International variation in radiation dose for computed tomography examinations: Prospective cohort study

Rebecca Smith-Bindman, Yifei Wang, Philip Chu, Robert Chung, Andrew J. Einstein, Jonathan Balcombe, Mary Cocker, Marcos Das, Bradley N. Delman, Michael Flynn, Robert Gould, Ryan K. Lee, Thomas Yellen-Nelson, Sebastian Schindera, J Anthony Seibert, Jay Starkey, Saravanabavaan Suntharalingam, Axel Wetter, Joachim E. Wildberger, Diana L Miglioretti

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Abstract

OBJECTIVE To determine patient, institution, and machine characteristics that contribute to variation in radiation doses used for computed tomography (CT). DESIGN Prospective cohort study. SETTING Data were assembled and analyzed from the University of California San Francisco CT International Dose Registry. PARTICIPANTS Standardized data from over 2.0 million CT examinations of adults who underwent CT between November 2015 and August 2017 from 151 institutions, across seven countries. MAIN OUTCOME MEASURES Mean effective doses and proportions of high dose examinations for abdomen, chest, combined chest and abdomen, and head CT were determined by patient characteristics (sex, age, and size), type of institution (trauma center, care provision 24 hours per day and seven days per week, academic, private), institutional practice volume, machine factors (manufacturer, model), country, and how scanners were used, before and after adjustment for patient characteristics, using hierarchical linear and logistic regression. High dose examinations were defined as CT scans with doses above the 75th percentile defined during a baseline period. RESULTS The mean effective dose and proportion of high dose examinations varied substantially across institutions. The doses varied modestly (10-30%) by type of institution and machine characteristics after adjusting for patient characteristics. By contrast, even after adjusting for patient characteristics, wide variations in radiation doses across countries persisted, with a fourfold range in mean effective dose for abdomen CT examinations (7.0-25.7 mSv) and a 17-fold range in proportion of high dose examinations (4-69%). Similar variation across countries was observed for chest (mean effective dose 1.7-6.4 mSv, proportion of high dose examinations 1-26%) and combined chest and abdomen CT (10.0-37.9 mSv, 2-78%). Doses for head CT varied less (1.4-1.9 mSv, 8-27%). In multivariable models, the dose variation across countries was primarily attributable to institutional decisions regarding technical parameters (that is, how the scanners were used). CONCLUSIONS CT protocols and radiation doses vary greatly across countries and are primarily attributable to local choices regarding technical parameters, rather than patient, institution, or machine characteristics. These findings suggest that the optimization of doses to a consistent standard should be possible.

Original languageEnglish (US)
Article numberk4931
JournalBMJ (Online)
Volume364
DOIs
StatePublished - Jan 1 2019

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Cohort Studies
Tomography
Prospective Studies
Radiation
Abdomen
Thorax
Institutional Practice
Head
San Francisco
Trauma Centers
Private Practice
Sex Characteristics
Registries
Linear Models
Logistic Models

ASJC Scopus subject areas

  • Medicine(all)

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International variation in radiation dose for computed tomography examinations : Prospective cohort study. / Smith-Bindman, Rebecca; Wang, Yifei; Chu, Philip; Chung, Robert; Einstein, Andrew J.; Balcombe, Jonathan; Cocker, Mary; Das, Marcos; Delman, Bradley N.; Flynn, Michael; Gould, Robert; Lee, Ryan K.; Yellen-Nelson, Thomas; Schindera, Sebastian; Seibert, J Anthony; Starkey, Jay; Suntharalingam, Saravanabavaan; Wetter, Axel; Wildberger, Joachim E.; Miglioretti, Diana L.

In: BMJ (Online), Vol. 364, k4931, 01.01.2019.

Research output: Contribution to journalArticle

Smith-Bindman, R, Wang, Y, Chu, P, Chung, R, Einstein, AJ, Balcombe, J, Cocker, M, Das, M, Delman, BN, Flynn, M, Gould, R, Lee, RK, Yellen-Nelson, T, Schindera, S, Seibert, JA, Starkey, J, Suntharalingam, S, Wetter, A, Wildberger, JE & Miglioretti, DL 2019, 'International variation in radiation dose for computed tomography examinations: Prospective cohort study', BMJ (Online), vol. 364, k4931. https://doi.org/10.1136/bmj.k4931
Smith-Bindman, Rebecca ; Wang, Yifei ; Chu, Philip ; Chung, Robert ; Einstein, Andrew J. ; Balcombe, Jonathan ; Cocker, Mary ; Das, Marcos ; Delman, Bradley N. ; Flynn, Michael ; Gould, Robert ; Lee, Ryan K. ; Yellen-Nelson, Thomas ; Schindera, Sebastian ; Seibert, J Anthony ; Starkey, Jay ; Suntharalingam, Saravanabavaan ; Wetter, Axel ; Wildberger, Joachim E. ; Miglioretti, Diana L. / International variation in radiation dose for computed tomography examinations : Prospective cohort study. In: BMJ (Online). 2019 ; Vol. 364.
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abstract = "OBJECTIVE To determine patient, institution, and machine characteristics that contribute to variation in radiation doses used for computed tomography (CT). DESIGN Prospective cohort study. SETTING Data were assembled and analyzed from the University of California San Francisco CT International Dose Registry. PARTICIPANTS Standardized data from over 2.0 million CT examinations of adults who underwent CT between November 2015 and August 2017 from 151 institutions, across seven countries. MAIN OUTCOME MEASURES Mean effective doses and proportions of high dose examinations for abdomen, chest, combined chest and abdomen, and head CT were determined by patient characteristics (sex, age, and size), type of institution (trauma center, care provision 24 hours per day and seven days per week, academic, private), institutional practice volume, machine factors (manufacturer, model), country, and how scanners were used, before and after adjustment for patient characteristics, using hierarchical linear and logistic regression. High dose examinations were defined as CT scans with doses above the 75th percentile defined during a baseline period. RESULTS The mean effective dose and proportion of high dose examinations varied substantially across institutions. The doses varied modestly (10-30{\%}) by type of institution and machine characteristics after adjusting for patient characteristics. By contrast, even after adjusting for patient characteristics, wide variations in radiation doses across countries persisted, with a fourfold range in mean effective dose for abdomen CT examinations (7.0-25.7 mSv) and a 17-fold range in proportion of high dose examinations (4-69{\%}). Similar variation across countries was observed for chest (mean effective dose 1.7-6.4 mSv, proportion of high dose examinations 1-26{\%}) and combined chest and abdomen CT (10.0-37.9 mSv, 2-78{\%}). Doses for head CT varied less (1.4-1.9 mSv, 8-27{\%}). In multivariable models, the dose variation across countries was primarily attributable to institutional decisions regarding technical parameters (that is, how the scanners were used). CONCLUSIONS CT protocols and radiation doses vary greatly across countries and are primarily attributable to local choices regarding technical parameters, rather than patient, institution, or machine characteristics. These findings suggest that the optimization of doses to a consistent standard should be possible.",
author = "Rebecca Smith-Bindman and Yifei Wang and Philip Chu and Robert Chung and Einstein, {Andrew J.} and Jonathan Balcombe and Mary Cocker and Marcos Das and Delman, {Bradley N.} and Michael Flynn and Robert Gould and Lee, {Ryan K.} and Thomas Yellen-Nelson and Sebastian Schindera and Seibert, {J Anthony} and Jay Starkey and Saravanabavaan Suntharalingam and Axel Wetter and Wildberger, {Joachim E.} and Miglioretti, {Diana L}",
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AU - Smith-Bindman, Rebecca

AU - Wang, Yifei

AU - Chu, Philip

AU - Chung, Robert

AU - Einstein, Andrew J.

AU - Balcombe, Jonathan

AU - Cocker, Mary

AU - Das, Marcos

AU - Delman, Bradley N.

AU - Flynn, Michael

AU - Gould, Robert

AU - Lee, Ryan K.

AU - Yellen-Nelson, Thomas

AU - Schindera, Sebastian

AU - Seibert, J Anthony

AU - Starkey, Jay

AU - Suntharalingam, Saravanabavaan

AU - Wetter, Axel

AU - Wildberger, Joachim E.

