PCORI funds Dissemination and Implementation projects to increase awareness and promote the use of PCORI research findings to improve healthcare practices and health outcomes. This project is proposing to conduct dissemination and implementation activities for the results of the research project: Why Do Radiation Doses in CT Differ across Hospitals and Countries?.
1. What research finding is this project disseminating or implementing?
The original PCORI-funded study created a large computed tomography (CT) radiation dose registry, including data from a large number of patients and healthcare institutions. Using these data, we quantified the radiation doses delivered by CT, created benchmarks (what are good target doses for CT radiation dose by anatomic area, indication, and patient size), developed audit reports to provide institutions with comparisons of their doses to other institutions with specific recommendations on what to change, and most importantly, assessed the impact of providing detailed feedback to institutions on their average- and high-dose exams. We studied the impact of providing institutional feedback using a randomized controlled trial. Following distribution of the audit reports, the proportion of high-dose CT examinations was reduced significantly—14 to 38 percent across the four anatomic areas studied—and the average doses were also reduced significantly. Our project was the first randomized study to identify strategies that can be used to modify and lower institutional radiation dose levels.
Our PCORI-funded research was conducted in partnership with healthcare organizations that used a specific dose monitoring tool, Radimetrics. Institutions sent us 100 percent of their CT scans, which we assembled and analyzed at the University of California San Francisco (UCSF). By purchasing Radimetrics, organizations demonstrated an interest in optimizing CT radiation doses, which allowed us to focus on developing and testing institutional feedback rather than the complexities of data collection. However, to widely disseminate and implement, we need to adapt our dose-optimization audit feedback to become more locally oriented and accessible to a wider range of institutions. On a practical level, to expand access to feedback to a much larger number of institutions, we will need to adapt the process by which the audit reports are generated to increase accessibility, usefulness, uptake, and impact.
2. Why is this research finding important?
Seventy-five million CT examinations are conducted in the US annually, and each one delivers a dose of radiation up to 500 times higher than a chest X-ray. Yet there are few standards for the conduct of CT examinations. This has resulted in excessive variation in the doses patients receive when they undergo CT, and the routine use of doses far higher than needed for medical diagnoses. Extensive epidemiological and biological evidence demonstrates that exposure to radiation in the same range as that delivered by CT increases a person's risk of developing cancer. The lack of standards for CT or consistency in how it is preformed represents a significant and unnecessary health risk. It is estimated that 2 to 5 percent of all cancer in the US comes from radiation exposure from CT. Although there has been increasing attention paid to CT use from consumer advocates, medical groups, quality organizations, and state and national legislators around improving the safety of medical imaging, little progress has been made. Our PCORI-funded trial developed and tested an approach that can be used for institutions to lower their doses.
Optimizing CT doses will result in doses more appropriate for and tailored to the specific type of imaging needed for individual exams. While our work cannot bring about changes in how all CT scans are performed in the US, it can contribute toward this goal, and the work of our stakeholders can expand the reach of our efforts.
3. What is the goal of the D&I project?
There are two goals of the proposed research. The first is to adapt the tools we developed to provide feedback to a large number of institutions. The second is to work with diverse stakeholders to enhance their widespread dissemination and implementation of these tools across as many institutions that perform CT scanning as possible, including radiology practices and non-radiology practices where a large number of CT scans are performed.
4. What is the project team doing?
The UCSF research team will adapt the audit feedback tools to:
- Simplify and work toward automating the audit reports
- Include in the audit reports summaries that institutions can use to respond to LeapFrog Surveys and Joint Commission Accreditation Standards
- Determine accurate sample size for CT that institutions need to assess to obtain an accurate report
- Include a measure of image quality in the report.
The UCSF team will work with our stakeholders to disseminate and implement the audit tools. Our plan is to cast a wide net and explore different approaches to encourage as many institutions as possible to use the audit tools. We will:
- Work with three large provider organizations to use the audit tools, including Veterans Affairs Medical Centers, the University of Pittsburgh Medical Group, and a large urology practice that owns and operates multiple CT scanners
- Work with diverse specialty organizations that perform CT, including urology, emergency medicine, cardiology, and The American College of Radiology to identify members to use the audit reports
- Work with the LeapFrog Group to engage the hospitals that complete their surveys to use the audit tools
5. How will the project team evaluate its D&I activities?
There are three components to the evaluation. We will:
- Assess how many institutions use the audit software (metrics: numbers of patients, scans, scanners, and institutions)
- Quantify the doses among users and assess whether the doses change over time (metrics: dose levels and dose change)
- Determine who is using the audit software and what factors enhance or hinder their use. We will survey users of our tools and use the Solberg framework to assess the dissemination and implementation of dose-optimization activities, and try to understand factors that encourage successful adoption.
6. How is the project team involving patients and others in this D&I project?
The Stakeholder Advisory Group include individuals reflecting provider organizations, payers, quality organizations, diverse specialty societies, accreditation organizations, patient advocacy organizations, and patient stakeholders. The stakeholders are an integral part of the effort to help tailor what we design for their constituents and settings, to help us recruit institutions to pilot test what we develop and to provide detailed feedback on their experiences, and to continue the implementation of this work even after this project is complete.
7. How will this project help ensure future uptake and use of PCORI results?
We have engaged diverse healthcare organizations and CT providers who are committed to continuing and expanding the work; including the Joint Commission, LeapFrog, and large healthcare provider organizations.
Learn more about PCORI’s Dissemination and Implementation program here.
Related PCORI-funded Research Project
Note: Results from the original project have completed PCORI’s Peer Review and are available here.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.