Radiation safety: ‘Who’s minding the children?’

The overuse of imaging and its potential harms in pediatric settings—especially exposure of children to ionizing radiation from CT scans—is so pressing an issue that it must be addressed urgently and systematically, according to the authors of a Viewpoint article published online in JAMA Pediatrics.

In issuing their call to vigilance in pediatric imaging, Alan Schroeder, MD, of Stanford and James Duncan, MD, of Washington University in St. Louis note that Medicare requires imaging providers to abide by national standards on radiation safety in order to get paid for their services.

“That such oversight exists for care provided to elderly patients but not for children, who are significantly more vulnerable to the harms of ionizing radiation, is an injustice,” Schroeder and Duncan write.

The authors acknowledge that information campaigns such as Image Gently have succeeded in putting radiation safety top of mind for parents as well as healthcare providers, adding that real gains have been demonstrated and documented at children’s hospitals.

Still, they point out, a lot of imaging is provided outside the hospital setting—and, even within the sphere of pediatric hospitals, too much variability persists.

“Although this variability may be brought to attention through research investigations, the individual hospitals remain anonymous and accountability remains virtually nonexistent,” they write. “If hospitals A and B see similar patients but hospital A performs a head CT on every child with minor traumatic brain injury while hospital B is much more selective, how is hospital A accountable for the excessive imaging? How can this information be made transparent and available to patients and families?”

What’s the holdup?  

Schroeder and Duncan propose the Joint Commission as a key player in the movement to increase radiation safety in pediatrics.

The Joint Commission may need some coaxing. Earlier this year, the authors point out, the organization developed a framework for a national patient-safety goal (NPSG) on CT imaging in children, consistent with its ongoing NPSG work.

The pediatric goal contained several elements, including implementing evidence-based practices for CT imaging of pediatric patients with minor head trauma, implementing criteria for appropriate use of dual-phase CT examinations (with and without contrast) of the head and chest, and monitoring and establishing goals for compliance for both elements.

The Joint Commission subsequently conducted a field review and invited comments—and is now reconsidering whether a NPSG is, in fact, needed for this part of healthcare, Schroeder and Duncan report.  

What sorts of comments prompted the reconsideration? The authors aren’t sure.  

“Is the healthcare profession not yet ready to tackle overuse of imaging in a systematic fashion?” they write. “Comments about proposed [national patient-safety goals] have not been publicly shared, but we can speculate on the concerns.”

Their best guesses are that the proposed goal elements may not have adequately addressed the bulk of unnecessary CT imaging, overuse metrics tend not to be popular and debate persists over the so-called linear no-threshold model for estimating malignancy risk from radiation exposure.

CT metrics matter

The evidently stalled NPSG effort notwithstanding, Schroeder and Duncan call for the refinement or establishment of benchmarks to move pediatric imaging closer to answering for its imaging decisions.

“If accountability is to be increased, then a need exists to develop CT imaging metrics that can be easily measured, interpreted and disseminated,” they write before citing as an example achievable benchmarks of care (ABCs) initially proposed in 1999.

Such ABCs have already been developed and disseminated in pediatrics: The median children’s hospital obtainment of chest radiographs in bronchiolitis in 2012, for example, was 53 percent, the authors note, while the ABC was set at 32 percent based on high-performing hospitals.

“ABCs certainly could be applied to imaging for a variety of conditions, including head injury and trauma in general, abdominal pain/possible appendicitis, sinus disease and afebrile seizures,” they write. “The existence of multicenter research networks and large databases such as Pediatric Health Information Systems, the National Trauma Data Bank and those found in various integrated health care systems should make the establishment of ABCs for these common conditions feasible.”

Once established, they add, programmatic accreditation could be contingent on adequate performance in relation to these benchmarks.

Image Gently can only go so far

Issuing their call for overuse of imaging in children to be addressed “urgently and systematically,” Schroeder and Duncan write that—owing not only to radiation exposure itself but also downstream interventions that can follow unnecessary exams—the time has come to demand standardization of care and accountability of results.

“Advocacy efforts that call for appropriate and safe imaging in children have been a tremendous help but will only go so far,” they write before pressing the Joint Commission to forge ahead with its work eyeing appropriate utilization and radiation safety in pediatric imaging.

“Comprehensive organizations such as the Joint Commission, which have influence over all hospitals and imaging centers where children receive care—not just the children’s hospitals from which data are currently extracted—have tremendous potential to ensure that children get the imaging they do need while avoiding the imaging they do not.”

Earlier this year, two pediatric radiologists debated the usefulness of Image Gently in the online pages of the Journal of the American College of Radiology.