1) A multi-hospital healthcare system evaluated the impact of an Image Gently and Image Wisely campaign to reduce unnecessary medical radiation from CT scans. 2) Results showed that between 2004-2014, CT usage decreased across all age groups while ultrasound usage increased, with MRI usage only increasing in pediatrics. By 2014 ultrasound became the predominant modality in pediatrics. 3) CT protocol optimization between 2011-2014 resulted in reduced radiation dose per scan for most head, chest, and abdomen/pelvis studies.

1. Evaluating an Image Gently and Image
Wisely Campaign in a Multihospital
Healthcare System

2. Kevin Fernandes, BS
Todd Miller, MD
Terry L. Levin, MD
Alan H. Schoenfeld, MS
E. Stephen Amis, Jr., MD

3. Background:
• 2% of cancers/year in the US may be attributable to medical
radiation from CT1
• 29,000 patients in the US/year may develop malignancy due to
CT2
• The potential life time risk of radiation induced malignancy is
heightened in children1,3,4
• Cancer incidence increases by 24% in exposed children5
• Image Gently (2007) & Image Wisely (2009) guidelines aim to
reduce exposure to unnecessary medical radiation

4. Objective:
Reduce CT use by educating our
referring medical community and
optimizing CT protocols

5. 1. Obtained number of imaging examinations (CT ,magnetic
resonance imaging (MR) and ultrasound (US) performed between
January 1, 2004 and December 31, 2014 using RIS system
a) 865,879 imaging procedures
2. Obtained patient age & unique number of patients seen yearly
using Clinical Looking Glass (Montefiore EHR search engine)
a) 4,508,030 patients
3. Stratified the annual volume of modality specific imaging
examinations by patient age: <20 years old, 20-39 years old, 40-59
years old.
4. Obtained dose as measured by volume CT dose index (CTDIvol)
from the Dose Index Registry (National Radiology Data Bank) for
each CT examination from January 1st 2011 to December 31, 2014.
Methods & Data:

6. Initiatives of the Image Gently/ImageWiselyCampaign
Multidepartmental
educational
initiative Review and
optimize CT
protocols
Interdepartmental
research to
evaluate efficacy of
alternative imaging
modalities for
specific clinical
scenarios

7. Educational Initiative:
• Annual Interdepartmental lecture series
Appropriate indications for ordering a CT
Medical radiation; potential risk versus benefit
Provided to departments of Emergency Medicine, Surgery, Pediatrics,
Family Medicine, and Internal Medicine including subspecialty groups
• Medical student Radiology clerkship formal lecture
Radiation safety
• Mandatory annual educational modules
incoming housestaff and CT technologists
• Encourage use of modifiedCT protocols
low dose, pediatric specific and focused CT imaging

8. • A decrease in CT % usage and a compensatory rise in US % usage was demonstrated in each
age category.
• MR %usage increased only in the pediatric population.
Results:
0%
10%
20%
30%
40%
50%
60%
70%
80%
CT-2004CT-2014 US-2004 US-2014 MR-
2004
MR-
2014
CT-2004CT-2014 US-2004 US-2014 MR-
2004
MR-
2014
CT-2004CT-2014 US-2004 US-2014 MR-
2004
MR-
2014
CT-2004CT-2014 US-2004 US-2014 MR-
2004
MR-
2014
Total Population <20 y/o 20-39 y/o 40-59 y/o
%ofTotalImaging
Imaging as a % of Total Imaging by Age 2004-2014

9. Between 2011 and 2014* a reduction or stabilization of radiation dose was demonstrated.
* CT dose data was not available prior to 2011
Results:
0
10
20
30
40
50
60
July-Dec2011
Jan-June2012
July-Dec2012
Jan-June2013
July-Dec2013
Jan-June2014
July-Dec2014
MEDIANCTDIVOL/SCAN(MGY)
YEAR
Median CTDI per Scan
CT HEAD BRAIN W IVCON
CT HEAD BRAIN WO IVCON
CT CHEST W IVCON
CT CHEST WO IVCON
CT ABDOMEN PELVIS W IVCON
CT ABDOMEN PELVIS WO IVCON

10. • From 2004-2009, CT composed the majority of all imaging
studies across all age groups.
• After initiation of the campaign, CT use declined across all
age groups with a corresponding increase in US use (2010-
2014). MR use was unchanged.
• By 2014, US became the predominant imaging modality in the
pediatric age group
• By 2014, CT protocol optimization resulted in reduced
dose/scan for most studies.
• Educational campaigns are effective in changing the ordering
patterns of referring physicians and complement the
radiologist’s efforts to decrease dose
Findings:

11. 1. Brenner DJ, Hall EJ. Computed tomography--an increasing source of
radiation exposure. The New England journal of medicine.
2007;357(22):2277-2284.
2. Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer
risks from computed tomographic scans performed in the United States in
2007. Archives of internal medicine. 2009;169(22):2071-2077.
3. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-
induced fatal cancer from pediatric CT. AJR. American journal of
roentgenology. 2001;176(2):289-296.
4. Brody AS, Frush DP, Huda W, Brent RL, American Academy of Pediatrics
Section on R. Radiation risk to children from computed tomography.
Pediatrics. 2007;120(3):677-682.
5. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680,000 people
exposed to computed tomography scans in childhood or adolescence:
data linkage study of 11 million Australians. BMJ. 2013;346:f2360.
References: