Justification of Medical Exposure in Diagnostic Imaging Proceedings Series Justification of Medical Exposure in Diagnostic Imaging Proceedings of an International Workshop Brussels, 2–4 September 2009 INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA ISBN 978–92–0–121110–1 ISSN 0074–1884 11-41111_P1532_cover.indd 1 2012-01-16 13:29:43 JUSTIFICATION OF MEDICAL EXPOSURE IN DIAGNOSTIC IMAGING PROCEEDINGS SERIES JUSTIFICATION OF MEDICAL EXPOSURE IN DIAGNOSTIC IMAGING PROCEEDINGS OF AN INTERNATIONAL WORKSHOP ON JUSTIFICATION OF MEDICAL EXPOSURE IN DIAGNOSTIC IMAGING ORGANIZED BY THE INTERNATIONAL ATOMIC ENERGY AGENCY IN COOPERATION WITH THE EUROPEAN COMMISSION AND HELD IN BRUSSELS, 2–4 SEPTEMBER 2009 INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA, 2011 COPYRIGHT NOTICE All IAEA scientific and technical publications are protected by the terms of the Universal Copyright Convention as adopted in 1952 (Berne) and as revised in 1972 (Paris). 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Enquiries should be addressed to the IAEA Publishing Section at: Marketing and Sales Unit, Publishing Section International Atomic Energy Agency Vienna International Centre PO Box 100 1400 Vienna, Austria fax: +43 1 2600 29302 tel.: +43 1 2600 22417 email: [email protected] http://www.iaea.org/books © IAEA, 2011 Printed by the IAEA in Austria December 2011 STI/PUB/1532 IAEA Library Cataloguing in Publication Data International Workshop on Justification of Medical Exposure in Diagnostic Imaging (2009 : Brussels, Belgium) Justification of medical exposure in diagnostic imaging : proceedings of an International Workshop on Justification of Medical Exposure in Diagnostic Imaging / organized by the International Atomic Energy Agency in cooperation with the European Commission and held in Brussels, 2–4 September 2009. — Vienna : International Atomic Energy Agency, 2011. p. ; 29 cm. — (Proceedings series, ISSN 0074–1884) STI/PUB/1532 ISBN 978–92–0–121110–1 Includes bibliographical references. 1. Ionizing radiation — Safety measures — Congresses. 2. Radiation — Health aspects. 3. Radiation protection. I. International Atomic Energy Agency. II. Series: Proceedings series (International Atomic Energy Agency). IAEAL 11–00710 FOREWORD The extent of the radiation exposure of patients has increased dramatically in recent times. The major part of the exposure now arises from practices that barely existed two decades ago. In some countries, the population dose from medical exposures now rivals that from the natural background. For practitioners and regulators, it is evident that this innovation has been driven both by the imaging industry and by an ever increasing array of new applications generated and validated in the clinical environment. Because of these increases, the radiation protection of patients has assumed much greater importance. The doses involved are large compared with those from occupational exposures. Much work has been done to optimize these doses, and much of what is required is well understood. However, more remains to be done to ensure that routine day to day practice throughout the world is well optimized. The other cornerstone of the radiation protection of patients is the justification of exposures as recommended by the International Commission on Radiological Protection (ICRP) and required by the International Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources (BSS), jointly sponsored by the IAEA and a number of other international organizations. The justification process must ensure that only those who can benefit from medical exposures will receive them. In practice, the benefit must be balanced against the risk. The theory of the radiation protection of the patient relies on this balance being struck in a way that ultimately favours patients and does not expose them to unnecessary risk. With the increase in the dose per examination, the issue of justification has acquired a new urgency to which the IAEA has responded vigorously over the last few years. The IAEA response initially involved two consultations with groups of experts. The first established that there is a prime facie case to be concerned that the implementation of justification is not all it should be. The second established that there is a robust set of tools that can greatly improve justification. These are mature enough to be deployed for clinical use in various parts of the world, although further refinement and nuancing is required. Arising from these initiatives, the IAEA and the European Commission (EC) organized a joint workshop