The document discusses Belgium's high level of radiation exposure from medical diagnostics compared to neighboring countries. A strategic committee was formed with subcommittees to develop guidelines, increase awareness, and create incentives to reduce radiation levels through accreditation and optimization of practices. The subcommittees are working to standardize prescription forms, calculate patient radiation doses, and create a clinical audit tool to improve quality while avoiding excessive costs and paperwork. The overall goal is to lower radiation exposure levels through coordinated guidelines and incentives.

1. Reduction of irradiation of the
Belgian population
which progress has been made?
Guy Marchal

2. Strategic committee
starting point
Over the last years the level of irradiation of the
Belgian population has increased dramatically
due to diagnostic examinations.
As a result Belgium is one of the world champions
in this regard.

3. Overall objectives
• The first objective of the strategic committee is to reduce
this growth and to bring the irradiation level back to the
level of the neighboring countries .
• The second objective of the strategic committee is to
improve the quality of the examinations performed.
• Pure cost savings can not be the goal. The money saved will
be needed to preserve the quality of the diagnostic imaging
service. (equipment that is needed but not fully used)
• In addition it is important to keep up with the fast
technological evolution in medical imaging. The new
technologies offer not only new diagnostic possibilities, but
are often also less invasive and potentially less irradiating.

4. Strategy
• To act efficiently, a well defined long term strategy is
needed. This strategy is defined by a strategic
committee.
• The strategic committee is composed by
representatives of different parties and analyses
potential difficulties that could arise during the
practical implementation and suggests possible
solutions.
• The strategic committee refers to three subcommittees
for the practical implementation of the overall
objectives. Members of the strategic committee are
also part of the core of the different subcommittees.

5. Subcommittee “guidelines”
• The task of this subcommittee is to formulate
guidelines for the proper use of ionizing
irradiation for diagnostic purposes.
• This group is composed by members of the FOD,
the RIZIV, the FANC, the Consilium Radiologicum,
BELNUC, representatives of other user groups,
and the Belgian society of hospital Physicists.
• Current members of the committee : Guy Marchal
(president), Lodewijk Van Bladel, Wim Janssens,
Aldo Perissino and Nils Reynders-Frederix

6. Current situation
• Initial document:
existing French guidelines (2005)
• Actualization (2010) by
– Sections of KBVR
– BELNUC
• Radiology :
Differences between Flemish and French versions. Correlation
needed as well as complete rewriting of Flemish version.
Nuclear medicine:
Document not ready yet
• Further correlation between two documents probably not
feasible.

7. Current situation
• Initial document:
existing French guidelines (2005)
• Actualization (2010) by
– Sections of KBVR
– BELNUC
• Radiology :
Differences between Flemish and French versions. Correlation
needed as well as complete rewriting of Flemish version.
Nuclear medicine:
Document not ready yet
• Further correlation between two documents probably not
feasible.
Potential negative financial impact of guidelines remains a major problem
for many to fully collaborate!

8. Proposal for a new prescription order
• containing
– Demographic patient data
– Clinical information
– Information needed for proper diagnosis or
therapy expected from imaging study
– Suggested examination
– Referring physician
– Expected irradiation dose?

9. Proposal for a new prescription order
• Expected from radiologist
– Prescription accepted or changed
– Argumentation if changed
– Registration number of equipment used
– Responsible radiologist
– Level of accreditation imaging department?

10. Subcommittee “sensibilisation”
• The main objective is to increase the awareness of both the
radiologist as well as the prescribing physician for the high level of
diagnostic irradiation of the Belgian population by a sensibilisation
campaign.
• The ultimate goal of this sensibilisation campaign is to reduce the
overall irradiation dose for the population
• This group is composed by members of the FOD, the RIZIV, the
FANC, the Consilium Radiologicum, BELNUC, representatives of
other user groups, representatives of the GP’s, “hoge
gezondheidsraad”,…
• Current members of the committee : Aldo Perissino and Wim
Janssens (president), Lodewijk Van Bladel, Guy Marchal, Nils
Reynders-Frederix, Hilde Engels, Jan Eyckmans and Corinne Souwer.

