Radiology stewardship and quality improvement: the process and costs of implementing a CT radiation dose optimization committee in a medium-sized community hospital system

Reject Analysis in Digital Radiography and Computed Tomography: A Belgian Imaging Department Case Study

Objective

Reject analysis is usually performed in digital radiography (DR) for quality assurance. Data for computed tomography (CT) rejects remains sparse. The aim of this study is to help provide a straightforward benchmark for reject analysis of both DR and CT.

Materials and methods

This retrospective observational study included 107,277 DR and 20,659 CT during 18 months in a tertiary care center. Rejected acquisitions were retrieved by Dose Archiving and Communication System (DACS). The DR and CT reject analysis included reject rates, reasons for rejection and supplementary radiation dose associated with these rejects.

Results

8,904 rejected DR and 514 rejected CT were retrieved. The DR reject rate was 8.3% whereas the CT reject rate was 2.5%. The cumulative effective dose (ED) of DR rejects was 377.3 mSv while the cumulative ED of CT rejects was 1267.4 mSv. The major reason for rejects was positioning for both DR (61%) and CT (44%).

Conclusion

This study helps constitute a simple reproducible method to analyze both DR and CT rejects simultaneously. Although CT rejects are less often monitored than DR rejects, the radiation dose associated with CT rejects is much higher, which emphasizes the need to systematically monitor both DR and CT rejects. Investigating the reasons and the most frequently rejected examinations gives an opportunity for improvement of imaging techniques in cooperation with technologists.

Strategies for Dose Optimization: Views From Health Care Systems

BACKGROUND

Advances in CT have facilitated widespread use of medical imaging while increasing patient lifetime exposure to ionizing radiation.

PURPOSE

To describe dose optimization strategies used by health care organizations to optimize radiation dose and image quality.

MATERIALS AND METHODS

A qualitative study of semistructured interviews conducted with 26 leaders from 19 health care systems in the United States, Europe, and Japan. Interviews focused on strategies that were used to optimize radiation dose at the organizational level. A directed content analysis approach was used in data analysis.

RESULTS

Analysis identified seven organizational strategies used by these leaders for optimizing CT dose: (1) engaging radiologists and technologists, (2) establishing a CT dose committee, (3) managing organizational change, (4) providing leadership and support, (5) monitoring and benchmarking, (6) modifying CT protocols, and (7) changes in equipment and work rules.

CONCLUSIONS

Leaders in these health systems engaged in specific strategies to optimize CT dose within their organizations. The strategies address challenges health systems encounter in optimizing CT dose at the organizational level and offer an evolving framework for consideration in dose optimization efforts for enhancing safety and use of medical imaging.

Implementation of a computed tomography dose management program across a multinational healthcare organization

OBJECTIVES

Radiation dose index monitoring (RDIM) systems may help identify CT dose reduction opportunities, but variability and complexity of imaging procedures make consistent dose optimization and standardization a challenge. This study aimed to investigate the feasibility to standardize and optimize CT protocols through the implementation of a Dose Excellence Program within a European healthcare network.

METHODS

The Dose Excellence Program consisted of a multidisciplinary team that developed standardized organizational adult CT protocols and thresholds for relevant radiation dose indices (RDIs). Baseline data were collected retrospectively from the RDIM (Phase I, 2015). Organization's protocols were implemented and monitored from the RDIM for deviations (Phase II, 2016). Following standardization, radiation dose optimization was initiated (Phase III, 2017). Data from the three most used protocols were retrospectively extracted and grouped by country for all phases. The mean number of series (RS) and RDIs were compared between phases and with organizational reference levels. A Mann-Whitney test was conducted; p < .05 was considered as significant.

RESULTS

Data from 9588, 12638, and 6093 examinations were analyzed from General Chest, General Head, and Thorax/Abdomen/Pelvis (TAP) multiphase respectively. Overall, after Phase III, mean RS and CTDI_vol p⁷⁵ were below the organizational reference levels in all countries for the three protocols. The CTDI_vol decreased by 45% in Switzerland (p < .00001), 32% in Turkey (p < .00001), and 28% in Switzerland (p = .0027) for General Chest, General Head, and TAP multiphase respectively.

CONCLUSIONS

The implementation of a Dose Excellence Program within a large-scale healthcare organization allowed unifying protocols and optimizing radiation dose across countries.

KEY POINTS

• Engaging a multidisciplinary team can enhance the use of an RDIM system for CT dose management in a multinational healthcare environment. • Deep dive of baseline data and standardization of CT practices by defining organizational clinical indication CT protocols with RPIDs is an essential step before optimization of radiation dose. • Following the implementation of the program, the mean RS and CTDIvol were below or equal to the organizational reference levels in all countries.

AAPM Medical Physics Practice Guideline 1.b: CT protocol management and review practice guideline

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: (a) Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. (b) Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Applying a New CT Quality Metric in Radiology: How CT Pulmonary Angiography Repeat Rates Compare Across Institutions

OBJECTIVES

To quantify overall CT repeat and reject rates at five institutions and investigate repeat and reject rates for CT pulmonary angiography (CTPA).

METHODS

In this retrospective study, we apply an automated repeat rate analysis algorithm to 103,752 patient examinations performed at five institutions from July 2017 to August 2019. The algorithm identifies repeated scans for specific scanner and protocol combinations. For each institution, we compared repeat rates for CTPA to all other CT protocols. We used logistic regression and analysis of deviance to compare CTPA repeat rates across institutions and size-based protocols.

RESULTS

Of 103,752 examinations, 1,447 contained repeated helical scans (1.4%). Overall repeat rates differed across institutions (P < .001) ranging from 0.8% to 1.8%. Large-patient CTPA repeat rates ranged from 3.0% to 11.2% with the odds (95% confidence intervals) of a repeat being 4.8 (3.5-6.6) times higher for large- relative to medium-patient CTPA protocols. CTPA repeat rates were elevated relative to all other CT protocols at four of five institutions, with strong evidence of an effect at two institutions (P < .001 for each; odds ratios: 2.0 [1.6-2.6] and 6.2 [4.4-8.9]) and somewhat weaker evidence at the others (P = .005 and P = 0.011; odds ratios: 2.2 [1.3-3.8] and 3.7 [1.5-9.1], respectively). Accounting for size-based protocols, CTPA repeat rates differed across institutions (P < .001).

DISCUSSION

The results indicate low overall repeat rates (<2%) with CTPA rates elevated relative to other protocols. Large-patient CTPA rates were highest (eg, 11.2% at one institution). Differences in repeat rates across institutions suggest the potential for quality improvement.

A Multiinstitutional Study on Wasted CT Scans for Over 60,000 Patients

OBJECTIVE. Repeated imaging is an unnecessary source of patient radiation exposure, a detriment to patient satisfaction, and a waste of time and money. Although analysis of rates of repeated and rejected images is mandated in mammography and recommended in radiography, the available data on these rates for CT are limited. MATERIALS AND METHODS. In this retrospective study, an automated repeat-reject rate analysis algorithm was used to quantify repeat rates from 61,102 patient examinations obtained between 2015 and 2018. The algorithm used DICOM metadata to identify repeat acquisitions. We quantified rates for one academic site and one rural site. The method allows scanner-, technologist-, protocol-, and indication-specific rates to be determined. Positive predictive values and sensitivity were estimated for correctly identifying and classifying repeat acquisitions. Repeat rates were compared between sites to identify areas for targeted technologist training. RESULTS. Of 61,102 examinations, 4676 instances of repeat scanning contributed excess radiation dose to patients. Estimated helical overlap repeat rates were 1.4% (95% CI, 1.2-1.6%) for the rural site and 1.1% (95% CI, 1.0-1.2%) for the academic site. Significant differences in rates of repeat imaging required because of bolus tracking (11.6% vs 4.3%; p < 0.001) and helical extension (3.3% vs 1.8%; p < 0.001) were observed between sites. Positive predictive values ranged from 91% to 99% depending on the reason for repeat imaging and site location. Sensitivity of the algorithm was 92% (95% CI, 87-96%). Rates tended to be highest for emergent imaging procedures and exceeded 9% for certain protocols. CONCLUSION. Our multiinstitutional automated quantification of repeat rates for CT provided a useful metric for unnecessary radiation exposure and identification of technologists in need of training.

Comparison of the Effectiveness of Single-Component and Multicomponent Interventions for Reducing Radiation Doses in Patients Undergoing Computed Tomography: A Randomized Clinical Trial

Importance

Computed tomography (CT) radiation doses vary across institutions and are often higher than needed.

Objective

To assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT.

Design, Setting, and Participants

This randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018.

Interventions

Imaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention.

Main Outcomes and Measures

Primary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics.

Results

Across 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001; chest: OR, 0.92; 95% CI, 0.86-0.99; P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P < .001; and head: OR, 0.71; 95% CI, 0.66-0.76; P < .001). Reductions in the proportions of high-dose scans were greater when measured using organ doses. The absolute reduction in the proportion of high-dose scans was 6.0% to 17.2%, reflecting 23% to 58% reductions in the proportions of high-dose scans across anatomical areas. Mean effective doses were significantly reduced after multicomponent intervention for abdomen (6% reduction, P < .001), chest (4%, P < .001), and chest and abdomen (14%, P < .001) CT scans. Larger reductions in mean organ doses were 8% to 43% across anatomical areas. Audit feedback alone reduced the proportions of high-dose scans and mean dose, but reductions in observed dose were smaller. Radiologist's satisfaction with CT image quality was unchanged and high during all periods.

Conclusions and Relevance

For imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest.

Trial Registration

ClinicalTrials.gov Identifier: NCT03000751.

Achieving CT Regulatory Compliance: A Comprehensive and Continuous Quality Improvement Approach

Computed tomography (CT) represents one of the largest sources of radiation exposure to the public in the United States. Regulatory requirements now mandate dose tracking for all exams and investigation of dose events that exceed set dose thresholds. Radiology practices are tasked with ensuring quality control and optimizing patient CT exam doses while maintaining diagnostic efficacy. Meeting regulatory requirements necessitates the development of an effective quality program in CT. This review provides a template for accreditation compliant quality control and CT dose optimization. The following paper summarizes a large health system approach for establishing a quality program in CT and discusses successes, challenges, and future needs.

Detection of unwarranted CT radiation exposure from patient and imaging protocol meta-data using regularized regression

BACKGROUND

Variability in radiation exposure from CT scans can be appropriate and driven by patient features such as body habitus. Quantitative analysis may be performed to discover instances of unwarranted radiation exposure and to reduce the probability of such occurrences in future patient visits. No universal process to perform identification of outliers is widely available, and access to expertise and resources is variable.

OBJECTIVE

The goal of this study is to develop an automated outlier detection procedure to identify all scans with an unanticipated high radiation exposure, given the characteristics of the patient and the type of the exam.

MATERIALS AND METHODS

This Institutional Review Board-approved retrospective cohort study was conducted from June 30, 2012 - December 31, 2013 in a quaternary academic medical center. The de-identified dataset contained 28 fields for 189,959 CT exams. We applied the variable selection method Least Absolute Shrinkage and Selection Operator (LASSO) to select important variables for predicting CT radiation dose. We then employed a regression approach that is robust to outliers, to learn from data a predictive model of CT radiation doses given important variables identified by LASSO. Patient visits whose predicted radiation dose was statistically different from the radiation dose actually received were identified as outliers.

RESULTS

Our methodology identified 1% of CT exams as outliers. The top-5 predictors discovered by LASSO and strongly correlated with radiation dose were Tube Current, kVp, Weight, Width of collimator, and Reference milliampere-seconds. A human expert validation of the outlier detection algorithm has yielded specificity of 0.85 [95% CI 0.78-0.92] and sensitivity of 0.91 [95% CI 0.85-0.97] (PPV = 0.84, NPV = 0.92). These values substantially outperform alternative methods we tested (F1 score 0.88 for our method against 0.51 for the alternatives).

CONCLUSION

The study developed and tested a novel, automated method for processing CT scanner meta-data to identify CT exams where patients received an unwarranted amount of radiation. Radiation safety and protocol review committees may use this technique to uncover systemic issues and reduce future incidents.

