BENEFITS OF CT AND HOW LEADING ACADEMIC INSTITUTIONS ARE COMMUNICATING RISK TO PATIENTS. James A. Brink, MD Massachusetts General Hospital
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1 BENEFITS OF CT AND HOW LEADING ACADEMIC INSTITUTIONS ARE COMMUNICATING RISK TO PATIENTS James A. Brink, MD Massachusetts General Hospital
2 BENEFITS OF CT Standard Axial Imaging Superb Anatomic Depiction Head to toe Innumerable Diagnoses Confirmed Excluded
3 Invasion of Gastrohepatic Ligament, Stomach HEPATOMA
4 IMPACTED STONE Edema in Lt. Trigone
5 SIGMOID VOLVULUS Bird s Beak
6 BENEFITS OF MDCT New uses of CT imaging CT Virtual Colonoscopy CT Angiography of Head, Pulmonary Vessels, Aorta and Extremities Coronary CT Angiography
7 9 MM TUBULAR ADENOMA: ASC COLON ACRIN
8 MUCOSAL LABELING Missed patch tool Shows colonic wall not displayed w/ autocenterline Useful in cases w/ limited distention Courtesy of Perry Pickhardt, M.D.
9 Motorcycle Accident? Arterial Injury
10 Motorcycle Accident Occluded Left Anterior Tibial Artery
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12 MPLE OF CORONARY ARTERY WITH A HEAVY PLAQUE DEN C t fk i J h M D
13 Courtesy of Kevin Johnson M D
14 Triple Rule-Out: Coronary Artery Disease Aortic Dissection Pulmonary Emboli
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17 RADIATION EXPOSURE FROM CT Collective dose to population rising High radiation dose per examination Compared to plain radiography Increasing number of indications Increasing availability Easier to perform Faster
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19 BENEFITS VS. RISKS Published in Radiology online before print, February 5, 2013
20 BENEFITS VS. RISKS year olds (n=21,947) CT scan between 2003 and 2007 Mortality status and f/u interval (~5.5 yrs) BIER VII estimates for radiation-induced cancer incidence and death Published in Radiology online before print, February 5, 2013
21 BENEFITS VS. RISKS Published in Radiology online before print, February 5, 2013
22 BENEFITS VS. RISKS Published in Radiology online before print, February 5, 2013
23 Unnecessary CT scans are not beneficial
24 ACR APPROPRIATENESS CRITERIA* Topic Variant Test AC 167 Topics, > 800 Variants 7578 Topics / Variants / Tests: CT is listed as a possible test in 931 / 7578 (12%) *March, 2010
25 ACR APPROPRIATENESS CRITERIA - HEMATEMESIS
26 BLUNT ABDOMINAL TRAUMA Unstable Patient
27 BLUNT ABDOMINAL TRAUMA Stable Patient -- Hematuria
28 BLUNT ABDOMINAL TRAUMA Stable Patient No Hematuria CT is listed as 7, 8, or 9 in 285 / 931 (31%) CT is listed as 9 in 115 / 931 (12%)
29 APPROPRIATE UTILIZATION In high risk patients, CT should be avoided when an ultrasound or MRI is of comparable diagnostic utility
30 RLQ PAIN: PREGNANT (26 WKS) Appendicoliths
31 RLQ PAIN: PREGNANT (32 WKS) Ureteral Calculus
32 RLQ PAIN IN PREGNANCY (W/ FEVER, WBCS) US and MR are more appropriate than CT for RLQ pain in pregnant women
33 ASYMPTOMATIC PATIENTS CT Colonography American Cancer Society endorsed CTC as screening test for colorectal cancer in 2008 Anticipated life-time risk of colorectal cancer = 5 6% Potential risk of radiation-induced cancer from CTC* 50 years 0.14% 70 years 0.07% (Benefit >> Risk) *Brenner DJ, Georgsson MA. Gastroenterology 2005:129;
34 COMMUNICATING RISK TO PATIENTS What do patients want to know? Informed consent? What are academic centers doing? Resources Image Gently / Image Wisely
35 Patient advocacy groups: Cincinnati Children s, Yale New-Haven Hospital Open-ended questions Sample questions suggested by Image Gently/ Wisely
36 SAMPLE QUESTIONS FROM IMAGE GENTLY/WISELY
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39 COMMUNICATING RISK TO PATIENTS What do patients want to know? Informed consent? What are academic centers doing? Resources Image Gently / Image Wisely
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42 COMMUNICATING RISK TO PATIENTS What do patients want to know? Informed consent? What are academic centers doing? Resources Image Gently / Image Wisely
43 SOUTHERN NEW HAMPSHIRE MEDICAL CTR.
44 STEPS TO MINIMIZE EXPOSURE Informed consent/patient notification Informed consent/patient notification on all pediatric patients and adults < 40 yrs for CT Chest / Abd Risk-- CT study with a dose of 10 msv may be associated with an increase in the possibility of fatal cancer of approximately 1 chance in Contrast Allergy-Quoted risk of one death per 250,000 administrations. Courtesy of Steven Birnbaum, MD
45 RADIATION MONITORING AND ALERTS Steven Birnbaum, M.D. Radiation Safety Officer Southern New Hampshire Medical Center
46 STEPS TO MINIMIZE EXPOSURE Courtesy of Steven Birnbaum, MD
47 RADIATION PROTECTION STRATEGIES Education of Clinicians and Radiologists Technical Modifications Algorithms for Utilizing Non-ionizing Modalities Identification of Patients w/ Elevated Exposure 5 scans in patients < 40yrs with benign conditions ( 50 msv) Notification of referring physician Notation in the patient s imaging record (like contrast allergy) Investigation of Extreme Exposure Further history and counseling for exposures > 100 msv Courtesy of Steven Birnbaum, MD
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49 AJR 2011; 196: Memorial Sloan Kettering MEMORIAL SLOAN KETTERING
50 TYPICAL RISK COMMUNICATION STRATEGIES Paternalistic approach I m your doctor and I know what is best for you. Quality assurance approach We have the latest equipment and the lowest dose Risk comparisons approach Number of CXR equivalents, transatlantic flights, etc. Risk numerology Dose in mgy, msv, etc.
51 SUGGESTIONS FOR IMPROVED BENEFIT & RISK COMMUNICATION Give simple clear messages 3 key messages Use numbers and visuals Richter Scale of Risk Dialog with the patient Address trade-offs Evaluate patient understanding
52 BOSTON CHILDREN S, HARVARD MEDICAL SCHOOL
53 10 y-old receiving bone scan 1 in 2,500 excess risk of cancer death from radiation 1 in 550 will naturally die of cancer (22%)
54 UNIVERSITY OF MICHIGAN
55
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57 UNIVERSITY OF CALIFORNIA AT SAN FRANCISCO
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59 COMMUNICATING RISK TO PATIENTS What do patients want to know? What are academic centers doing? Informed consent? Resources Image Gently / Image Wisely
60 *accessed on February 18, 2013
61
62 BENEFITS/RISK PRIMER Primer presentation on RadiologyInfo.org
63
64 BENEFITS OF CT AND HOW LEADING ACADEMIC INSTITUTIONS ARE COMMUNICATING RISK TO PATIENTS James A. Brink, MD Massachusetts General Hospital
Dose-equivalent equivalent = absorbed
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