11. Current situation
• Sensibilisation of public and patients
• Information, per specialism about the level of diagnostic
irradiation in their region
• Publicity about the guidelines
• Relevant individual information of each prescribing physician
• A change in the procedures and criteria for reimbursement

12. Current situation
• Sensibilisation of public and patients
• Information, per specialism about the level of diagnostic
irradiation in their region
– The level of irradiation per inhabitant
– The relative contribution of each specialism in the
prescription of the irradiating examinations
– The examinations that contribute most to the irradiation per
specialism
• Publicity about the guidelines
• Relevant individual information of each prescribing physician
• A change in the procedures and criteria for reimbursement

13. Current situation
• Sensibilisation of public and patients
• Information, per specialism about the level of diagnostic
irradiation in their region
• Publicity about the guidelines
– Integration in the software of the medical record management (2010 )
– Didactic brochures (2011)
– Involvement of medical faculties, high schools medical technology
• Relevant individual information of each prescribing physician
• A change in the procedures and criteria for reimbursement

14. Current situation
• Sensibilisation of public and patients
• Information, per specialism about the level of diagnostic
irradiation in their region
• Publicity about the guidelines
• Relevant individual information of each prescribing physician
– The principle of precaution
– The unnecessary examinations
– The useless prescriptions
– The erroneous prescriptions
• A change in the procedures and criteria for reimbursement

15. Current situation
• Sensibilisation of public and patients
• Information, per specialism about the level of diagnostic
irradiation in their region
• Publicity about the guidelines
• Relevant individual information of each prescribing physician
• A change in the procedures and criteria for reimbursement
– Standardized prescription form
– Electronic communication of reports towards referring physicians
– The patient management software must allow to calculate the
cumulative patient dose (2010 ).
– Possibility for radiologists to change requests in function of existing
guidelines (2010).

16. Subcommittee
accreditation and optimalisation
• This workgroup will try to formulate incentives to
motivate the hospitals to promote dose reduction.
These incentives are needed to support the use of the
guidelines and to reach the strategic goals.
• This group is composed by members of the FOD, the
mutualities, the RIZIV, the FANC, the Consilium
Radiologicum, medical physicists.
• Current members of the committee : Guy Marchal
(president), Aldo Perisinno, Greet Haelterman, An
Fremout, Pascal Meeus, Nils Reynders-Frederix,
Françoise Malchair, Julien Struyven, Denis Tack and
Hilde Bosmans.

17. Financial incentives?
• Alternative for current mainly “fee for service
model” towards a larger degree of
forfaitarisation?
• Financial co-responsabilisation of prescribers?
• Extra financial compensation in function of
quality parameters.
• ….

18. Current situation
• Optimalisation both by improved techniques
as well as better training and optimal use
• Collaboration between FANC, physicists, academia,
radiologists, via working groups, round tables, etc..
• Accreditation
– COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC RADIOLOGY
PRACTICES (IAEA)

19. Proposed audit tool
COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC
RADIOLOGY PRACTICES:
A TOOL FOR QUALITY IMPROVEMENT
QUALITY ASSURANCE AUDIT
FOR DIAGNOSTIC RADIOLOGY IMPROVEMENT AND LEARNING (QUAADRIL)
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA, 2010

20. COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC
RADIOLOGY PRACTICES
Document contains 4 chapters:
– QUALITY MANAGEMENT PROCEDURES AND
INFRASTRUCTURE
– PATIENT RELATED PROCEDURES
– TECHNICAL PROCEDURES
– EDUCATION, TRAINING AND RESEARCH PROGRAMS

21. COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC
RADIOLOGY PRACTICES
• document contains 4 chapters:
– QUALITY MANAGEMENT PROCEDURES AND
INFRASTRUCTURE
– PATIENT RELATED PROCEDURES
– TECHNICAL PROCEDURES
– EDUCATION, TRAINING AND RESEARCH PROGRAMS
The intention is to reduce this audit book towards a for Belgium
clinically relevant accreditation instrument (2010)

22. Conclusion
• There is a clear demand from the authorities to
reduce the number of useless examinations
• There is a positive evolution in the collaboration
between the FANC, the radiologists and the
medical physicists working towards a more
clinically relevant approach.
• What has to be avoided is too much emphasis on
administration and paperwork, useless expenses,
and no time left for better patient care.