CT DOSE Collaboratory

Quality Improvement Clinical Trial

Official title:

CT Dose Optimization and Standardization Endeavor (DOSE) Collaboratory

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03000751
• Other study ID #: RSB-181191
• Secondary ID: R01CA181191
• Status: Completed
• Phase: N/A
• Start date: July 2016
• Est. completion date: December 2020

Study information

• Verified date: March 2024
• Source: University of California, San Francisco
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This is a pragmatic stepped-wedge cluster randomized controlled trial to explore variation in doses used for diagnostic CT by pooling radiation dose data across diverse healthcare delivery systems. To compare different strategies for lowering and optimizing dose and identify the barriers and facilitators to implementing successful dose optimization strategies and standardizing practice.

Description:

The investigators are using a stepped-wedge cluster randomized controlled trial, collecting radiation dose information on CT from across all collaborating health care facilities, and leading several different interventions to optimize dose across facilities. In addition to collecting the CT radiation dose data, and using these results to provide feedback to the collaborating health care facilities, they will be conducting surveys of several individuals at each site, including key informants, such as lead radiologists, technologists, and medical physicist, and radiology administrators. They will compare and identify facilitators and barriers (assessed through surveys of participating facilities) associated with successful and failed implementation of dose optimization.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 864080
• Est. completion date: December 2020
• Est. primary completion date: December 2020
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: N/A to 99 Years

Eligibility

Inclusion Criteria:

• Diagnostic CT scans of the head, chest, and/or abdomen/pelvis performed within the study period

Exclusion Criteria:

• non-diagnostic scans that are not of the head, chest, and/or abdomen/pelvis

Related Conditions & MeSH terms

• Ionizing Radiation Exposure
• Quality Improvement

Intervention

Other:
• Simple Audit Report
The simple audit provides comparison and feedback on radiation doses.
• Multi-Component Intervention
The multi-component intervention gives tailored feedback on needed changes plus guidance using quality improvement methods that facilitate organizational change. Provides access to experts, detailed audit, collaborative calls, and site visits (as needed).
• In-Person Meeting
Collaborator meeting with an emphasis on quality improvement.

Locations

Country	Name	City	State
n/a

Sponsors (25)

Lead Sponsor

Collaborator

University of California, San Francisco

Albert Einstein Healthcare Network, Center for Diagnostic Imaging, Children's Mercy Hospital Kansas City, City of Hope Medical Center, Community Health Network, East Texas Medical Center Regional Healthcare System, Emory University, Henry Ford Health System, Huntsville Hospital Health System, Maastricht University Medical Center, Mount Sinai Hospital, New York, National Cancer Institute (NCI), Nicklaus Children's Hospital f/k/a Miami Children's Hospital, Olive View-UCLA Education & Research Institute, Oxford University Hospitals NHS Trust, San Francisco VA Health Care System, St. Joseph Hospital of Orange, St. Luke's International Hospital, Japan, Universität Duisburg-Essen, University Hospital, Basel, Switzerland, University of California, Davis, University of California, Irvine, University of California, San Diego, University of Virginia

References & Publications (159)

171. Morgan KL, Rubin, D.L. Rerandomization to improve covariate balance in experiments. The Annals of Statistics 2012;40:1263-82.

1990 Recommendations of the International Commission on Radiological Protection. Ann ICRP. 1991;21(1-3):1-201. No abstract available. — View Citation

Aarons G, Horowitz J, Dlugosz L, Ehrhart M. The role of organizational processes in dissemination and implementation researach. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and Implementation Research in Health: Translating Science to Practice. New York: Oxford University Press, Inc.; 2012:

American Association of Physicists in Medicine Position Statement on Radiation Risks from Medical Imaging Procedures. 2011

American Association of Physicists in Medicine. AAPM Report No 96. The Measurement, reporting and management of radiation dose in CT, Report of AAPM Task group 23 of the Diagnostic Imaging Council CT Committee. College Park, MD: American Association of Physicists in Medicine; 2008

Amis ES Jr, Butler PF, Applegate KE, Birnbaum SB, Brateman LF, Hevezi JM, Mettler FA, Morin RL, Pentecost MJ, Smith GG, Strauss KJ, Zeman RK; American College of Radiology. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol. 2007 May;4(5):272-84. doi: 10.1016/j.jacr.2007.03.002. — View Citation

Baker LC, Atlas SW, Afendulis CC. Expanded use of imaging technology and the challenge of measuring value. Health Aff (Millwood). 2008 Nov-Dec;27(6):1467-78. doi: 10.1377/hlthaff.27.6.1467. — View Citation

Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet. 2004 Jan 31;363(9406):345-51. doi: 10.1016/S0140-6736(04)15433-0. — View Citation

Berrington de Gonzalez A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, Land C. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009 Dec 14;169(22):2071-7. doi: 10.1001/archinternmed.2009.440. — View Citation

Bhargavan M, Sunshine JH. Utilization of radiology services in the United States: levels and trends in modalities, regions, and populations. Radiology. 2005 Mar;234(3):824-32. doi: 10.1148/radiol.2343031536. Epub 2005 Jan 28. — View Citation

Board of Radiation Effects Research Division on Earth and Life Sciences National Research Council of the National Academies. Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2 Washington, D.C.: The National Academies Press; 2006.

Bogdanich W. After stroke scans, patients face serious risk. New York TImes. July 31, 2010, 2010.

Bogdanich W. Listing of articles published in the NY TImes over the last year in the 'Radiation Boom' series by Walt Bogdanich examine issues arising from the increasing use of medical radiation and the new technologies that deliver it. . http://topics.nytimes.com/top/news/us/series/radiation_boom/index.html?ref=health.

