Department of Radiology and Biomedical Imaging, University of California, San Francisco.
Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
JAMA Intern Med. 2020 May 1;180(5):666-675. doi: 10.1001/jamainternmed.2020.0064.
Computed tomography (CT) radiation doses vary across institutions and are often higher than needed.
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.
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT03000751.
计算机断层扫描（CT）的辐射剂量因机构而异，且往往高于实际所需。
评估两种干预措施降低 CT 检查患者辐射剂量的效果。
设计、地点和参与者：这是一项随机临床试验，纳入了 2015 年 11 月 1 日至 2017 年 9 月 21 日期间来自 6 个国家的 100 个医疗机构的 864080 名 18 岁以上成年人，他们接受了腹部、胸部、腹部和胸部联合或头部 CT 检查。数据分析于 2017 年 10 月 4 日至 2018 年 12 月 14 日进行。
影像机构在收到比较与其他机构的辐射剂量指标的审计反馈后，单独接收多组分干预措施，包括带有针对性建议的审计反馈、为期 7 周的质量改进合作和最佳实践分享。机构被随机分配到从常规护理过渡到干预的时间点。
主要结局是高剂量 CT 扫描的比例和机构层面的有效剂量平均值。次要结局是器官剂量。使用分层广义线性模型比较干预前后的结局，该模型调整了时间趋势和患者特征。
在 100 家机构中，864080 名成年人接受了 1156657 次 CT 扫描。多组分干预显著降低了有效剂量测量的高剂量 CT 扫描比例。高剂量扫描比例的绝对变化为 1.1%至 7.9%，高剂量扫描比例的百分比降低为 4%至 30%（腹部：比值比 [OR]，0.82；95%CI，0.77-0.88；P<0.001；胸部：OR，0.92；95%CI，0.86-0.99；P=0.03；腹部和胸部联合：OR，0.49；95%CI，0.41-0.59；P<0.001；头部：OR，0.71；95%CI，0.66-0.76；P<0.001）。使用器官剂量测量时，高剂量扫描比例的降低更大。高剂量扫描比例的绝对减少为 6.0%至 17.2%，反映了各个解剖区域高剂量扫描比例降低了 23%至 58%。腹部（降低 6%，P<0.001）、胸部（降低 4%，P<0.001）和胸部和腹部（降低 14%，P<0.001）CT 扫描的有效剂量在多组分干预后均显著降低。各解剖区域的平均器官剂量降低幅度更大，为 8%至 43%。单独的审计反馈降低了高剂量扫描和平均剂量的比例，但观察到的剂量减少幅度较小。放射科医生对 CT 图像质量的满意度在所有时期都保持不变且很高。
对于影像机构，详细的 CT 辐射剂量反馈加上可操作的建议和质量改进教育可显著降低剂量，尤其是器官剂量。单独的审计反馈效果有限。
ClinicalTrials.gov 标识符：NCT03000751。
