareness to the risks of radiation exposure. Although a trend of decrease in overuse have been observed, great variability has been shown across different facilities, as well as among physicians, with more pronounced overuse in non-teaching and non-children dedicated EDs. The leading types of paediatric ED CTs are head and abdominal scans. Decision rules, such as PECARN for head injury and the Alvarado score for abdominal pain, as well as using alternative imaging modalities, have been shown to reduce CT overuse in these two categories. MRI has the obvious benefit of avoiding radiation exposure, but the disadvantages of higher costs, less availability and less tolerability in younger children. Although anecdotally paediatric ED MRI usage has increased in recent years, only scarce reports have been published. In our opinion, there is need to conduct up-to-date studies covering paediatric CT and MRI overuse trends, usage variability and adherence to clinical protocols.

Repeated CT scans in trauma transfers: An analysis of indications, radiation dose exposure, and costs.

OBJECTIVES: To identify the number of CT scans repeated in acute trauma patients receiving imaging before being referred to a trauma center, to define indications, and to assess radiation doses and costs of repeated CT. METHODS: This retrospective study included all adult trauma patients transferred from other hospitals to a Level-I trauma center during 2014. Indications for repeated CT scans were categorized into: inadequate CT image data transfer, poor image quality, repetition of head CT after head injury together with completion to whole-body CT (WBCT), and follow-up of injury known from previous CT. Radiation doses from repeated CT were determined; costs were calculated using a nation-wide fee schedule. RESULTS: Within one year, 85/298 (28.5%) trauma patients were transferred from another hospital because of severe head injury (n=45,53%) and major body trauma (n=23;27%) not manageable in the referring hospital, repatriation from a foreign country (n=14;16.5%), and no ICU-capacity (n=3;3.5%). Of these 85 patients, 74 (87%) had repeated CT in our center because of inadequate CT data transfer (n=29;39%), repetition of head CT with completion to WBCT (n=24;32.5%), and follow-up of known injury (n=21;28.5%). None occurred because of poor image quality. Cumulative dose length product (DLP) and annual costs of potential preventable, repeated CT (inadequate data transfer) was 631mSv (81'304mGy*cm) and 35'233€, respectively. CONCLUSION: A considerable number of transferred trauma patients undergo potentially preventable, repeated CT, adding radiation dose to patients and costs to the health care system.

Ultra low-dose chest ct with iterative reconstructions as an alternative to conventional chest x-ray prior to heart surgery (CRICKET study): Rationale and design of a multicenter randomized trial.

BACKGROUND: Stroke after cardiac surgery is a severe complication with a persistently high incidence of 1.4 - 9.7%. Postoperative strokes are mainly embolic and can be provoked by manipulation and clamping of the aorta during cardiac surgery, resulting in the mobilization of atherothrombotic material and calcifications from the aortic wall. Computed tomography (CT) can offer preoperative visualization of aortic calcifications with low radiation exposure. We hypothesize that preoperative knowledge regarding the location and extent of aortic calcifications can be used to optimize surgical strategy and decrease postoperative stroke rate. METHODS/DESIGN: The CRICKET study (ultra low-dose chest CT with iterative reconstructions as an alternative to conventional chest x-ray prior to heart surgery) is a prospective multicenter randomized clinical trial to evaluate whether non-contrast chest CT before cardiac surgery can decrease postoperative stroke rate by optimizing surgical strategy. Patients scheduled to undergo cardiac surgery aged 18 years and older are eligible for inclusion. Exclusion criteria are pregnancy, a chest/cardiac CT in the past three months, emergency surgery, concomitant or prior participation in a study with ionizing radiation and unwillingness to be informed about incidental findings. Subjects (n = 1.724) are randomized between routine care, including a chest x-ray, or routine care with an additional low dose chest CT. The primary objective is to investigate whether the postoperative in-hospital stroke rate is reduced in the CT arm compared to the routine care arm of the randomized trial. The secondary outcome measures are altered surgical approach based on CT findings and cost-effectiveness.