Integrated research of a multi-wavelength method in anisotropic scattering flame on soot temperature and radiative coefficient reconstruction

At present, the studies of scattering flame problems combined with multi-wavelength reconstruction technology are rather limited. In this paper, a multi-wavelength method combined with a collocation spectral method (CSM)-discrete ordinates method (DOM) forward method is developed for the simultaneous reconstruction of temperature and inhomogeneous radiative coefficient of an axisymmetric laminar ethylene diffusion flame. The scattering source term in the radiative transfer equation is solved by the forward solution method based on DOM, which couples a spatial scheme of CSM and the spherical rings arithmetic progression quadrature. The Tikhonov regularized method is employed to overcome the ill-posed matrix to obtain the global radiative source term. The boundary radiation intensity is input into the algorithm as a known value for inversion of temperature, absorption coefficient, and scattering coefficient. The retrieval results demonstrate that the temperature and the radiation parameters of the scattering flame can be well reconstructed for the flame with axisymmetric distribution, even for the flame with noisy data. In addition, the scattering coefficient is more difficult to rebuild than temperature. The inversion accuracy does not deteriorate with a slight increase in noise. Also, the addition of scattering terms to the proposed algorithm can improve the accuracy in reconstructing the radiation parameters. The developed method in this paper would be useful for multispectral algorithms, which could be used in later experiments based on hyperspectral techniques.

Opportunities to Reduce CT Radiation Exposure, Experience Over 5 Years at the NIH Clinical Center

Our current study was undertaken in order to compare CT exposures during various dose-reduction initiatives at the National Institutes of Health Clinical center, to show trends in exposure reduction over a 5-y period, and to provide benchmarks that other facilities may use. Using an in-house extraction tool (Radiation Exposure Extraction Engine), we derived CT exposure data from Digital Imaging and Communications in Medicine (DICOM) headers over 5 y. We present parameters used and compare most common exams between 2010 and 2015. During a period of exposure-reduction initiatives, data of 79 396 exams from nine CT scanners on 87 scan protocols were analyzed. Adult chest exposures were reduced 53% and chest, abdomen and pelvis exams were reduced 43%  (p < 0.001). Only extremity exams did not show significantly reduced exposure. Collecting data over several years allowed us to confirm and compare several initiatives. We demonstrated significant exposure reductions during continued reduction efforts on common exams. Our results may provide benchmarks for similar centers.

AAPM medical physics practice guideline 6.a.: Performance characteristics of radiation dose index monitoring systems

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: •Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. •Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Optimizing Radiation Doses for Computed Tomography Across Institutions: Dose Auditing and Best Practices

IMPORTANCE

Radiation doses for computed tomography (CT) vary substantially across institutions.

OBJECTIVE

To assess the impact of institutional-level audit and collaborative efforts to share best practices on CT radiation doses across 5 University of California (UC) medical centers.

DESIGN, SETTING, AND PARTICIPANTS

In this before/after interventional study, we prospectively collected radiation dose metrics on all diagnostic CT examinations performed between October 1, 2013, and December 31, 2014, at 5 medical centers. Using data from January to March (baseline), we created audit reports detailing the distribution of radiation dose metrics for chest, abdomen, and head CT scans. In April, we shared reports with the medical centers and invited radiology professionals from the centers to a 1.5-day in-person meeting to review reports and share best practices.

MAIN OUTCOMES AND MEASURES

We calculated changes in mean effective dose 12 weeks before and after the audits and meeting, excluding a 12-week implementation period when medical centers could make changes. We compared proportions of examinations exceeding previously published benchmarks at baseline and following the audit and meeting, and calculated changes in proportion of examinations exceeding benchmarks.

RESULTS

Of 158 274 diagnostic CT scans performed in the study period, 29 594 CT scans were performed in the 3 months before and 32 839 CT scans were performed 12 to 24 weeks after the audit and meeting. Reductions in mean effective dose were considerable for chest and abdomen. Mean effective dose for chest CT decreased from 13.2 to 10.7 mSv (18.9% reduction; 95% CI, 18.0%-19.8%). Reductions at individual medical centers ranged from 3.8% to 23.5%. The mean effective dose for abdominal CT decreased from 20.0 to 15.0 mSv (25.0% reduction; 95% CI, 24.3%-25.8%). Reductions at individual medical centers ranged from 10.8% to 34.7%. The number of CT scans that had an effective dose measurement that exceeded benchmarks was reduced considerably by 48% and 54% for chest and abdomen, respectively. After the audit and meeting, head CT doses varied less, although some institutions increased and some decreased mean head CT doses and the proportion above benchmarks.

