KLAS study explores CT dose through provider best practices and perceptions of vendors.

1.2 mSv1 CTA of the carotid arteries, demonstrating the benefit of iDose4 when attempting to evaluate the small vascular structures in the area of the distal carotids. 328 mAs, 120 kVp, iDose4 level 3.

Concerns about patients being overexposed to radiation dose have come to a head in recent years. Providers are looking for ways to retain diagnostic image quality while reducing the dose patients are exposed to while being scanned.

This past year, KLAS Enterprises, a health care IT, medical equipment, and services research firm, focused their annual CT performance study on the very hot topic of dose. KLAS interviewed 119 technologists, directors, and physicians about their plans to address this issue. Providers were asked to share their dose reduction best practices. They also were asked what role vendors are playing in their plans and which vendor they perceived to be the low-dose leader.

The following article presents a summary of the findings from the report CT 2011: Focused on Dose. The vendors included in this study are GE, Philips, Siemens, and Toshiba. The best practices and perceptions of providers are shared here.

Who Is the Low-dose Leader?

Kirk Ising, Strategic Operations Director, KLAS

In this study, KLAS found that all four vendors have been successful in developing technology to reduce dose; however, some have been more successful than others at getting the word out about their low-dose initiatives. When providers were asked who they perceive to be the low-dose CT leader, they indicated that GE and Siemens are leading the battle for low-dose mind share. Seventy percent of study participants picked either Siemens or GE as the leader in low-dose imaging (38%, Siemens; 32%, GE). Toshiba and Philips split the remainder evenly, both with 15% of providers picking them as the low-dose leader.

Providers identified several factors that made a vendor the low-dose leader in their eyes. The majority of providers picked their incumbent vendor (see Figure 1). But it also became apparent that a vendor’s dose reduction technology, typically their iterative reconstruction tools, was a key ingredient. Also important to providers was the vendor’s involvement with training and education.

Eye on Iterative Reconstruction

Iterative reconstruction tools continue to be the biggest and most positively regarded dose-reduction tools that vendors offer. All four vendors now have a system. GE’s ASiR has received many positive reviews from customers. Several said that they have seen noticeable dose reduction while maintaining the image quality their radiologists expect.

Holly Wallace, Senior Research Analyst, KLAS

Siemens IRIS also was seen as a major benefit by many of their customers. “We are just getting started, but I would say one of the best things we did was add the IRIS dose-reducing package. It has really helped out; we calculate that we have reduced dose by about 25% to 30%, and we still get pretty good images,” a lead technologist reported. Siemens also has their CareDose 4D and SAFIRE, continuing to expand their dose reduction technology offerings.

Philips iDose was mentioned by only a few customers, but those customers were happy with iDose’s capabilities in dose reduction. Toshiba’s Adaptive Iterative Dose Reduction (AIDR) software was just recently approved as a part of their new Aquilion PRIME CT scanner, and it comes as a standard feature with the system. However, as the KLAS report went to press, the Toshiba product was still pending FDA approval and AIDR was not mentioned by any Toshiba customers.

While KLAS has heard only positive feedback on the functionality of iDose and ASiR, customers of both Philips and GE have mentioned that it is expensive to upgrade to that technology. This can be a difficult line for vendors and providers to walk. As vendors invest their R&D dollars into new dose-reduction technology, they must decide if they should charge providers for the updates and, if so, how much. Providers, on the other hand, who want that focus on R&D feel that charging for this new technology is like paying extra for seatbelts on a car.

Beyond dose-reducing technology, vendors also are working on ways to monitor the CT dose so that comparisons can be made and improvements tracked.

Education and Setting Protocols

Adaptive Iterative Dose Reduction (AIDR) and NEMA XR 25 Dose Check Software are standard features on Toshiba?s Aquilion PRIME.

A vendor’s commitment to education and support when it comes to reducing dose is clearly something providers want. Here is what one radiology director had to say, “We have really made some progress in regard to lowering dose, but we thought the vendor would be more involved than they have been. They sold us the machine, but they haven’t done anything else for us in terms of updating us or educating us further. We have a strong team, so we still feel we are ahead of the game, but we are on our own; the vendor has moved on.”

