1. RADIATION MONITORING STRATEGY IN EUROPE Guy FRIJA TORONTO, May 2013

2. Professor of Radiology and Consultant in Paris Hôpital Européen Georges Pompidou Oncologic, Cardiovascular and Trauma center

3. FACTS  European regulatory background  European heterogeneity  Referral Guidelines : underuse

4. EUROPEAN REGULATORY BACKGROUND  Euratom Directive, 1997 optimisation, DRL justification maintenance clinical audit  New BSS in preparation

5. EUROPEAN REGULATORY BACKGROUND  Into National Law  National Regulatory Body  HERCA

6. EUROPEAN HETEROGENEITY DOSE DATAMED 2, 2013  Heterogeneity in : Demographics, Equipments, Practices

8. 11 OECD-2012

13. COLLECTIVE DOSE

14.  UNSCEAR, 2008 World 1.9 mSv Australia 2.2 mSv USA 3.3 mSv  Europe, 2013 1.1 mSv

15. REFERRAL GUIDELINES  European survey by the ESR  Availability of RG (~ 70%)  Production: UK and France  Adopted and adaptated: others

16. EUROPEAN REFERRAL GUIDELINES  Evidence based  Almost 400 situations  Recommendations, textual format

18.  “ In Belgium we have referral guidelines; in fact, nobody really takes them into account ”…  “Referral guidelines for diagnostic imaging in general are not in use in Hungary ”…  “They are not used in the Netherlands ”…  “Although we have several official referral guidelines published (in Spain), they are not used generally speaking ”…  “In Italy the referral guidelines were published in 2004 by the Ministry of Health. Unfortunately they are not always followed in clinical practice ”…  “There is no official guide line enforcement in the State service in Ireland ”…  “In Germany, the guidelines are note routinely used ”…  “In France, there are guidelines, but they are not used ”…

19. CHANGE IN PARADIGM ProducingUsing

20. CHANGE IN PARADIGM Using EBM Producing EBM CDS

21. European Projects  ESR – CDS Project  ESR – ACR co-operation  ESR – HERCA co-operation

22. ESR – CDS PROJECT  Principle approved by the EC and by HERCA  RCR, SFR, ESR: common approach  NDSC and ACR experiences

23. ESR – CDS PROJECT  Initially limited to the top 10-20 clinical situations  Potentially extended to paediatric, cardiovascular and others…

24. ESR – ACR : Globalisation  MOU in 2013  Cross-relations in the professional field, including R.P. and CDS  Global Summitt

25. ESR – HERCA  Common understanding of the challenges  Shared strategies Justification: CDS Optimisation: CT Public awareness

26. New solutions : WHY ? Regulation only: failed  Fragmented approach - by topics - by stakeholders  Theories on behavioural changes

27. Total Quality Monitoring of RP  GPS Approach  Clinical audit  Public campaign … and regulation !!!

28. Total Quality Monitoring  G lobal All the steps All the stakeholders  P ersonalised Patient centric Clinical setting  S afe Justification Optimisation Technological improvements GPS

29. ALL THE STEPS G PS Protocol Examination Report Dose exposure Scheduling Risk factorJustification Order IT SUPPORT!!!!!

30. STAKEHOLDERS G PS

31. PERSONALISED G P S  Patient centric Individual risk-benefit No dose threshold

32. Individual Risk-Benefit GPSGPS Oncology Screening Prediction

33. PERSONALISED G P S  Dose recording management Tailored Clinically relevant

34. Tailored Dose recording Courtesy of Quaelum

35. TOTAL SAFETY MONITORING GP S  Avoid unnecessary tests  Record the Dose (CT)  Optimise the protocols  Track the perls  Optimise the equipments (CT)

36. DLP max. = 994 mGy.cm Wrong arm position

37. PERFORMANCE QUALITY CONTROL  Correct patient positioning Scout view Isocentre of the Gantry  Over scanning - Overlapping

38. CLINICAL AUDIT  Developing a model adapted to this global approach  Tool potentially useful

39. PUBLIC CAMPAIGN  Image Gently: behavioural changes  Paediatric campaign in Europe, with the ESPR

40. IMPORTANCE OF IT CDS Patient dataJustification Traceability Follow-up Dose recording Compliance DRL Audit Profiling CDS CPOE IT

41. STAKEHOLDERS  Medical board  Administrative staff  Radiographers  Radiologists  Medical physicists  IT department

42. SAFETY  Technological improvements CT dose reduction

43. CT Dose Reduction  New softwares : iterative reconstruction Dose decrease up to 70-90 % !!!!  Policy of Equipment upgrade Immediate Benefit !!!!!

44. TAKE HOME  Holistic approach  Patient centric  Appropriate IT tools

45. CONCLUSION Beyond dose exposure  The best use of imaging resources for the patients and the society benefits

46. THANK YOU!!!!