CONCLUSIONS AND RELEVANCE

Reviewing institutional doses and sharing dose-optimization best practices resulted in lower radiation doses for chest and abdominal CT and more consistent doses for head CT.

Tracking Patterns of Nonadherence to Prescribed CT Protocol Parameters

PURPOSE

Quantification of the frequency, understanding the motivation, and documentation of the changes made by CT technologists at scan time are important components of monitoring a quality CT workflow.

METHODS

CT scan acquisition data were collected from one CT scanner for a period of 1 year. The data included all relevant acquisition parameters needed to define the technical side of a CT protocol. An algorithm was created to sort these data in groups of irradiation events with the same combinations of scan acquisition parameters. For scans modified at scan time, it was hypothesized that these examinations would show up only once in the organized data. A classification scheme was developed to place each "one-off" examination into a category related to what motivated the scan-time change.

RESULTS

A total of 132,707 irradiation events were organized into 434 groups of unique scan acquisition parameters. One hundred forty-four irradiation events had acquisition parameters that showed up only once in the data. These "one-offs" were classified as follows: 25% represented rarely used protocols, 17% were due to service scans, 16% were changed for unknown and therefore undesired reasons, 15% were changed by technologists trying to adapt protocol to patient size, 12% were allowable scan-time changes, 8% of scans had tube current maxed out, and 6% of scans were changed to a higher dose mode as requested by radiologists.

CONCLUSIONS

The outcome of this study suggests many areas of needed technologist training and chances for optimizing this institution's CT protocols.

From Information Management to Information Visualization: Development of Radiology Dashboards

OBJECTIVE

The development and implementation of a dashboard of medical imaging department (MID) performance indicators.

METHOD

Several articles discussing performance measures of imaging departments were searched for this study. All the related measures were extracted. Then, a panel of imaging experts were asked to rate these measures with an open ended question to seek further potential indicators. A second round was performed to confirm the performance rating. The indicators and their ratings were then reviewed by an executive panel. Based on the final panel's rating, a list of indicators to be used was developed. A team of information technology consultants were asked to determine a set of user interface requirements for the building of the dashboard. In the first round, based on the panel's rating, a list of main features or requirements to be used was determined. Next, Qlikview was utilized to implement the dashboard to visualize a set of selected KPI metrics. Finally, an evaluation of the dashboard was performed.

RESULTS

92 MID indicators were identified. On top of this, 53 main user interface requirements to build of the prototype of dashboard were determined. Then, the project team successfully implemented a prototype of radiology management dashboards into study site. The visual display that was designed was rated highly by users.

CONCLUSION

To develop a dashboard, management of information is essential. It is recommended that a quality map be designed for the MID. It can be used to specify the sequence of activities, their related indicators and required data for calculating these indicators. To achieve both an effective dashboard and a comprehensive view of operations, it is necessary to design a data warehouse for gathering data from a variety of systems. Utilizing interoperability standards for exchanging data among different systems can be also effective in this regard.

A Comprehensive CT Dose Reduction Program Using the ACR Dose Index Registry

PURPOSE

The purpose of this article is to demonstrate the role of the ACR Dose Index Registry(®) (DIR) in a dose reduction program at a large academic health care system.

METHODS

Using the ACR DIR, radiation doses were collected for four common CT examination types (head without contrast, chest with contrast, chest without contrast, and abdomen and pelvis with contrast). Baseline analysis of 7,255 CT examinations from seven scanners across the institution was performed for the period from December 1, 2011, to March 15, 2012. A comprehensive dose reduction initiative was guided by the identification of targets for dose improvement from the baseline analysis. Data for 14,938 examinations from the same seven scanners were analyzed for the postimplementation period of January 1, 2013, to July 1, 2013.

RESULTS

The program included protocol changes, iterative reconstruction, optimization of scan acquisition, technologist education, and continuous monitoring with feedback tools. Average decrease in median dose-length product (DLP) across scanners was 30% for chest CT without contrast, 29% for noncontrast head CT, 26% for abdominal and pelvic CT with contrast, and 10% for chest CT with contrast. Compared with average median DLP in the ACR DIR, the median institution-wide CT DLPs after implementation were lower by 33% for chest CT without contrast, 32% for chest CT with contrast, 26% for abdominal and pelvic CT with contrast, and 6% for head CT without contrast.