Boone JM, Brunberg JA. Computed tomography use in a tertiary care university hospital. J Am Coll Radiol. 2008 Feb;5(2):132-8. doi: 10.1016/j.jacr.2007.07.008. — View Citation

Boone JM, Hendee WR, McNitt-Gray MF, Seltzer SE. Radiation exposure from CT scans: how to close our knowledge gaps, monitor and safeguard exposure--proceedings and recommendations of the Radiation Dose Summit, sponsored by NIBIB, February 24-25, 2011. Radiology. 2012 Nov;265(2):544-54. doi: 10.1148/radiol.12112201. Epub 2012 Sep 10. — View Citation

Boone JM, Kwan AL, Seibert JA, Shah N, Lindfors KK, Nelson TR. Technique factors and their relationship to radiation dose in pendant geometry breast CT. Med Phys. 2005 Dec;32(12):3767-76. doi: 10.1118/1.2128126. — View Citation

Boone JM. Dose spread functions in computed tomography: a Monte Carlo study. Med Phys. 2009 Oct;36(10):4547-54. doi: 10.1118/1.3223634. — View Citation

Boone JM. Method for evaluating bow tie filter angle-dependent attenuation in CT: theory and simulation results. Med Phys. 2010 Jan;37(1):40-8. doi: 10.1118/1.3264616. — View Citation

Boone JM. Multidetector CT: opportunities, challenges, and concerns associated with scanners with 64 or more detector rows. Radiology. 2006 Nov;241(2):334-7. doi: 10.1148/radiol.2412060169. No abstract available. — View Citation

Boutis K, Cogollo W, Fischer J, Freedman SB, Ben David G, Thomas KE. Parental knowledge of potential cancer risks from exposure to computed tomography. Pediatrics. 2013 Aug;132(2):305-11. doi: 10.1542/peds.2013-0378. Epub 2013 Jul 8. — View Citation

Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008743. doi: 10.1002/14651858.CD008743.pub2. — View Citation

Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001 Feb;176(2):289-96. doi: 10.2214/ajr.176.2.1760289. — View Citation

Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, Lubin JH, Preston DL, Preston RJ, Puskin JS, Ron E, Sachs RK, Samet JM, Setlow RB, Zaider M. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A. 2003 Nov 25;100(24):13761-6. doi: 10.1073/pnas.2235592100. Epub 2003 Nov 10. — View Citation

Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007 Nov 29;357(22):2277-84. doi: 10.1056/NEJMra072149. No abstract available. — View Citation

Brody AS, Frush DP, Huda W, Brent RL; American Academy of Pediatrics Section on Radiology. Radiation risk to children from computed tomography. Pediatrics. 2007 Sep;120(3):677-82. doi: 10.1542/peds.2007-1910. — View Citation

Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006 Nov 8;6:54. doi: 10.1186/1471-2288-6-54. — View Citation

Caoili EM, Cohan RH, Ellis JH, Dillman J, Schipper MJ, Francis IR. Medical decision making regarding computed tomographic radiation dose and associated risk: the patient's perspective. Arch Intern Med. 2009 Jun 8;169(11):1069-71. doi: 10.1001/archinternmed.2009.139. No abstract available. — View Citation

Catalano C, Francone M, Ascarelli A, Mangia M, Iacucci I, Passariello R. Optimizing radiation dose and image quality. Eur Radiol. 2007 Dec;17 Suppl 6:F26-32. doi: 10.1007/s10406-007-0225-6. — View Citation

Center for Medicare and Medicaid Services. Section 135(b)of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) mandates an Appropriate Use of Imaging Services demonstration project. The goal of the demonstration is to collect data regarding physician use of advanced diagnostic imaging services to determine the appropriateness of services in relation to established criteria and physician peers. 2010; http://www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=CMS1222075.

Chaillet N, Dube E, Dugas M, Audibert F, Tourigny C, Fraser WD, Dumont A. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol. 2006 Nov;108(5):1234-45. doi: 10.1097/01.AOG.0000236434.74160.8b. — View Citation

Cho RC, Chu P, Smith-Bindman R. Second trimester prenatal ultrasound for the detection of pregnancies at increased risk of Trisomy 18 based on serum screening. Prenat Diagn. 2009 Feb;29(2):129-39. doi: 10.1002/pd.2166. — View Citation

Conference of Radiation Control Program Directors. Nationwide evaluation of x-ray trends (NEXT): Tabulation and graphical summary of 2000 survey of computed tomography . Frankfort, KY2007.

Crain AL, Solberg LI, Unutzer J, Ohnsorg KA, Maciosek MV, Whitebird RR, Beck A, Molitor BA. Designing and implementing research on a statewide quality improvement initiative: the DIAMOND study and initiative. Med Care. 2013 Sep;51(9):e58-66. doi: 10.1097/MLR.0b013e318249d8a4. — View Citation

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. — View Citation

Damschroder LJ, Banaszak-Holl J, Kowalski CP, Forman J, Saint S, Krein SL. The role of the champion in infection prevention: results from a multisite qualitative study. Qual Saf Health Care. 2009 Dec;18(6):434-40. doi: 10.1136/qshc.2009.034199. — View Citation

Duncan JR, Evens RG. Using information to optimize medical outcomes. JAMA. 2009 Jun 10;301(22):2383-5. doi: 10.1001/jama.2009.827. No abstract available. — View Citation

