The American College of Radiology (ACR) urges parents not to delay or forgo needed medical imaging care for their children based solely on a study (Miglioretti et al) on radiation risk from pediatric computed tomography (CT) scans to be published online in JAMA Pediatrics. Parents should, however, discuss the risks and benefits of any procedure, including CT scans, with their child’s physician and factor this important information into their joint decision-making.

Medical imaging exams are directly linked to greater life expectancy, declines in mortality rates, and are generally safer and less expensive than the invasive procedures that they replace, such as exploratory surgery. Diagnostic scans reduce the number of invasive surgeries, unnecessary hospital admissions and the length of hospital stays. However, they must be used judiciously, when indicated, and when the needed information cannot be obtained in other ways, in order to minimize radiation exposure to all Americans — particularly children.

“CT scans are most often performed on children who have experienced trauma to the head, neck or spine, may suffer from neurological disorders or injury, or may need fast and accurate evaluation for complex and life threatening clinical issues — including complications of chest infections, such as lung abscess in patients with pneumonia. If an imaging scan is warranted, the immediate benefits outweigh a potential and very small long-term risk. Parents should certainly discuss such potential risk with their physician, but this appropriate concern should not translate into refusal of necessary and potentially life-saving care,” said Marta Hernanz-Schulman, MD, FACR, FAAP, chair of the American College of Radiology Pediatric Imaging Commission.

Parents should keep a record of their child’s X-ray history, the type of study done, place and date. Before any scan is done, appropriate questions to ask the physician include:

  • How will having this exam improve my child’s health care?
  • Are there alternatives that do not use radiation, which in this case might be equally effective?
  • Will my child receive a “child-sized” radiation dose?
  • Is this facility ACR-accredited?

Government can help ensure appropriate imaging and lower the radiation dose that Americans (including children) receive from scans each year by:

  • Requiring accreditation of all imaging facilities (including hospitals and outpatient imaging services) — ACR accreditation signifies that equipment is surveyed regularly by a medical physicist, technologists are appropriately certified and the interpreting physicians have met stringent education and training standards. This avoids repeat imaging due to poor quality scans and the associated radiation exposure. Patients can find accredited facilities at ACR.org. The ACR also recognizes in its accreditation facilities that appropriately “child-size” the techniques used in the CT scans obtained at that facility.

  • Encouraging/Incentivizing use of ACR Appropriateness Criteria® based decision support/exam order entry systems — These systems educate providers on which exam is best for a patient’s condition (including tests with no radiation exposure like ultrasound or MRI) or when no scan is warranted. This ensures that patients get the right scan for the right reason at the right time, reduces inappropriate imaging and avoids unnecessary exposure to radiation. This way, the child’s physician obtains the needed information by requesting the exam that evidence shows will be most helpful for the child’s condition.

  • Encouraging/Incentivizing participation in the ACR Dose Index Registry® — Facilities contribute anonymized, HIPAA-compliant dose information on every scan, and periodically compare their dose indices to national benchmarks. This ongoing and regular feedback allows facilities opportunities to adjust dose accordingly and gauge how their radiation reduction efforts are working over time, to “child-size” the technique of the examination.

  • Incentivizing and encouraging medical imaging integration in electronic health records (EHR) — Duplicative and unnecessary testing is reduced, quality of care enhanced, and costs lowered, when referring physicians have access to patients’ prior imaging. Most comprehensive digital imaging facilities have the ability to capture, display, archive, and even share images and related information. This should be leveraged to enable secure electronic access to imaging data via EHRs. The government should use the Medicare/Medicaid EHR Incentive Program ("meaningful use") to incentivize electronic exchange of imaging data between hospitals, so that the child’s scan will not need to be repeated.

Regarding the specifics of the JAMA Pediatrics study:

Children who get CT scans should have them when there is an immediate and significant health condition, whose treatment will be guided by the findings on the CT scan. The absolute potential lifetime cancer risks reported in the study are very small compared with the lifetime risk of developing cancer in the general population, in comparison with the definitive and clear benefits of a clinically justified scan. Modern CT scanners use radiation doses that are up to 90 percent lower than those of even 10 years ago.

Providers are far more aware of the potential risks involved than in years past, more apt to ensure the necessity for the exam and to consider alternatives. This is evidenced by the declining number of CT scans performed in children since 2007 (as cited by Miglioretti et al). Caution has governed the ACR’s long history of efforts to reduce dose and ensure appropriate imaging including:

  1. Image Gently® — ACR is a founding member of the Alliance for Radiation Safety in Pediatric Imaging with the Society for Pediatric Radiology (SPR) the American Association of Physicists in Medicine (AAPM) and the American Society of Radiologic Technologists (ASRT). Image Gently focuses on pediatric patients, and educates providers on opportunities to lower radiation dose used in the imaging of children. The campaign, started in Jan. 2008, now includes over 70 Medical Organizations Worldwide.
  2. Image Wisely® — ACR, with the Radiological Society of North America (RSNA), AAPM and ASRT co-founded the initiative to educate physicians on opportunities to lower dose and ensure appropriate imaging in adult patients. The initiative also provides patient education materials, including a patient medical imaging record card developed with the Food and Drug Administration.
  3. Choosing Wisely® — ACR identified a list of imaging exams that may not always be necessary, and therefore bear specific discussion and consideration of alternatives before they are requested. The ACR partnered with Consumer Reports to distribute patient-friendly resources for consumers and physicians to engage in important conversations regarding these medical imaging exams. The ACR worked with the American Board of Internal Medicine Foundation and 8 other organizations on the Choosing Wisely campaign.

While opportunities remain to ensure appropriate requesting of CT scans, growth in use of pediatric CT scans has leveled in recent years. Reports by the Neiman Health Policy Institute and the Moran Company show that overall use of CT scans has declined since 2008 and imaging is the slowest growing of all physician services according to the Health Care Cost Institute.

“We urge government to work with ACR and other stakeholders to streamline, enhance and promote Electronic Health Records that promote universal access to prior imaging scans and avoid duplicative testing. We also urge providers, patients and parents to take advantage of the many ACR quality and safety programs, such as facility accreditation, ACR Appropriateness Criteria, decision support systems to guide providers to the right test for their patients, and initiatives such as Image Gently and Image Wisely, in order to help ensure children and adults receive safe, appropriate, high quality care,” said Dr. Hernanz-Schulman.