CONCLUSIONS

A comprehensive CT dose reduction program using the ACR DIR can lead to substantial dose reduction within a large health care system.

Compliance with AAPM Practice Guideline 1.a: CT Protocol Management and Review - from the perspective of a university hospital

The purpose of this paper is to describe our experience with the AAPM Medical Physics Practice Guideline 1.a: “CT Protocol Management and Review Practice Guideline”. Specifically, we will share how our institution's quality management system addresses the suggestions within the AAPM practice report. We feel this paper is needed as it was beyond the scope of the AAPM practice guideline to provide specific details on fulfilling individual guidelines. Our hope is that other institutions will be able to emulate some of our practices and that this article would encourage other types of centers (e.g., community hospitals) to share their methodology for approaching CT protocol optimization and quality control. Our institution had a functioning CT protocol optimization process, albeit informal, since we began using CT. Recently, we made our protocol development and validation process compliant with a number of the ISO 9001:2008 clauses and this required us to formalize the roles of the members of our CT protocol optimization team. We rely heavily on PACS‐based IT solutions for acquiring radiologist feedback on the performance of our CT protocols and the performance of our CT scanners in terms of dose (scanner output) and the function of the automatic tube current modulation. Specific details on our quality management system covering both quality control and ongoing optimization have been provided. The roles of each CT protocol team member have been defined, and the critical role that IT solutions provides for the management of files and the monitoring of CT protocols has been reviewed. In addition, the invaluable role management provides by being a champion for the project has been explained; lack of a project champion will mitigate the efforts of a CT protocol optimization team. Meeting the guidelines set forth in the AAPM practice guideline was not inherently difficult, but did, in our case, require the cooperation of radiologists, technologists, physicists, IT, administrative staff, and hospital management. Some of the IT solutions presented in this paper are novel and currently unique to our institution.

PACS number: 87.57.Q

Data-driven CT protocol review and management—experience from a large academic hospital

PURPOSE

Protocol review plays a critical role in CT quality assurance, but large numbers of protocols and inconsistent protocol names on scanners and in exam records make thorough protocol review formidable. In this investigation, we report on a data-driven cataloging process that can be used to assist in the reviewing and management of CT protocols.

METHODS

We collected lists of scanner protocols, as well as 18 months of recent exam records, for 10 clinical scanners. We developed computer algorithms to automatically deconstruct the protocol names on the scanner and in the exam records into core names and descriptive components. Based on the core names, we were able to group the scanner protocols into a much smaller set of "core protocols," and to easily link exam records with the scanner protocols. We calculated the percentage of usage for each core protocol, from which the most heavily used protocols were identified.

RESULTS

From the percentage-of-usage data, we found that, on average, 18, 33, and 49 core protocols per scanner covered 80%, 90%, and 95%, respectively, of all exams. These numbers are one order of magnitude smaller than the typical numbers of protocols that are loaded on a scanner (200-300, as reported in the literature). Duplicated, outdated, and rarely used protocols on the scanners were easily pinpointed in the cataloging process.

CONCLUSIONS

The data-driven cataloging process can facilitate the task of protocol review.

Improving service uptake and quality of care of integrated maternal health services: the Kenya Kwale District improvement collaborative

BACKGROUND

Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack of progress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother.

METHODS

Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office.

RESULTS

The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012).

CONCLUSION

Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries.

Lung cancer screening with low-dose computed tomography for primary care providers

This review provides an update on lung cancer screening with low-dose computed tomography (LDCT) and its implications for primary care providers. One of the unique features of lung cancer screening is the potential complexity in patient management if an LDCT scan reveals a small pulmonary nodule. Additional tests, consultation with multiple specialists, and follow-up evaluations may be needed to evaluate whether lung cancer is present. Primary care providers should know the resources available in their communities for lung cancer screening with LDCT and smoking cessation, and the key points to be addressed in informed and shared decision-making discussions with patients.

AAPM medical physics practice guideline 1.a: CT protocol management and review practice guideline

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States.

The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner.

Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized.