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The Emerging Problem of Patients’ Overexposure to Radiation, Capstone Project Example

Pages: 13

Words: 3693

Capstone Project

Abstract

This paper explores the emerging problem of patients’ overexposure to radiation as a result of diagnostic machinery, particularly the use of computer tomography (CT) scans. Indeed, with the increased use of radiation-based diagnostic equipment in patient diagnosis, risks related to excessive radiation (including cancer) have emerged.  There are two current problems associated with the use of CT scans: 1) high variation in the level of radiation released per scan; 2) the ordering of CT scans for patients where it is not needed.  In order to deal with this problem, medical scholars have proposed a number of solutions including decreased use of CT scanning equipment, use of alternative diagnostic equipment (where possible), and increased education of doctors and patients to understand risks inherent in the procedure.  This paper explores how more robust education initiatives, coupled with greater supervision at the hospital administrator and department head level, may help to reduce the number of unneeded CT scans.

Introduction

The issue regarding overutilization of imaging equipment in patient diagnosis is emerging as a key concern of patients and doctors alike. Indeed, although the use of imaging equipment facilitates the accurate diagnosis of illness; at the same time, it can expose patients to excessively high radiation levels, putting individuals at an increased risk for cancer. The problem has received increasing coverage in medical journals.  David Brenner and Eric Hall identified over use of computed tomography (CT) as a potential public health threat: Basing their analysis on the current number of CT scans in the United States; the authors conclude there is a strong case too many CT scans are being performed (Brenner & Hill, 2007).

Problem Statement

Looking at more specific studies on where the primary overutilization is occurring, the use of CT scans on children, particularly in emergency rooms, is particularly disconcerting.  Larson et al. analyzed hospital data from 1985-2008 regarding use of CT scans in pediatric emergency room visit. The researchers found the number of pediatric ED visits that included CT examination increased from .33 to 1.65 million over the time period, a 500% increase  (CAGR of 13.2 %) (Larson, Johnson, Schnell, Goske, Salisbury, Forman, 2011).  These findings are particularly worrisome because children are more vulnerable to radiation exposure.

With the literature pointing out potential excessive use of CT imaging technology, what does this mean at the patient level?  Smith-Bindman examines the issue and concludes that too many CT scans are being used for diagnosis in conditions that likely do not require the technology (Smith-Bindman, 2010).  She recommends new guidelines for the use of CT scans, as well as educating doctors about alternatives that can result in equally effective (Smith-Bindman, 2010). The literature supports the problem statement that there is currently a problem with the overuse of imaging technology, particularly CT scans, in patient care. I hope that through examining the underlying reasons for the increased use of imaging equipment that clinicians can be educated about this problem, more alternatives can be introduced to using CT scans, and the problem can ultimately be addressed at the patient and aggregate level.

In particular,  using  PICO methodology of patient, intervention, comparison, observation- the question I want to ask is: For an individual (patient) seeking a computed tomography (CT) scan (intervention), are there other imaging alternatives (comparison) that will provide similar diagnostic benefits (outcome)  without the same level of radiation?

Literature Review

The overutilization of imaging technology in patient diagnosis, particularly computed tomography (CT) scans, is an important medical issue with far-reaching consequences. Indeed, recent studies have revealed elderly Medicare recipients often times receiving two CT scans in one day, a practice with little medical benefit that puts individuals at higher risk for a number of diseases including cancer.  This paper will propose that the overuse of CT scans for diagnostic purposes is not only a problem that is widespread throughout the medical community, but it is also a problem that can be addressed through a number of solutions. In particular, greater government regulation of CT scanning, education initiatives for both doctors and patients, and improvements in scanning technology will all help to reduce excess radiation and disease incidence related to CT scan use.

Although medical studies chronicling problems associated with the overuse of radiation imaging, and in particular the use of CT, are not numerous, they present an existing problem that can be changed.  David Brenner and Eric Hall of Columbia University identified over use of CT scans as a dangerous, unaddressed public health threat in the United States.  Indeed, although CT scans are a common diagnostic procedure for a wide range of medical conditions, there are numerous inherent risks in the procedure due to its use of radiation.  In order to understand what risks the use of radiation introduces and estimates the risks to patients, the authors detail that a CT scan can have more than 200 times the radiation of a typical x-ray (Brenner & Hall, 2007). In addition, the authors employ methodology to estimate the risks presented by CT scans: Although the risks introduced on an individual level are rather small (risk of various cancers increases roughly 1-3% in individuals), when applied to the entire population, the increased risk of radiation is noticeable.  According to their model, the authors estimate that 1.5-2.0% of all cancer cases may be attributable to over use of CT scans (Brenner & Hall, 2007). While this percentage is small, when distributed over an increasing population, it represents a substantial public health issue that can be addressed through a number of measures.

