Choosing Wisely Campaign: ACR’s Recommendations Accurate!

The Choosing Wisely Campaign is a recent initiative of the ABIM Foundation to encourage physicians and patients to take a second look at tests and procedures that may be unnecessary… and potentially, harmful. The American College of Radiology was one of nine US specialty societies that developed lists of the Five Things Physicians and Patients Should Question.

See the ACR’s outlined recommendations of the procedures that should be utilized less in radiology practices:

• Imaging for uncomplicated headache, absent specific risk factors for structural disease or injury.
• Imaging for suspected pulmonary embolism (PE) without moderate or high pretest probability of PE.
• Preoperative chest x-rays without specific reasons due to patient history or physical exam.
• CT to evaluate suspected appendicitis in children until ultrasound is considered an option.
• Follow-up imaging for adnexal (reproductive tract) cysts 5 cm or less in diameter in reproductive-age women.

All five of these recommendations are ones that I would certainly agree with. In fact, I wouldstrongly emphasize that CT for possible pulmonary embolism in young women be avoided unless there are clinical criteria which raise suspicion to at least moderate level. Additionally, ultrasound is a great modality to check for appendicitis in children, especially those that are young and/ or thin.

For the full recommendations by the ACR, please see here. Remember, informed patients are an integral part of the Choosing Wisely campaign.

Professional Recommendations for Low Dose Optimization

I came across an article from the Journal of the American College of Radiology on a number of recommendations for optimizing patient dose level in chest CT scans, the third most commonly performed CT exam in the country.

As the article points out, the lungs are an ideal organ for low dose radiation CT scans. Some of the recommendations offered include:

  • Doctors should ensure that patients understand all instructions fully, including when to hold their breath and how much movement is permitted.
  • Automated exposure control (AEC) techniques should be used as often as possible to assist with breathing in children and adults.
  • Iterative reconstruction techniques reduce radiation dose exposure substantially and should be performed as often as possible.
  • Centering patients in the gantry isocenter avoids excessive scan length dose. Additionally, CT scans should only be performed on the area of indication.
  • Reading thicker sections ensures CT scan radiation risk reduction, while allowing fine details to be examined in nosier, thicker sections. This procedure should be utilized by imaging professionals.
  • All CT scans should be done for a clinical and justifiable reason.

The tips and pointers in this article are all good tools for lowering patient radiation dose in chest CT. We have found that the use of iterative reconstruction is a big help – lowering dose by as much as 40%. Now that model based iterative reconstruction has recently become available in the USA (GE’s version is called VEO), we can look for dose reductions of more like 80%!