Feigal DW Jr. FDA public health notification: reducing radiation risk from computed tomography for pediatric and small adult patients. Int J Trauma Nurs. 2002 Jan-Mar;8(1):1-2. doi: 10.1067/mtn.2002.121511. No abstract available. — View Citation

Foley WD, Mallisee TA, Hohenwalter MD, Wilson CR, Quiroz FA, Taylor AJ. Multiphase hepatic CT with a multirow detector CT scanner. AJR Am J Roentgenol. 2000 Sep;175(3):679-85. doi: 10.2214/ajr.175.3.1750679. — View Citation

Fontaine P, Flottemesch TJ, Solberg LI, Asche SE. Is consistent primary care within a patient-centered medical home related to utilization patterns and costs? J Ambul Care Manage. 2011 Jan-Mar;34(1):10-9. doi: 10.1097/JAC.0b013e3181ff7019. — View Citation

Fortney J, Enderle M, McDougall S, Clothier J, Otero J, Altman L, Curran G. Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics. Implement Sci. 2012 Apr 11;7:30. doi: 10.1186/1748-5908-7-30. — View Citation

Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013 Jun;103(6):e38-46. doi: 10.2105/AJPH.2013.301299. Epub 2013 Apr 18. — View Citation

Glasgow RE, Klesges LM, Dzewaltowski DA, Estabrooks PA, Vogt TM. Evaluating the impact of health promotion programs: using the RE-AIM framework to form summary measures for decision making involving complex issues. Health Educ Res. 2006 Oct;21(5):688-94. doi: 10.1093/her/cyl081. Epub 2006 Aug 31. — View Citation

Glasgow RE. RE-AIMing research for application: ways to improve evidence for family medicine. J Am Board Fam Med. 2006 Jan-Feb;19(1):11-9. doi: 10.3122/jabfm.19.1.11. — View Citation

Goldstein RB, Bree RL, Benson CB, Benacerraf BR, Bloss JD, Carlos R, Fleischer AC, Goldstein SR, Hunt RB, Kurman RJ, Kurtz AB, Laing FC, Parsons AK, Smith-Bindman R, Walker J. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med. 2001 Oct;20(10):1025-36. doi: 10.7863/jum.2001.20.10.1025. — View Citation

Greevy R, Lu B, Silber JH, Rosenbaum P. Optimal multivariate matching before randomization. Biostatistics. 2004 Apr;5(2):263-75. doi: 10.1093/biostatistics/5.2.263. — View Citation

Greevy RA Jr, Grijalva CG, Roumie CL, Beck C, Hung AM, Murff HJ, Liu X, Griffin MR. Reweighted Mahalanobis distance matching for cluster-randomized trials with missing data. Pharmacoepidemiol Drug Saf. 2012 May;21 Suppl 2(0 2):148-54. doi: 10.1002/pds.3260. — View Citation

Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. J Gen Intern Med. 2006 Feb;21 Suppl 2(Suppl 2):S14-20. doi: 10.1111/j.1525-1497.2006.00357.x. — View Citation

Haggstrom DA, Quale C, Smith-Bindman R. Differences in the quality of breast cancer care among vulnerable populations. Cancer. 2005 Dec 1;104(11):2347-58. doi: 10.1002/cncr.21443. — View Citation

Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology. 2009 Aug;252(2):332-45. doi: 10.1148/radiol.2522082335. — View Citation

Hertz-Picciotto I. Breast Cancer and the Environment: A Life Course Approach. Dec 2011 2011.

Hoeffner EG, Case I, Jain R, Gujar SK, Shah GV, Deveikis JP, Carlos RC, Thompson BG, Harrigan MR, Mukherji SK. Cerebral perfusion CT: technique and clinical applications. Radiology. 2004 Jun;231(3):632-44. doi: 10.1148/radiol.2313021488. Epub 2004 Apr 29. — View Citation

Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med. 2006 Jul-Aug;4(4):317-26. doi: 10.1370/afm.570. — View Citation

Huberman MM. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage Publications; 1994.

Huda W, Magill D, He W. CT effective dose per dose length product using ICRP 103 weighting factors. Med Phys. 2011 Mar;38(3):1261-5. doi: 10.1118/1.3544350. — View Citation

Huda W, Nickoloff EL, Boone JM. Overview of patient dosimetry in diagnostic radiology in the USA for the past 50 years. Med Phys. 2008 Dec;35(12):5713-28. doi: 10.1118/1.3013604. — View Citation

Hysong SJ. Meta-analysis: audit and feedback features impact effectiveness on care quality. Med Care. 2009 Mar;47(3):356-63. doi: 10.1097/MLR.0b013e3181893f6b. — View Citation

Image Gently. 2009. http://www.pedrad.org/associations/5364/ig/index.cfm?page=369. Accessed Feb 13, 2009.

Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care. 2006 Dec;15(6):433-6. doi: 10.1136/qshc.2006.018549. — View Citation

Jilcott S, Ammerman A, Sommers J, Glasgow RE. Applying the RE-AIM framework to assess the public health impact of policy change. Ann Behav Med. 2007 Oct;34(2):105-14. doi: 10.1007/BF02872666. — View Citation

Kagay CR, Quale C, Smith-Bindman R. Screening mammography in the American elderly. Am J Prev Med. 2006 Aug;31(2):142-9. doi: 10.1016/j.amepre.2006.03.029. — View Citation

Keegan J, Miglioretti DL, Gould R, Donnelly LF, Wilson ND, Smith-Bindman R. Radiation dose metrics in CT: assessing dose using the National Quality Forum CT patient safety measure. J Am Coll Radiol. 2014 Mar;11(3):309-15. doi: 10.1016/j.jacr.2013.10.009. — View Citation

Kerlikowske K, Smith-Bindman R, Abraham LA, Lehman CD, Yankaskas BC, Ballard-Barbash R, Barlow WE, Voeks JH, Geller BM, Carney PA, Sickles EA. Breast cancer yield for screening mammographic examinations with recommendation for short-interval follow-up. Radiology. 2005 Mar;234(3):684-92. doi: 10.1148/radiol.2343031976. — View Citation

Land CE. Studies of cancer and radiation dose among atomic bomb survivors. The example of breast cancer. JAMA. 1995 Aug 2;274(5):402-7. — View Citation

Leconte I, Feger C, Galant C, Berliere M, Berg BV, D'Hoore W, Maldague B. Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density. AJR Am J Roentgenol. 2003 Jun;180(6):1675-9. doi: 10.2214/ajr.180.6.1801675. — View Citation

Lee CI, Haims AH, Monico EP, Brink JA, Forman HP. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology. 2004 May;231(2):393-8. doi: 10.1148/radiol.2312030767. Epub 2004 Mar 18. — View Citation

Levin DC, Rao VM, Parker L, Frangos AJ, Sunshine JH. Bending the curve: the recent marked slowdown in growth of noninvasive diagnostic imaging. AJR Am J Roentgenol. 2011 Jan;196(1):W25-9. doi: 10.2214/AJR.10.4835. — View Citation

Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR, Coleman B, DePriest P, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach M, Patel MD, Platt LD, Puscheck E, Smith-Bindman R; Society of Radiologists in Ultrasound. Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q. 2010 Sep;26(3):121-31. doi: 10.1097/RUQ.0b013e3181f09099. — View Citation

Linet MS, Kim KP, Rajaraman P. Children's exposure to diagnostic medical radiation and cancer risk: epidemiologic and dosimetric considerations. Pediatr Radiol. 2009 Feb;39 Suppl 1(Suppl 1):S4-26. doi: 10.1007/s00247-008-1026-3. Epub 2008 Dec 16. — View Citation

Loupatatzis C, Schindera S, Gralla J, Hoppe H, Bittner J, Schroder R, Srivastav S, Bonel HM. Whole-body computed tomography for multiple traumas using a triphasic injection protocol. Eur Radiol. 2008 Jun;18(6):1206-14. doi: 10.1007/s00330-008-0875-3. Epub 2008 Feb 13. — View Citation

Marin D, Nelson RC, Guerrisi A, Barnhart H, Schindera ST, Passariello R, Catalano C. 64-section multidetector CT of the upper abdomen: optimization of a saline chaser injection protocol for improved vascular and parenchymal contrast enhancement. Eur Radiol. 2011 Sep;21(9):1938-47. doi: 10.1007/s00330-011-2139-x. Epub 2011 May 11. — View Citation

Marin D, Nelson RC, Rubin GD, Schindera ST. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011 Jul;197(1):33-41. doi: 10.2214/AJR.11.6755. — View Citation

Marin D, Nelson RC, Schindera ST, Richard S, Youngblood RS, Yoshizumi TT, Samei E. Low-tube-voltage, high-tube-current multidetector abdominal CT: improved image quality and decreased radiation dose with adaptive statistical iterative reconstruction algorithm--initial clinical experience. Radiology. 2010 Jan;254(1):145-53. doi: 10.1148/radiol.09090094. — View Citation

Marshall C, & Rossman, G.B. Designing Qualitative Research. 4th ed. Newbury Park: Sage Publications; 2006.

Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346:f2360. doi: 10.1136/bmj.f2360. — View Citation

Medicare Payment Advisory Commission. A Data Book: Healthcare Spending and the Medicare Program, June 2010.

Mettler FA Jr, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008 Jul;248(1):254-63. doi: 10.1148/radiol.2481071451. — View Citation

Miglioretti DL, Smith-Bindman R, Abraham L, Brenner RJ, Carney PA, Bowles EJ, Buist DS, Elmore JG. Radiologist characteristics associated with interpretive performance of diagnostic mammography. J Natl Cancer Inst. 2007 Dec 19;99(24):1854-63. doi: 10.1093/jnci/djm238. Epub 2007 Dec 11. — View Citation

Miglioretti DL, Zhang Y, Johnson E, Lee C, Morin RL, Vanneman N, Smith-Bindman R. Personalized technologist dose audit feedback for reducing patient radiation exposure from CT. J Am Coll Radiol. 2014 Mar;11(3):300-8. doi: 10.1016/j.jacr.2013.10.017. — View Citation

Mittman B. Implementation Science in Health Care. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and Implementation Research in Health. New York: Oxford University Press; 2012:400-418

National Council on Radiation Protection and Measurements. NCRP Report No 160, Ionizing Radiation Exposure of the Population of the United States, press release available , full report soon to be released; 2009

National Council on Radiation Protection and Measurements. NCRP Report No. 93, Ionizing Radiation Exposure of the Population of the United States. 1987

National Research Council (US) Committee on the Biological Effects of Ionizing Radiation (BEIR V). Health Effects of Exposure to Low Levels of Ionizing Radiation: Beir V. Washington (DC): National Academies Press (US); 1990. Available from http://www.ncbi.nlm.nih.gov/books/NBK218704/ — View Citation

NQF. National Quality Forum Measure 0739, Radiation Dose of Computed Tomography (CT) Steward: University of California San Francisco. 2011; http://www.qualityforum.org/QPS/0739

Padgett D. Qualitative Methods in Social Work Research: Challenges and Rewards. Thousand Oaks, CA: Sage; 1998

Paterson A, Frush DP, Donnelly LF. Helical CT of the body: are settings adjusted for pediatric patients? AJR Am J Roentgenol. 2001 Feb;176(2):297-301. doi: 10.2214/ajr.176.2.1760297. — View Citation

Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Newbury Park: Sage Publications; 2002.

Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de Gonzalez A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. doi: 10.1016/S0140-6736(12)60815-0. Epub 2012 Jun 7. — View Citation

Pierce DA, Preston DL. Radiation-related cancer risks at low doses among atomic bomb survivors. Radiat Res. 2000 Aug;154(2):178-86. doi: 10.1667/0033-7587(2000)154[0178:rrcral]2.0.co;2. — View Citation

Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol. 2007 Apr;188(4):927-33. doi: 10.2214/AJR.06.0793. — View Citation

Preston DL, Ron E, Tokuoka S, Funamoto S, Nishi N, Soda M, Mabuchi K, Kodama K. Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiat Res. 2007 Jul;168(1):1-64. doi: 10.1667/RR0763.1. — View Citation

Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies--a synthesis of systematic review findings. J Eval Clin Pract. 2008 Oct;14(5):888-97. doi: 10.1111/j.1365-2753.2008.01014.x. — View Citation

Radiation protection 118 : referral guidelines for imaging. Luxembourg European Commission, Directorate- General for the Environment; 2001

Radiological protection and safety in medicine. A report of the International Commission on Radiological Protection. Ann ICRP. 1996;26(2):1-47. No abstract available. Erratum In: Ann ICRP 1997;27(2):61. — View Citation

Roberts HC, Roberts TP, Smith WS, Lee TJ, Fischbein NJ, Dillon WP. Multisection dynamic CT perfusion for acute cerebral ischemia: the "toggling-table" technique. AJNR Am J Neuroradiol. 2001 Jun-Jul;22(6):1077-80. — View Citation

Rydberg J, Buckwalter KA, Caldemeyer KS, Phillips MD, Conces DJ Jr, Aisen AM, Persohn SA, Kopecky KK. Multisection CT: scanning techniques and clinical applications. Radiographics. 2000 Nov-Dec;20(6):1787-806. doi: 10.1148/radiographics.20.6.g00nv071787. — View Citation

Schindera ST, Diedrichsen L, Muller HC, Rusch O, Marin D, Schmidt B, Raupach R, Vock P, Szucs-Farkas Z. Iterative reconstruction algorithm for abdominal multidetector CT at different tube voltages: assessment of diagnostic accuracy, image quality, and radiation dose in a phantom study. Radiology. 2011 Aug;260(2):454-62. doi: 10.1148/radiol.11102217. Epub 2011 Apr 14. — View Citation

Schindera ST, Nauer C, Treier R, Trueb P, von Allmen G, Vock P, Szucs-Farkas Z. [Strategies for reducing the CT radiation dose]. Radiologe. 2010 Dec;50(12):1120, 1122-7. doi: 10.1007/s00117-010-2053-2. German. — View Citation

Schindera ST, Nelson RC, Lee ER, Delong DM, Ngyen G, Toncheva G, Yoshizumi TT. Abdominal multislice CT for obese patients: effect on image quality and radiation dose in a phantom study. Acad Radiol. 2007 Apr;14(4):486-94. doi: 10.1016/j.acra.2007.01.030. — View Citation

Schindera ST, Nelson RC, Toth TL, Nguyen GT, Toncheva GI, DeLong DM, Yoshizumi TT. Effect of patient size on radiation dose for abdominal MDCT with automatic tube current modulation: phantom study. AJR Am J Roentgenol. 2008 Feb;190(2):W100-5. doi: 10.2214/AJR.07.2891. — View Citation

Schindera ST, Nelson RC, Yoshizumi T, Toncheva G, Nguyen G, DeLong DM, Szucs-Farkas Z. Effect of automatic tube current modulation on radiation dose and image quality for low tube voltage multidetector row CT angiography: phantom study. Acad Radiol. 2009 Aug;16(8):997-1002. doi: 10.1016/j.acra.2009.02.021. Epub 2009 May 5. — View Citation

Schindera ST, Odedra D, Raza SA, Kim TK, Jang HJ, Szucs-Farkas Z, Rogalla P. Iterative reconstruction algorithm for CT: can radiation dose be decreased while low-contrast detectability is preserved? Radiology. 2013 Nov;269(2):511-8. doi: 10.1148/radiol.13122349. Epub 2013 Jun 20. — View Citation

Schindera ST, Treier R, von Allmen G, Nauer C, Trueb PR, Vock P, Szucs-Farkas Z. An education and training programme for radiological institutes: impact on the reduction of the CT radiation dose. Eur Radiol. 2011 Oct;21(10):2039-45. doi: 10.1007/s00330-011-2168-5. Epub 2011 May 31. — View Citation

Schueler K, Chu P, Smith-Bindman R. "Racial Differences in the Use of Mammography:" A Meta-analytical Review of Literature Describing Economic, Social, and Cultural Reasons for Variation in Use of Mammography". Submitted. 2005

Seale C. The Quality of Qualitative Research. Thousand Oaks: Sage Publications; 1999

Seeram E, Brennan PC. Diagnostic reference levels in radiology. Radiol Technol. 2006 May-Jun;77(5):373-84; quiz 385-7. No abstract available. — View Citation

Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA. 2006 Jul 26;296(4):427-40. doi: 10.1001/jama.296.4.427. — View Citation

Sickles EA, Miglioretti DL, Ballard-Barbash R, Geller BM, Leung JW, Rosenberg RD, Smith-Bindman R, Yankaskas BC. Performance benchmarks for diagnostic mammography. Radiology. 2005 Jun;235(3):775-90. doi: 10.1148/radiol.2353040738. — View Citation

Smith AB, Dillon WP, Lau BC, Gould R, Verdun FR, Lopez EB, Wintermark M. Radiation dose reduction strategy for CT protocols: successful implementation in neuroradiology section. Radiology. 2008 May;247(2):499-506. doi: 10.1148/radiol.2472071054. Epub 2008 Mar 27. — View Citation

Smith-Bindman R, Ballard-Barbash R, Miglioretti DL, Patnick J, Kerlikowske K. Comparing the performance of mammography screening in the USA and the UK. J Med Screen. 2005;12(1):50-4. doi: 10.1258/0969141053279130. — View Citation

Smith-Bindman R, Chu P, Bacchetti P, Waters JJ, Mutton D, Alberman E. Prenatal screening for Down syndrome in England and Wales and population-based birth outcomes. Am J Obstet Gynecol. 2003 Oct;189(4):980-5. doi: 10.1067/s0002-9378(03)00721-x. — View Citation

Smith-Bindman R, Chu P, Goldberg JD. Second trimester prenatal ultrasound for the detection of pregnancies at increased risk of Down syndrome. Prenat Diagn. 2007 Jun;27(6):535-44. doi: 10.1002/pd.1725. — View Citation

Smith-Bindman R, Chu P, Miglioretti DL, Quale C, Rosenberg RD, Cutter G, Geller B, Bacchetti P, Sickles EA, Kerlikowske K. Physician predictors of mammographic accuracy. J Natl Cancer Inst. 2005 Mar 2;97(5):358-67. doi: 10.1093/jnci/dji060. — View Citation

Smith-Bindman R, Chu P, Wang Y, Chung R, Lopez-Solano N, Einstein AJ, Solberg L, Cervantes LF, Yellen-Nelson T, Boswell W, Delman BN, Duong PA, Goode AR, Kasraie N, Lee RK, Neill R, Pahwa A, Pike P, Roehm J, Schindera S, Starkey J, Suntharalingam S, Jeuke — View Citation

Smith-Bindman R, Chu PW, Ecker J, Feldstein VA, Filly RA, Bacchetti P. Adverse birth outcomes in relation to prenatal sonographic measurements of fetal size. J Ultrasound Med. 2003 Apr;22(4):347-56; quiz 357-8. doi: 10.7863/jum.2003.22.4.347. — View Citation

Smith-Bindman R, Chu PW, Ecker JL, Feldstein VA, Filly RA, Bacchetti P. US evaluation of fetal growth: prediction of neonatal outcomes. Radiology. 2002 Apr;223(1):153-61. doi: 10.1148/radiol.2231010876. — View Citation

Smith-Bindman R, Hosmer W, Feldstein VA, Deeks JJ, Goldberg JD. Second-trimester ultrasound to detect fetuses with Down syndrome: a meta-analysis. JAMA. 2001 Feb 28;285(8):1044-55. doi: 10.1001/jama.285.8.1044. — View Citation

Smith-Bindman R, Hosmer WD, Caponigro M, Cunningham G. The variability in the interpretation of prenatal diagnostic ultrasound. Ultrasound Obstet Gynecol. 2001 Apr;17(4):326-32. doi: 10.1046/j.1469-0705.2001.00346.x. — View Citation

Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, Brand R, Grady D. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998 Nov 4;280(17):1510-7. doi: 10.1001/jama.280.17.1510. — View Citation

Smith-Bindman R, Kerlikowske K, Gebretsadik T, Newman J. Is screening mammography effective in elderly women? Am J Med. 2000 Feb;108(2):112-9. doi: 10.1016/s0002-9343(99)00406-4. — View Citation

Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de Gonzalez A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009 Dec 14;169(22):2078-86. doi: 10.1001/archinternmed.2009.427. — View Citation

Smith-Bindman R, McCulloch CE, Ding A, Quale C, Chu PW. Diagnostic imaging rates for head injury in the ED and states' medical malpractice tort reforms. Am J Emerg Med. 2011 Jul;29(6):656-64. doi: 10.1016/j.ajem.2010.01.038. Epub 2010 Jul 13. Erratum In: Am J Emerg Med. 2011 Sep;29(7):839. Ding, Alex [corrected to Ding, Alexander]. — View Citation

Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, Greenlee RT, Kruger RL, Hornbrook MC, Roblin D, Solberg LI, Vanneman N, Weinmann S, Williams AE. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012 Jun 13;307(22):2400-9. doi: 10.1001/jama.2012.5960. — View Citation

Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of diagnostic medical imaging in a large integrated health system. Health Aff (Millwood). 2008 Nov-Dec;27(6):1491-502. doi: 10.1377/hlthaff.27.6.1491. — View Citation

Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004 Oct;24(5):558-65. doi: 10.1002/uog.1704. — View Citation

Smith-Bindman R. Environmental causes of breast cancer and radiation from medical imaging: findings from the Institute of Medicine report. Arch Intern Med. 2012 Jul 9;172(13):1023-7. doi: 10.1001/archinternmed.2012.2329. — View Citation

Smith-Bindman R. Is computed tomography safe? N Engl J Med. 2010 Jul 1;363(1):1-4. doi: 10.1056/NEJMp1002530. Epub 2010 Jun 23. No abstract available. — View Citation