AU - Miglioretti, Diana L

PY - 2019/1/1

Y1 - 2019/1/1

N2 - OBJECTIVE To determine patient, institution, and machine characteristics that contribute to variation in radiation doses used for computed tomography (CT). DESIGN Prospective cohort study. SETTING Data were assembled and analyzed from the University of California San Francisco CT International Dose Registry. PARTICIPANTS Standardized data from over 2.0 million CT examinations of adults who underwent CT between November 2015 and August 2017 from 151 institutions, across seven countries. MAIN OUTCOME MEASURES Mean effective doses and proportions of high dose examinations for abdomen, chest, combined chest and abdomen, and head CT were determined by patient characteristics (sex, age, and size), type of institution (trauma center, care provision 24 hours per day and seven days per week, academic, private), institutional practice volume, machine factors (manufacturer, model), country, and how scanners were used, before and after adjustment for patient characteristics, using hierarchical linear and logistic regression. High dose examinations were defined as CT scans with doses above the 75th percentile defined during a baseline period. RESULTS The mean effective dose and proportion of high dose examinations varied substantially across institutions. The doses varied modestly (10-30%) by type of institution and machine characteristics after adjusting for patient characteristics. By contrast, even after adjusting for patient characteristics, wide variations in radiation doses across countries persisted, with a fourfold range in mean effective dose for abdomen CT examinations (7.0-25.7 mSv) and a 17-fold range in proportion of high dose examinations (4-69%). Similar variation across countries was observed for chest (mean effective dose 1.7-6.4 mSv, proportion of high dose examinations 1-26%) and combined chest and abdomen CT (10.0-37.9 mSv, 2-78%). Doses for head CT varied less (1.4-1.9 mSv, 8-27%). In multivariable models, the dose variation across countries was primarily attributable to institutional decisions regarding technical parameters (that is, how the scanners were used). CONCLUSIONS CT protocols and radiation doses vary greatly across countries and are primarily attributable to local choices regarding technical parameters, rather than patient, institution, or machine characteristics. These findings suggest that the optimization of doses to a consistent standard should be possible.

AB - OBJECTIVE To determine patient, institution, and machine characteristics that contribute to variation in radiation doses used for computed tomography (CT). DESIGN Prospective cohort study. SETTING Data were assembled and analyzed from the University of California San Francisco CT International Dose Registry. PARTICIPANTS Standardized data from over 2.0 million CT examinations of adults who underwent CT between November 2015 and August 2017 from 151 institutions, across seven countries. MAIN OUTCOME MEASURES Mean effective doses and proportions of high dose examinations for abdomen, chest, combined chest and abdomen, and head CT were determined by patient characteristics (sex, age, and size), type of institution (trauma center, care provision 24 hours per day and seven days per week, academic, private), institutional practice volume, machine factors (manufacturer, model), country, and how scanners were used, before and after adjustment for patient characteristics, using hierarchical linear and logistic regression. High dose examinations were defined as CT scans with doses above the 75th percentile defined during a baseline period. RESULTS The mean effective dose and proportion of high dose examinations varied substantially across institutions. The doses varied modestly (10-30%) by type of institution and machine characteristics after adjusting for patient characteristics. By contrast, even after adjusting for patient characteristics, wide variations in radiation doses across countries persisted, with a fourfold range in mean effective dose for abdomen CT examinations (7.0-25.7 mSv) and a 17-fold range in proportion of high dose examinations (4-69%). Similar variation across countries was observed for chest (mean effective dose 1.7-6.4 mSv, proportion of high dose examinations 1-26%) and combined chest and abdomen CT (10.0-37.9 mSv, 2-78%). Doses for head CT varied less (1.4-1.9 mSv, 8-27%). In multivariable models, the dose variation across countries was primarily attributable to institutional decisions regarding technical parameters (that is, how the scanners were used). CONCLUSIONS CT protocols and radiation doses vary greatly across countries and are primarily attributable to local choices regarding technical parameters, rather than patient, institution, or machine characteristics. These findings suggest that the optimization of doses to a consistent standard should be possible.

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