What Patients Want to Know about Imaging Examinations: A Multiinstitutional U.S. Survey in Adult and Pediatric Teaching Hospitals on Patient Preferences for Receiving Information before Radiologic Examinations.

Purpose To identify what information patients and parents or caregivers found useful before an imaging examination, from whom they preferred to receive information, and how those preferences related to patient-specific variables including demographics and prior radiologic examinations. Materials and Methods A 24-item survey was distributed at three pediatric and three adult hospitals between January and May 2015. The χ2 or Fisher exact test (categorical variables) and one-way analysis of variance or two-sample t test (continuous variables) were used for comparisons. Multivariate logistic regression was used to determine associations between responses and demographics. Results Of 1742 surveys, 1542 (89%) were returned (381 partial, 1161 completed). Mean respondent age was 46.2 years ± 16.8 (standard deviation), with respondents more frequently female (1025 of 1506, 68%) and Caucasian (1132 of 1504, 75%). Overall, 78% (1117 of 1438) reported receiving information about their examination most commonly from the ordering provider (824 of 1292, 64%), who was also the most preferred source (1005 of 1388, 72%). Scheduled magnetic resonance (MR) imaging or nuclear medicine examinations (P < .001 vs other examination types) and increasing education (P = .008) were associated with higher rates of receiving information. Half of respondents (757 of 1452, 52%) sought information themselves. The highest importance scores for pre-examination information (Likert scale ≥4) was most frequently assigned to information on examination preparation and least frequently assigned to whether an alternative radiation-free examination could be used (74% vs 54%; P < .001). Conclusion Delivery of pre-examination information for radiologic examinations is suboptimal, with half of all patients and caregivers seeking information on their own. Ordering providers are the predominant and preferred source of examination-related information, with respondents placing highest importance on information related to examination preparation. © RSNA, 2018 Online supplemental material is available for this article.

Pediatric Chest CT Diagnostic Reference Ranges: Development and Application.

Purpose To determine diagnostic reference ranges on the basis of the size of a pediatric patient's chest and to develop a method to estimate computed tomographic (CT) scanner-specific mean size-specific dose estimates (SSDEs) as a function of patient size and the radiation output of each CT scanner at a site. Materials and Methods The institutional review boards of each center approved this retrospective, HIPAA-compliant, multicenter study; informed consent was waived. CT dose indexes (SSDE, volume CT dose index, and dose length product) of 518 pediatric patients (mean age, 9.6 years; male patients, 277 [53%]) who underwent CT between July 1, 2012, and June 30, 2013, according to the guidelines of the Quality Improvement Registry in CT Scans in Children were retrieved from a national dose data registry. Diagnostic reference ranges were developed after analysis of image quality of a subset of 111 CT examinations to validate image quality at the lower bound. Pediatric dose reduction factors were calculated on the basis of SSDEs for pediatric patients divided by SSDEs for adult patients. Results Diagnostic reference ranges (SSDEs) were 1.8-3.9, 2.2-4.5, 2.7-5.1, 3.6-6.6, and 5.5-8.4 mGy for effective diameter ranges of less than 15 cm, 15-19 cm, 20-24 cm, 25-29 cm, and greater than or equal to 30 cm, respectively. The fractions of adult doses (pediatric dose reduction factors) used within the consortium for patients with lateral dimensions of 8, 11, 14, 17, 20, 23, 26, 29, 32, 35, and 38 cm were 0.29, 0.33, 0.38, 0.44, 0.50, 0.58, 0.66, 0.76, 0.87, 1.0, and 1.15, respectively. Conclusion Diagnostic reference ranges developed in this study provided target ranges of pediatric dose indexes on the basis of patient size, while the pediatric dose reduction factors of this study allow calculation of unique reference dose indexes on the basis of patient size for each of a site's CT scanners. © RSNA, 2017 Online supplemental material is available for this article.

Improving health literacy: use of an informational brochure improves parents' understanding of their child's fluoroscopic examination.