Solberg L. Quality improvement in primary care: The role of organization, systems, and collaboratives. In: Sollecito WA, Johnson JK, eds. McLaughlin and Kaluzny's continuous quality improvement in health care. Fourth ed. Burlington, MA: Jones & Bartlett Learning; 399-419. 2011

Solberg LI, Asche SE, Margolis KL, Whitebird RR, Trangle MA, Wineman AP. Relationship between the presence of practice systems and the quality of care for depression. Am J Med Qual. 2008 Nov-Dec;23(6):420-6. doi: 10.1177/1062860608324547. — View Citation

Solberg LI, Asche SE, Margolis KL, Whitebird RR. Measuring an organization's ability to manage change: the change process capability questionnaire and its use for improving depression care. Am J Med Qual. 2008 May-Jun;23(3):193-200. doi: 10.1177/1062860608314942. — View Citation

Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE, Mosser G, O'Connor PJ, Ohnsorg KA, Rolnick SJ. Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. Jt Comm J Qual Improv. 2000 Apr;26(4):171-88. doi: 10.1016/s1070-3241(00)26013-6. — View Citation

Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O'Connor PJ. Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med. 2006 Jul-Aug;4(4):310-6. doi: 10.1370/afm.571. — View Citation

Solberg LI, Engebretson KI, Sperl-Hillen JM, O'Connor PJ, Hroscikoski MC, Crain AL. Ambulatory care quality measures for the 6 aims from administrative data. Am J Med Qual. 2006 Sep-Oct;21(5):310-6. doi: 10.1177/1062860606289071. — View Citation

Solberg LI, Glasgow RE, Unutzer J, Jaeckels N, Oftedahl G, Beck A, Maciosek MV, Crain AL. Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care. Med Care. 2010 Jul;48(7):576-82. doi: 10.1097/MLR.0b013e3181dbea62. — View Citation

Solberg LI, Hroscikoski MC, Sperl-Hillen JM, O'Connor PJ, Crabtree BF. Key issues in transforming health care organizations for quality: the case of advanced access. Jt Comm J Qual Saf. 2004 Jan;30(1):15-24. doi: 10.1016/s1549-3741(04)30002-x. — View Citation

Solberg LI, Kottke TE, Brekke ML, Magnan S. Improving prevention is difficult. Eff Clin Pract. 2000 May-Jun;3(3):153-5. No abstract available. — View Citation

Solberg LI, Taylor N, Conway WA, Hiatt RA. Large multispecialty group practices and quality improvement: what is needed to transform care? J Ambul Care Manage. 2007 Jan-Mar;30(1):9-17; discussion 18-20. doi: 10.1097/00004479-200701000-00003. — View Citation

Solberg LI, Vinz C, Trevis JE. A technology solution for the high-tech diagnostic imaging conundrum. Am J Manag Care. 2012 Aug;18(8):421-5. — View Citation

Solberg LI. Care coordination: what is it, what are its effects and can it be sustained? Fam Pract. 2011 Oct;28(5):469-70. doi: 10.1093/fampra/cmr071. No abstract available. — View Citation

Solberg LI. Guideline implementation: what the literature doesn't tell us. Jt Comm J Qual Improv. 2000 Sep;26(9):525-37. doi: 10.1016/s1070-3241(00)26044-6. — View Citation

Solberg LI. Improving medical practice: a conceptual framework. Ann Fam Med. 2007 May-Jun;5(3):251-6. doi: 10.1370/afm.666. — View Citation

Sommer WH, Schenzle JC, Becker CR, Nikolaou K, Graser A, Michalski G, Neumaier K, Reiser MF, Johnson TR. Saving dose in triple-rule-out computed tomography examination using a high-pitch dual spiral technique. Invest Radiol. 2010 Feb;45(2):64-71. doi: 10.1097/RLI.0b013e3181c15842. — View Citation

Stengel JW, Webb EM, Poder L, Yeh BM, Smith-Bindman R, Coakley FV. Acute appendicitis: clinical outcome in patients with an initial false-positive CT diagnosis. Radiology. 2010 Jul;256(1):119-26. doi: 10.1148/radiol.10091229. Epub 2010 May 26. — View Citation

Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002 May 7;136(9):641-51. doi: 10.7326/0003-4819-136-9-200205070-00006. — View Citation

Szucs-Farkas Z, Kurmann L, Strautz T, Patak MA, Vock P, Schindera ST. Patient exposure and image quality of low-dose pulmonary computed tomography angiography: comparison of 100- and 80-kVp protocols. Invest Radiol. 2008 Dec;43(12):871-6. doi: 10.1097/RLI.0b013e3181875e86. — View Citation

Szucs-Farkas Z, Schaller C, Bensler S, Patak MA, Vock P, Schindera ST. Detection of pulmonary emboli with CT angiography at reduced radiation exposure and contrast material volume: comparison of 80 kVp and 120 kVp protocols in a matched cohort. Invest Radiol. 2009 Dec;44(12):793-9. doi: 10.1097/RLI.0b013e3181bfe230. — View Citation

Szucs-Farkas Z, Schibler F, Cullmann J, Torrente JC, Patak MA, Raible S, Hoppe H, Wyttenbach R, Vock P, Schindera ST. Diagnostic accuracy of pulmonary CT angiography at low tube voltage: intraindividual comparison of a normal-dose protocol at 120 kVp and a low-dose protocol at 80 kVp using reduced amount of contrast medium in a simulation study. AJR Am J Roentgenol. 2011 Nov;197(5):W852-9. doi: 10.2214/AJR.11.6750. — View Citation

Szucs-Farkas Z, Strautz T, Patak MA, Kurmann L, Vock P, Schindera ST. Is body weight the most appropriate criterion to select patients eligible for low-dose pulmonary CT angiography? Analysis of objective and subjective image quality at 80 kVp in 100 patients. Eur Radiol. 2009 Aug;19(8):1914-22. doi: 10.1007/s00330-009-1385-7. Epub 2009 Mar 31. — View Citation

The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP. 2007;37(2-4):1-332. doi: 10.1016/j.icrp.2007.10.003. — View Citation

The Joint Commission Sentinel Event Alert System. 2011; http://www.jointcommission.org/assets/1/18/SEA_471.PDF.

The US House of Representatives, Energy and Commerce Committee, Subcommittee on Health held a hearing entitled

U.S. Food and Drug Administration. FDA White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. 2010; http://www.fda.gov/Radiation- EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm199994.htm.

UK National Health Program Department of Health. The Ionising Radiation (Medical Exposure) Regulations 2000 (together with notes on good practice). 2007, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007957, accessed January 15, 2011

US Food and Drug Administration. Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010. 2009

Venkatesan A, Chu P, Kerlikowske K, Sickles EA, Smith-Bindman R. Positive predictive value of specific mammographic findings according to reader and patient variables. Radiology. 2009 Mar;250(3):648-57. doi: 10.1148/radiol.2503080541. Epub 2009 Jan 21. — View Citation

Wall BF. Diagnostic reference levels--the way forward. Br J Radiol. 2001 Sep;74(885):785-8. doi: 10.1259/bjr.74.885.740785. No abstract available. — View Citation

Whitebird RR, Kreitzer M, Crain AL, Lewis BA, Hanson LR, Enstad CJ. Mindfulness-based stress reduction for family caregivers: a randomized controlled trial. Gerontologist. 2013 Aug;53(4):676-86. doi: 10.1093/geront/gns126. Epub 2012 Oct 15. — View Citation

Whitebird RR, Kreitzer MJ, Lewis BA, Hanson LR, Crain AL, Enstad CJ, Mehta A. Recruiting and retaining family caregivers to a randomized controlled trial on mindfulness-based stress reduction. Contemp Clin Trials. 2011 Sep;32(5):654-61. doi: 10.1016/j.cct.2011.05.002. Epub 2011 May 12. — View Citation

Whitebird RR, Kreitzer MJ, O'Connor PJ. Mindfulness-Based Stress Reduction and Diabetes. Diabetes Spectr. 2009 Sep 21;22(4):226-230. doi: 10.2337/diaspect.22.4.226. No abstract available. — View Citation

Whitebird RR, Solberg LI, Margolis KL, Asche SE, Trangle MA, Wineman AP. Barriers to improving primary care of depression: perspectives of medical group leaders. Qual Health Res. 2013 Jun;23(6):805-14. doi: 10.1177/1049732313482399. Epub 2013 Mar 20. — View Citation

* Note: There are 159 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in Mean Effective Dose (ED)	We will assess the change in the mean effective dose after the simple audit and multi-component interventions (MCI) in comparison to before the audit and multi-component interventions. The numbers given below reflect absolute change in mean dose (in millisieverts) relative to the baseline period.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Primary	Percentage of CT Scans With an Effective Dose Above Benchmark	We will assess the change in the percentage of examinations with an effective dose above the benchmark after the simple audit and after multi-component intervention (MCI) in comparison to doses before the audit and MCI. The benchmark for each anatomic area is defined as the 75th percentile of the dose distribution during the pre-intervention (baseline) period.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Secondary	Mean Dose Length Product	We will assess the change in the dose length product after the audit and MCI in comparison to before the audit and MCI.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Secondary	Proportion of CT Scans With a Dose Length Product Above Benchmark	We will assess the change in the proportion of examinations with a dose length product above the benchmark after the audit and after the MCI in comparison to doses before the audit and MCI. The benchmark for each anatomic area is defined as the 75th percentile of the dose distribution during the pre intervention period.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Secondary	Change in Mean Volume Computed Tomography Dose Index (CTDIvol)	We will assess the change in the mean volume CT dose index (CTDIvol) from before versus after the audit and MCI intervention. CTDIvol (in units of milligray, mGy) is a measure of radiation dose, reflecting the amount of radiation imparted per CT slice by the scanner. Higher CTDIvol signifies more radiation dose. In general, a reduction in CTDIvol would be a sign of quality improvement, minimizing excess radiation exposure to the patient.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Secondary	Percentage of CT Scans With a CTDIvol Above Benchmark	We will assess the change in the percentage of examinations with a CTDIvol above the benchmark after the audit and after multicomponent intervention in comparison to doses before the audit and multicomponent intervention. The benchmark for each anatomic area is defined as the 75th percentile of the dose distribution during the pre intervention period.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81
Secondary	Change in Mean Organ Doses: Brain Dose for Head CT; Lung Dose For Chest CT; Colon and Liver Dose for Abdomen CT	We will assess the change in organ doses after the simple audit and multi-component interventions (MCI) in comparison to before the audit and multi-component interventions. The numbers given below reflect absolute change in mean dose (in millisieverts) relative to the baseline period.	Sites were randomized to 1 of 3 tracks, which determined the timing of intervention: Track A: audit at week 40, MCI at week 68 Track B: audit at week 44, MCI at week 74 Track C: audit at week 53, MCI at week 81

External Links

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