Many providers in the course of the study shared the sentiment. Vendors play an important role in the ability of providers to be successful as they strive to make CT imaging safer for patients. Unfortunately, many providers have had to find ways to reduce dose by themselves. Vendors are the system experts, but they differ in their ability to help providers learn about and make use of dose-saving technology. Part of the equation is how well the vendor is able to help providers adapt current protocols to better utilize the dose-reduction technologies that are available on the vendor’s system. The other part of the equation is education for both physicians and technologists.

KLAS found that Siemens and GE customers were fairly pleased with their vendor’s efforts to help them to adapt existing protocols to better utilize dose-reducing technologies. Philips and Toshiba customers were less pleased with their vendor in this regard. While all the vendors do reasonably well at helping with protocols, dose education is not done nearly as well, especially for physicians.

Figure 1

Providers believed that all four vendors could improve physician education, especially because physicians can have the most impact on the reworking of protocols and are the ultimate judges of image quality. As far as education for technologists, GE, Siemens, and Toshiba are all middle-of-the-road vendors. However, Philips customers rated the company lowest for both physician and technologist education. One Philips customer said, “Philips’ training programs need to be improved. [They need] to offer continual training and education for staff members because they are always advancing their technologies. Philips really does not come through on that for us. They could even build that into their contract.”

Although vendors may offer amazing technology and have training available for providers, they need to go the extra mile and proactively engage their customers on this issue. The communication piece seems to be missing so that providers aren’t aware of what education and training they can get from their vendor. Help providers be aware of it, fit it into their schedule, and place emphasis on it.

Best Practices for Dose Reduction

The GE Discovery CT750 HD with ASiR.

While software and equipment are critical parts of the low dose equation, the efforts of the imaging department are also critical. Most providers said they are doing several things to lower dose, but the most common best practice that providers mentioned was reworking protocols. For many, this was best achieved using a team approach, involving physicists, radiologists, and technologists. Some indicated that they held periodic meetings with the key stakeholders to review their progress. When it comes to reworking protocols, the focus was often on specifically setting the protocols for different heights and weights of patients.

One radiology director described their facility’s approach: “We absolutely look at every scan protocol and always try to optimize those. We do that continually as new revisions of software come out and as new systems come out. We have definitely looked at every protocol and tracked each one from before we implemented it to after we implemented it to make sure we are seeing benefits. We have one person who leads that effort in our CT department. He is a very savvy and technically oriented technologist. He works very closely with our vendor, the radiologists, and our QA coordinator in doing that.”

Renal computed tomography angiography (CTA) using IRIS software from Siemens Healthcare.

Fifteen percent of providers mentioned utilizing ACR guidelines as a measuring stick and have focused their efforts around meeting or bettering those guidelines. Only 7% of respondents looked to their vendors for education and collaboration, and 5% mentioned trying to find alternate nondose modalities. Many of the providers who shared best practices were still in the initial stages of forming a response to dose concerns. As internal processes become more developed, providers will be able to push their CT systems to their full capabilities.

Several providers mentioned tracking dose as their best practice to reduce dose, but most providers are currently doing it by storing a screenshot in the PACS. The data are static and cannot really be used in a meaningful way, beyond manual review. The way dose is currently tracked also makes it difficult to record in the patient record. While providers feel it is critically important to track dose in the EMR, only 10% of respondents were actually doing it.

Critical Conclusions

GE and Siemens have risen to be the industry low-dose leaders by offering their iterative reconstruction technology, and also their involvement and help with adjusting protocols to reduce dose. Philips and Toshiba are playing catch-up. All vendors need to work on educating providers, especially physicians.

Current best practices include reworking protocols, using ACR guidelines to benchmark progress, and creating collaborations with key stakeholders to review efforts. Ten percent of providers indicated that they were tracking dose, and many more wanted to but felt they did not have the tools necessary to do so.

Concerns about CT dose have proliferated in the media, and the public and regulatory agencies are now paying attention. Vendors and providers must work together to achieve the best images with the least amount of dose possible.

Kirk Ising is Strategic Operations Director at KLAS and report author. Holly Wallace is Senior Research Analyst at KLAS.