There are two primary causes identified in the literature related to patient’s intake of excess radiation via CT scans: 1) Unnecessary diagnostic scans for patients who might not need them; 2) Dangerous levels or radiation given to patients due to a miscalibration of the machine or errors by radiological staff. The use of CT scans is unevenly distributed throughout the population:  Certain patient populations and those in emergency departments are more likely to receive CT scans than others. One of the main sub-populations at risk is children; this is not only because children’s cells replicate at a higher rate than older individuals and are thus at greater risk for radiation poisoning, but for the same reason (faster division of cells) they are also at a higher risk for some cancers.  In order to understand the utilization of CT scans with children, Larson et al. analyzed hospital data from 1985-2008 regarding use of CT scans in pediatric emergency room visit. The researchers found the number of pediatric ED visits that included CT examination increased from 330,000 to 1.65 million over the 23 year time period, a 500% increase (Larson, Johnson, Schnell, Goske, Salisbury, Forman, 2011). The authors pointed out that not only has the absolute number of scans increased, but the ratio has also increased showing that doctors are more willing to use CT scans on children, perhaps without realizing the risks and opportunities to use other diagnostic equipment.

In addition to the overuse of CT scans, errors in use of the CT machinery may also expose patients to unhealthy levels of radiation. Smith-Bindman et al. performed a study in which they tried to assess the level of radiation received by a patient at four medical institutions in San Francisco, California for a routine CT scan. The study’s authors found there was a 13-fold variation between the highest and lowest dose for each CT type a patient could receive at the four medical institutions (Smith-Bindman et.al, 2009).  Overall, the authors were unable to find a discernible pattern in the variance of radiation.  Taking the average estimates obtained from the radiation scans, the authors estimated that 1 in every 270 forty-year- old women undergoing a CT angigogram would likely develop cancer (Smith-Bindman et al., 2009).

After exploring the potential causal mechanisms behind excessive radiation exposure, the issue arises regarding the potential scope of this problem.  While a number of different estimates have emerged regarding the absolute risk CT scans pose to the general population, Berrington de Gonzalez et al. conducted research in order to estimate the potential cancer risks from CT scans performed in the year 2007. The authors estimated the number of different CT scans performed in the US in 2007 via using Medicare claims data and surveys of use across nearly 2,450 facilities in the US.  After correcting for the age and sex distribution in the population, the authors estimated that approximately 72 million CT scans were performed in 2007: The number of CT scans increased with age and were more prevalent for female patients (60%) than male patients (40%).  Overall, the authors estimated that 29,000 future cancer cases would result from the number of CT scans performed in 2007 (Berrington de Gonzálea et. al, 2007).  While the absolute number of cases is quite small compared to the general population of the United States (well below 1 percent), the number is quite substantial when compared to the number of new cancers diagnosed annually: Indeed, there were 1.4 million cases of cancer diagnosed in 2007, the authors estimate is roughly 2% all cancer cases diagnosed in that year. However, one must remember that the new incidence cases is distributed over a wide range of time, in this light, the risks added by CT scans is substantial.

With the origin, causes, and scope of the problem examined, this section will now turn to potential solutions for the situation. There are three primary solutions presented in the literature to address the problem related to overuse of CT scanners: 1) increased education for doctors and patients (focusing on communication between the two); 2) use of different, less powerful scanners; 3) reexamination of cost-benefit analysis of CT scans.  Lee et al. conduct a study gauging knowledge of the radiation levels and risks related to CT scans: The results showed that doctors and individuals both lacked a keen understanding of potential risks with only seven percent of patients knowing the risks associated with CT scans (Lee et al., 2004). With evidence that both doctors and patients could benefit from increased education in the area, Lee et al. posit that doctors more educated about the risks could also communicate them better to patients, who in turn, could make a more informed decision regarding the test.
Brenner and Hall address two other ways that the overuse of CT scans could be mitigated.  First, doctors can often times replace CT scans with alternative diagnostic methods that include ultrasonography and magnetic resource imaging (MRI) (Brenner &Hall, 2007).  Indeed, ultrasonography can be used successfully in the diagnosis of appendicitis, and MRI, while still not cost competitive with CT scans, is being explored as another means to prevent excess radiation.  Finally, clinicians would be well served reexamining when CT scans are truly necessary and when they are practiced merely as a function of defensive medication.  As Brenner and Lee (2007) state, in situations where patients truly need a CT scan, the diagnostic information gained from the CT scan far outweighs the risks involved.  However, if nearly 33% of CT scans currently performed are not needed, there is a robust area for further examination.

While the overuse of CT scans, and medical studies detailing the problem, are still in a nascent phase, this area is fecund for further research.  Indeed, the risks associated with excess CT scans presents palpable risks to children and adults alike in the form of excess radiation.  At the same time, unlike many medical problems, the solution set for this problem can be implemented at numerous points to reduce both supply and demand. Efforts to better education doctors and patients, the use of new equipment emitting less radiation, and a further review of existing practices can help ameliorate the problem.

Proposed Solution

There are a number of potential theories to help ameliorate the problem of overusing radiation equipment (CT scans) as a key diagnostic tool. Indeed, while many theories propose solutions that either work on reducing supply from the health  provider side or reducing demand on the consumer side, there is one theory that attempts to change the behavior of both parties: education initiatives that outline the risks and benefits of CT scans.  One might posit that education efforts are already robust, and thus, would not likely improve this problem.  However, the medical literature paints a dramatically different picture.

Lee et al. conducted a survey of clinicians and patients  regarding the potential risks and benefits of CT scans.  The study found that only seven percent of patients were given an explanation of potential risks associated with CT scans; in addition, all patients and most emergency department (ED) physicians and radiologists were unable to accurately estimate the dose for one CT scan compared with that for one chest radiograph  (Lee, Haims, Monico, Brink, & Forman, 2004). While the study had a limited sample size, it indicates that a problem might currently exist not only in clinicians understanding of potential dangers associated with CT scans, but also in what information they give to patients on the subject.  Baumann et al. conduct a study that shows a similar picture: The authors conduct a cross-sectional study of acute abdominal patients aged 18 and older asking them several questions related to radiation exposure and cancer risks emanating from CT scans.  The study found that while patients were more confident when CT scans were used in diagnosis, they had a poor understanding of radiation exposure and difficulty in remembering previous exposure (Baumann, Chen, Mills, Glaspey, Thompson, Jones & Farner, 2011).   These two studies indicate that general knowledge regarding CT scans and their impact could be improved in both the doctor and patient population.

With this point in mind, some clinicians have stated that CT scans are indispensible in certain conditions, particularly in emergency department diagnosis. There is inevitably truth in that statement, however, even in patients with higher risk for cancer or who have cancer, educational efforts could be expanded.  Hassan et al. conduct a cost-benefit analysis of using whole body CT scans, a common practice, in the detection of colon cancer (Hassan, Pickhardt, Laghi, Zullo, Kim, Iafrate, Di Giulo, & Morini, 2009).  The study found that whole-body scans offer little benefit to patients, while putting them at risk for greater radiation exposure in an already at-risk population.  The study shows how comparative effectiveness research can be a powerful educational tool to educate doctors regarding the economic and clinical tradeoffs.

While many theories have been proposed to help reduce unnecessary use of CT scans, education of patients and doctors would likely have a palpable impact on the problem.  Indeed, not only would more informed doctors be able to give patients clear explanations regarding the risks involved, but patients could, in many circumstances, be more proactive in making decisions about their care.

Solutions

The first solution focuses on educating patients regarding the risks associated with CT scans including the connection between excessive radiation and increased risks for cancer.  Education initiatives at the patient level should focus on giving adults undergoing CT scans information regarding the level of radiation and risks associated with the scan for diagnostic purposes; although CT scans are also used extensively in emergency care, the opportunity for education in those circumstances is limited.  Doctors in all departments, particularly radiology, will be targeted to understand risks associated with CT scan and the current level of CT scans ordered in each department.

The second main solution is to use alternative diagnostic methods (where possible) that do not require patient exposure to excessive radiation-this will also include examination of patient’s medical history to establish previous levels of radiation exposure. While there is inevitably an element of education in this solution, this part of solution focuses on hospital investment in alternative diagnostic equipment including MRI, ultrasound, or thermography technology.

Evaluation

In order to evaluate whether the solutions proposed have ameliorated the problem, there are several levels that need to be evaluated at the hospital level (Brenner & Hall, 2007).

At the macro level (entire hospital), there are a number of metrics to be evaluated.  First, the most important metric is the total number of CT scans performed in the hospital compared to historical levels of CT scans performed at the hospital and against benchmark hospitals of similar size located in the region. While this metric will provide a rough estimation whether the interventions have worked, as an absolute number, it will also need to be measured against patient volume to be calibrated correctly.

In addition to examining aggregate number of CT scans performed, administrators will also need to disaggregate department use of CT scans to identify which departments still exhibit a high level of use.  In accordance with the literature, special emphasis should be given to CT scans in the pediatric, emergency, and gerontology departments- hospital departments that traditionally order the most scans (Larson, D.B. et al., 2011).  The combination of aggregate and department data should give a more complete picture to understand the problem.  The resources to analyze these metrics should already be place; a tally of CT scan data should be available via insurance claims forms and patient data already stored on hospital computers.  At the department level, this initiative will need buy in from department heads to compile and analyze existing data.

In addition to collecting statistics, hospital administration will also need to authorize a systematic case study of patient CT scans (Smith-Bindman, Lipson & Marcus, 2009).  The systematic case study will involve randomly selecting patients that received CT scans over the past quarter in the hospital.  Once the random hospital files are selected, hospital administrators and the chief medical officer will need to go over each file to determine whether the CT scan was appropriate based on the patient’s medical history and diagnosed medical condition.  Although this method is more qualitative in nature, it provides a “bottom-up” approach in addition to the “top-down” approach implemented via statistical methods.  Similar to the statistics exercise, the existing resources for this evaluation already exist in the hospital- it will merely be a reallocation exercise to produce and analyze the data.  The projected outcome of this deliverable is whether doctors appropriately ordered a CT scan in the case.

The third part of the evaluation is more complicated: the main question to be evaluated is whether the hospital has adequate investment in diagnostic equipment such as MRIs, ultrasound, or thermography technology (Brenner & Hall, 2007).

In order to evaluate whether this goal is met, hospital administrators should form a special sub-committee composed of administrators and doctors (e.g., radiation department) to assess the hospital’s needs and investment in this area.  The main outcome assessed is whether the hospital has acquired enough equipment and the use of that equipment.

The final assessment tool is the assessment of surveys given to patients who received a CT scan.  A random survey was given to patients who underwent CT scans checking whether they were given proper education regarding the risks associated with the procedure.  Department heads will be in charge of collection and analysis of the surveys; the outcome measured will be compliance with new regulations to educate all patients regarding the dangers associated with CT scans.

Dissemination Plan

As this project is aimed towards changing best practice standards in hospitals across the nation, I plan to disseminate the study’s findings at three different levels. First, I plan to disseminate the findings to the hospital I work at in order to change current practice (Brenner & Hall, 2007): In addition, I will also present findings personally to department heads as the literature has identified changing doctors’ behavior as a key catalyst in this problem (Smith-Bindman et al., 2009).  The results will not only be presented to hospital administration, but will also be presented to department heads, who in turn, will present results to doctors. Second, I  would seek to disseminate findings in two types of journals: 1) Hospital administration articles that focus on cutting costs and establishing best practices; 2) Radiology journals that focus on the excessive costs associated with CT scans.  Third, I would present findings at conferences aimed at hospital administration education.  In particular, I would target publishing findings in Health Affairs magazine; Health Affairs is a prominent journal that is typically read by policymakers due to the attenuated and easy-to-read format to impact policy (Otten, 1992).

Conclusion

This paper has examined the problem of excess radiation in the use of diagnostic radiation equipment, particularly CT scans.  There are two current problems associated with the use of CT scans: 1) high variation in the level of radiation released per scan; 2) the ordering of CT scans for patients where it is not needed.  In order to deal with this problem, medical scholars have proposed a number of solutions including decreased use of CT scanning equipment, use of alternative diagnostic equipment (where possible), and increased education of doctors and patients to understand risks inherent in the procedure.  This paper explored how more robust education initiatives, coupled with greater supervision at the hospital administrator and department head level, may help to reduce the number of unneeded  CT scans.  Although the paper’s recommendations were based at the hospital level, they could also be useful in the promulgation of state or federal regulations regarding diagnostic equipment.

References 

Baumann, B.M., Chen, E.H., Mills, A.M., Glaspey, L.G., Thompson, N.M., Jones, M.J., Farner, M.C. (2011).  Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure.  Annals of Emergency Medicine.  58(1), 1-7.

Berrington de González A, Mahesh M, Kim K-P; et al (2009). Projected cancer risks from computed tomographic scans performed in the United States in 2007.Archives of Internal Medicine, 169(22), 2071-2077.

Brenner, D & Hall, E (2007). Computed Tomography- An increasing source of radiation exposure. New England Journal of Medicine.  357 2277-2284. 

Larson, D.B., Johnson, L.W., Schnell, B.M., Goske, M.J., Salisbury, S.R., Forman, H.P. (2011). Rising use of CT in Child Visits to the emergency eepartment in the United States 1995-2008. Radiology.  259(3), 793-801.

Lee, C.I., Haims, A.H., Monico, E.P., Brink, J.A. & Forman, H.A. (2004).   Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks.  231 (2), 393-398.

Otten, A.L. (1992).  The influence on the mass media on health policy. Health Affairs, 11(4), 111-118. 

Smith-Bindman R, Lipson J, Marcus R, et al. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine. 169 (22), 2078–86.

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