OBJECTIVE: The purpose of this study was to determine parents' knowledge about pediatric fluoroscopic procedures and potential risk from ionizing radiation before and after being given an informational brochure. SUBJECTS AND METHODS: We reviewed responses from 120 randomly selected participants who were parents or guardians of pediatric patients undergoing diagnostic fluoroscopic examinations. A questionnaire assessed participants' knowledge of the procedure, radiation exposure, and whether their child had a prior examination before and after receiving an informational brochure. In a feedback survey, participants rated the brochure. A repeated measures mixed model was used to evaluate the effect of the brochure on the participants' knowledge. RESULTS: Participant demographics were women (79%), English speaking (99%), white (90%), and education higher than 12th grade (76%). The median age of patients undergoing the fluoroscopic examination was 4 years. Participant knowledge increased (p < 0.0001) between pre- and postbrochure (least-squares means) for those without a previous examination from 38.3 to 63.4 (total test score) and from 46.3 to 61.8 for those with a prior examination. The proportion of correct answers was higher (p < 0.0001) postbrochure compared with pre-brochure in areas of examination name (99% vs 93%), procedure details (97% vs 87%); use of radiation (100% vs 68%), and radiation dose comparison (79% vs 25%). Overall, 99% (119/120) rated the brochure "good" or "great" (p < 0.0001). CONCLUSION: An informational brochure given to participants before their child's fluoroscopic procedure improved their knowledge of the examination and radiation exposure. No participants refused their child's examination.

Diagnostic reference ranges and the American College of Radiology Dose Index Registry: the pediatric experience.

CT scans are powerful tools used in the care of pediatric patients daily. Yet the increased use of CT warrants careful monitoring. This article defines diagnostic reference levels and how they can be used to guide practice. Once a facility has adapted its techniques and protocols to fall within diagnostic reference levels or target values, the facility can expand its quality-improvement efforts to include a new concept, diagnostic reference ranges (DRRs). DRRs take into account the subjective image quality of the examination and provide a minimum estimated patient dose, below which accurate interpretation of an image might be difficult, and an upper estimated dose, above which the patient dose may be higher than necessary. This paper also describes how the American College of Radiology Dose Index Registry can be used by a facility as a continuous quality improvement tool to monitor and manage appropriate patient dose.

Curbing potential radiation-induced cancer risks in oncologic imaging: perspectives from the 'image gently' and 'image wisely' campaigns.

Medical imaging that uses ionizing radiation, such as CT, radiography, nuclear medicine, and fluoroscopy, is a cornerstone of the care of oncology patients and provides great benefit. Ionizing radiation at high doses is a known carcinogen.The exact degree of the risk of carcinogenesis from the lower doses of ionizing radiation used in medical imaging is less clear. The purpose of this review is to provide the oncology community with knowledge about the doses used in medical imaging, radiation-induced cancer risks from imaging, considerations to keep in mind when balancing imaging benefits and risks in pediatric and adult oncologic settings, dose reduction strategies, and the "Image Gently" and "Image Wisely" campaigns; the latter campaigns facilitate the translation of existing evidence into best practices for providers and patients.

Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action but where will we arrive?

Radiation awareness and protection of patients have been the fundamental responsibilities in diagnostic imaging since the discovery of x-rays late in 1895 and the first reports of radiation injury in 1896. In the ensuing years, there have been significant advancements in equipment that uses either x-rays to form images, such as fluoroscopy or computed tomography (CT), or the types of radiation emitted during nuclear imaging procedures (e.g., positron emission tomography [PET]). These advancements have allowed detailed and indispensable evaluation of a vast array of disorders. In fact, in 2001, CT and MRI were cited by physicians as the most significant medical innovations in the previous 3 decades. Rapid technological advancements in the last decade with CT, especially, have required imaging professionals to keep pace with increasingly complex technology to derive the maximum benefits of improved image acquisition and display techniques, in essence, the improved quality of the examination. It has also been challenging to fulfill the fundamental responsibilities of safety during this period of rapid growth (e.g., radiation protection, management of the risk of additional interventions driven by incidental findings, performing studies that were not indicated). The purpose of this paper is to define critical issues pertinent to ensuring patient safety through the appropriate assessment, recording, monitoring, and reporting of the radiation dose from CT.

The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography.

Transition from film-screen to digital radiography requires changes in radiographic technique and workflow processes to ensure that the minimum radiation exposure is used while maintaining diagnostic image quality. Checklists have been demonstrated to be useful tools for decreasing errors and improving safety in several areas, including commercial aviation and surgical procedures. The Image Gently campaign, through a competitive grant from the FDA, developed a checklist for technologists to use during the performance of digital radiography in pediatric patients. The checklist outlines the critical steps in digital radiography workflow, with an emphasis on steps that affect radiation exposure and image quality. The checklist and its accompanying implementation manual and practice quality improvement project are open source and downloadable at www.imagegently.org. The authors describe the process of developing and testing the checklist and offer suggestions for using the checklist to minimize radiation exposure to children during radiography.

System for verifiable CT radiation dose optimization based on image quality. part I. Optimization model.

PURPOSE: To develop and validate a mathematical radiation dose optimization model for computed tomography (CT) of the chest, abdomen, and pelvis. MATERIALS AND METHODS: This quality improvement project was determined not to constitute human subject research. A model for measuring water-equivalent diameter (DW) based on the topogram was developed and validated on each axial section in eight CT examinations of the chest, abdomen, and pelvis (500 images). A model for estimating image noise and size-specific dose estimates (SSDEs) using image and metadata was developed and validated in 16 examinations of anthropomorphic phantoms. A model to quantify radiologist image quality preferences was developed and applied to evaluations of 32 CT examinations of the abdomen and pelvis by 10 radiologists. The scanners' dose modulation algorithms were modeled and incorporated into an application capable of prediction of image noise and SSDE over a range of patient sizes. With use of the application, protocol techniques were recommended to achieve specific image noise targets. Comparisons were evaluated by using two-tailed nonpaired and paired t tests. RESULTS: The mean difference between topogram- and axial-based DW estimates was -3.5% ± 2.2 (standard deviation). The mean difference between estimated and measured image noise and volume CT dose index on the anthropomorphic phantoms was -6.9% ± 5.5 and 0.8% ± 1.8, respectively. A three-dimensional radiologist image quality preference model was developed. For the prediction model validation studies, mean differences between predicted and actual effective tube current-time product, SSDE, and estimated image noise were -0.9% ± 9.3, -1.8% ± 10.6, and -0.5% ± 4.4, respectively. CONCLUSION: CT image quality and radiation dose can be mathematically predicted and optimized on the basis of patient size and radiologist-specific image noise target curves.

Image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography.

OBJECTIVE: The purpose of this review is to summarize 10 steps a practice can take to manage radiation exposure in pediatric digital radiography. CONCLUSION: The Image Gently campaign raises awareness of opportunities for lowering radiation dose while maintaining diagnostic quality of images of children. The newest initiative in the campaign, Back to Basics, addresses methods for standardizing the approach to pediatric digital radiography, highlighting challenges related to the technology in imaging of patients of widely varying body sizes.

Diagnostic reference ranges for pediatric abdominal CT.

PURPOSE: To develop diagnostic reference ranges (DRRs) and a method for an individual practice to calculate site-specific reference doses for computed tomographic (CT) scans of the abdomen or abdomen and pelvis in children on the basis of body width (BW). MATERIALS AND METHODS: This HIPAA-compliant multicenter retrospective study was approved by institutional review boards of participating institutions; informed consent was waived. In 939 pediatric patients, CT doses were reviewed in 499 (53%) male and 440 (47%) female patients (mean age, 10 years). Doses were from 954 scans obtained from September 1 to December 1, 2009, through Quality Improvement Registry for CT Scans in Children within the National Radiology Data Registry, American College of Radiology. Size-specific dose estimate (SSDE), a dose estimate based on BW, CT dose index, dose-length product, and effective dose were analyzed. BW measurement was obtained with electronic calipers from the axial image at the splenic vein level after completion of the CT scan. An adult-sized patient was defined as a patient with BW of 34 cm. An appropriate dose range for each DRR was developed by reviewing image quality on a subset of CT scans through comparison with a five-point visual reference scale with increments of added simulated quantum mottle and by determining DRR to establish lower and upper bounds for each range. RESULTS: For 954 scans, DRRs (SSDEs) were 5.8-12.0, 7.3-12.2, 7.6-13.4, 9.8-16.4, and 13.1-19.0 mGy for BWs less than 15, 15-19, 20-24, 25-29, and 30 cm or greater, respectively. The fractions of adult doses, adult SSDEs, used within the consortium for patients with BWs of 10, 14, 18, 22, 26, and 30 cm were 0.4, 0.5, 0.6, 0.7, 0.8, and 0.9, respectively. CONCLUSION: The concept of DRRs addresses the balance between the patient's risk (radiation dose) and benefit (diagnostic image quality). Calculation of reference doses as a function of BW for an individual practice provides a tool to help develop site-specific CT protocols that help manage pediatric patient radiation doses.

Large-scale quality improvement for radiation protection of children worldwide: lessons from the past applied to the present.

OBJECTIVE: The objective of this article is to highlight strategies that can be used to implement changes locally for improved safety of pediatric patients. Specific examples of international organizations engaged with quality improvement are discussed. CONCLUSION: Large-scale quality improvement to promote radiation protection for children is being aggressively pursued by numerous international organizations. These international agencies use quality improvement methods on a global scale to optimize medical imaging for all diagnostic imaging modalities that use ionizing radiation with the intent of lowering radiation dose to children. This work, although vast in scope, requires highly focused project goals with access to scientific expertise. In addition, these coordinated efforts must provide education, collegial support, and resources (both financial and technical) that enable radiology professionals to implement change locally for improved safety of pediatric patients.