on the justification of medical exposures in Brussels with a view to consolidating these conclusions and broadening the interest groups involved in considering the problem. These proceedings report the work and conclusions of this workshop. Over 40 countries and several international organizations were involved, and concluded that there are major issues to be addressed in the implementation of justification in practice. A concerted global campaign to improve ‘awareness, appropriateness and audit’ (the three A’s campaign) is required, as set out in the conclusions. The campaign will necessarily involve all the key players in the field. The International Action Plan for the Radiological Protection of Patients was approved by the General Conference of the IAEA in 2002, and its implementation has been the subject of a resolution at succeeding General Conferences. Recently, the IAEA Secretariat was encouraged to “develop further guidance on justification of medical exposures and optimization of protection, taking into account, inter alia, the outcomes of the September 2009 workshop hosted jointly with the European Commission”. These proceedings are prepared and issued in response to this. The IAEA thanks J. Malone (Ireland), who had a major role in organizing the workshop and in preparing the proceedings for publication. The IAEA officers responsible for this publication were O. Holmberg and R. Czarwinski of the Division of Radiation, Transport and Waste Safety. EDITORIAL NOTE These Proceedings have been edited by the editorial staff of the IAEA to the extent considered necessary for the reader’s assistance. The views expressed remain, however, the responsibility of the named authors or participants. In addition, the views are not necessarily those of the governments of the nominating Member States or of the nominating organizations. Although great care has been taken to maintain the accuracy of information contained in this publication, neither the IAEA nor its Member States assume any responsibility for consequences which may arise from its use. The use of particular designations of countries or territories does not imply any judgement by the publisher, the IAEA, as to the legal status of such countries or territories, of their authorities and institutions or of the delimitation of their boundaries. The mention of names of specific companies or products (whether or not indicated as registered) does not imply any intention to infringe proprietary rights, nor should it be construed as an endorsement or recommendation on the part of the IAEA. The authors are responsible for having obtained the necessary permission for the IAEA to reproduce, translate or use material from sources already protected by copyrights. Material prepared by authors who are in contractual relation with governments is copyrighted by the IAEA, as publisher, only to the extent permitted by the appropriate national regulations. CONTENTS SUMMARY . 1 OPENING ADDRESSES . 5 Opening address — IAEA. 7 E. Amaral Opening address — European Commission . 9 A. Janssens SETTING THE SCENE (Session 1) Justification: The IAEA initiative . 13 O. Holmberg Justification and tools for change: Scene setting . 17 J. Malone Re-examining ethical issue: Philosophical considerations . 25 S. Sia Overutilization in medical imaging. 31 W.R. Hendee REFERRAL GUIDELINES (Session 2) Referral guidelines: Why, how and for whom? . 37 D. Remedios Medical radiation protection of the patient: Issues in Canada . 43 J. Mayo, J. Chen Medical justification of CT imaging and use of appropriateness criteria in the USA . 47 C.H. McCollough, J.G. Fletcher, J.A. Brink Appropriateness in cardiology: The Homer syndrome of the imaging specialist . 59 E. Picano Some aspects of diagnostic radiology in Brazil . 67 J.P. Matushita, H.J. Khoury COMMUNICATION AND RISK (Session 3) Media perspective: A good story . 73 P. Rickwood Communication, consent and the patient: Unlocking the radiological chamber of secrets . 77 E. Picano Dose and risk: The hard facts . 83 P.W. Horton Training and dose awareness: Critical factors in physicians’ motivation. 91 P. Smeesters, T. Kiffel Knowledge of referring physicians with respect to dose, risk and related communications . 95 R. Guleria AUDIT AND JUSTIFICATION (Session 4) EC clinical audit guidelines: Justification is among the priorities of an audit programme . 103 H. Järvinen Clinical audit for referral guidelines: A problem solving tool . 109 D. Remedios A study on justification of CT examinations in Sweden. 113 W. Leitz, A. Almén, S. Richter Whether or not to image: