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Rofo 2019; 191(08): 739-751
DOI: 10.1055/a-0824-7603
Quality/Quality Assurance
© Georg Thieme Verlag KG Stuttgart · New York

Diagnostic Reference Levels for Diagnostic and Interventional X-Ray Procedures in Germany: Update and Handling

Artikel in mehreren Sprachen: English | deutsch
Alexander Schegerer
1   Department of Medical and Occupational Radiation Protection, Federal Office for Radiation Protection, Neuherberg, Germany
,
Reinhard Loose
2   Institute for Radiology and Nuclear Medicine, Paracelsus Medical University, General Hospital Nuremberg, Germany
,
Lothar J. Heuser
3   Diagnostic and Interventional Radiology, Ruhr-Universität Bochum, Germany
,
Gunnar Brix
1   Department of Medical and Occupational Radiation Protection, Federal Office for Radiation Protection, Neuherberg, Germany
› Institutsangaben
Weitere Informationen

Publikationsverlauf

08. Februar 2018

18. November 2018

Publikationsdatum:
21. Januar 2019 (online)

Auch verfügbar auf
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Abstract

Purpose Recent developments in medical technology have broadened the spectrum of X-ray procedures and changed exposure practice in X-ray facilities. For this reason, diagnostic reference levels (DRLs) for diagnostic and interventional X-ray procedures were updated in 2016 and 2018, respectively. It is the aim of this paper to present the procedure for the update of the DRLs and to give advice on their practical application.

Materials and Methods For the determination of DRLs, data from different independent sources that collect dose-relevant data from different facilities in Germany were considered. Seven different weight intervals were specified for classifying pediatric X-ray procedures. For each X-ray procedure considered, the 25th, 50th, and 75th percentile of the respective national distribution of the dose-relevant parameters were determined. Additionally, effective doses that correspond to the DRLs were estimated.

Results In procedures with already existing DRLs before 2016, the values were lowered by circa 20 % on average. Numerous DRLs were established for the first time (9 for interventional procedures, 10 for CT examinations).

Conclusion For dose optimizations even below the new national DRLs, the BfS recommends establishing local reference levels, using dose management software (particularly in CT and interventional radiology), adapting dose-relevant parameters of X-ray protocols to the individual patient size, and establishing internal radiation protection teams responsible for optimizing X-ray procedures in clinical practice. When applying good medical practice and using modern equipment, the median dose values of the nationwide dose distributions can not only be easily achieved but can even be undercut.

Key Points:

  • German diagnostic reference levels (DRLs) für diagnostic and interventional X-ray procedures were updated in 2016 and 2018, respectively.

  • For X-ray procedures for which DRLs existed already before the update, the updated DLRs were lowered by circa 20 %, on average.

  • For CT and interventional radiology, new DRLs were established.

  • X-ray procedures have to be optimized even below the DRLs.

Citation Format

  • Schegerer A, Loose R, Heuser LJ et al. Diagnostic Reference Levels for Diagnostic and Interventional X-Ray Procedures in Germany: Update and Handling. Fortschr Röntgenstr 2019; 191: 739 – 751

Key words

patient exposure - dose optimization and reduction - diagnostic reference levels (DRLs) - diagnostic and interventional radiology - pediatric X-ray examinations
 

  • References

  • 1 Nekolla EA, Schegerer AA, Griebel J. et al. Häufigkeit und Dosis diagnostischer und interventioneller Röntgenanwendungen. Der Radiologe 2017; 57: 555-562
    CrossrefPubMedGoogle Scholar
  • 2 Amis ES, Butler PF. ACR white paper on radiation dose in medicine: three years later. J Am Coll Radiol 2010; 7: 865-870
    CrossrefPubMedGoogle Scholar
  • 3 Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. The Lancet 2004; 363: 345-351
    CrossrefPubMedGoogle Scholar
  • 4 Bundesrepublik Deutschland. Verordnung über den Schutz vor Schäden durch Röntgenstrahlung (Röntgenverordngung – RöV). BGBl 2014; I: 2010
    PubMedGoogle Scholar
  • 5 International commission on radiological protection (ICRP). Radiological protection and safety in medicine. ICRP Publication 73. Ann ICRP 1996; 26: 1-47
    PubMedGoogle Scholar
  • 6 International commission on radiological protection (ICRP). Radiological protection in medicine. ICRP Publication 105. Ann ICRP 2007; 37: 1-63
    PubMedGoogle Scholar
  • 7 European commission. Guidance on diagnostic reference levels (DRLs) for medical expsoures. Radiation Protection 1999 109
    PubMedGoogle Scholar
  • 8 International commission on radiological protection (ICRP). Diagnostic reference levels in medical imaging. ICRP Publication 135. Ann ICRP 2017; 46: 1-143
    CrossrefPubMedGoogle Scholar
  • 9 Veit R, Guggenberger R, Noßke D. et al. Diagnostische Referenzwerte für Röntgenuntersuchungen. Der Radiologe 2010; 50: 907-912
    CrossrefPubMedGoogle Scholar
  • 10 Bundesministerium für Umwelt, Naturschutz und Reaktorsicherheit. Qualitätssicherung durch ärztliche und zahnärztliche Stellen. GMBl 2015; 51: 1026
    PubMedGoogle Scholar
  • 11 Bundesamt für Strahlenschutz (BfS). Bekanntmachung der diagnostischen Referenzwerte für radiologische und nuklearmedizinische Untersuchungen. Bundesanzeiger. 143 05.08.2003; 17503
    PubMedGoogle Scholar
  • 12 Bundesamt für Strahlenschutz (BfS). Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnostische und interventionelle Röntgenuntersuchungen. Bundesanzeiger.111 28.07.2010; 2594
    PubMedGoogle Scholar
  • 13 Bundesamt für Strahlenschutz (BfS). Bekanntmachung der aktualisierten diagnostischen Referenzwerte für interventionelle Röntgenuntersuchungen. Bundesanzeiger. AT 03.09.2018 B8
    PubMedGoogle Scholar
  • 14 Bundesamt für Strahlenschutz (BfS). Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnostische und interventionelle Röntgenuntersuchungen. Bundesanzeiger. AT 15.07.2016 B8
    PubMedGoogle Scholar
  • 15 Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen AQUA GmbH. Qualitätsreport 2012. 2013 1/08.2013
    PubMedGoogle Scholar
  • 16 Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen AQUA GmbH. Qualitätsreport 2013. 2014 1/08.2014
    PubMedGoogle Scholar
  • 17 Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen AQUA GmbH. Qualitätsreport 2014. 2015 1/08.2015
    PubMedGoogle Scholar
  • 18 Heuser LJ, Arnold CN, Morhard D. et al. DeGIR-Qualitätsreport 2011 – Bericht über die Behandlungsqualität minimalinvasiver Methoden. Teil 1: Verfahren zur Rekanalisation eingeengter und verschlossener Arterien. Fortschr Röntgenstr 2012; 184: 570-576
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 19 Heuser LJ, Arnold CN, Morhard D. et al. Qualitätsreport 2011: Bericht üfer die Behandlungsqualität minimalinvasiver Methoden – Teil 2: Interventionelle Therapie (EVAR) von Aortenaneurysmen. Fortschr Röntgenstr 2013; 185: 709-719
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 20 Schegerer AA, Nagel HD, Stamm G. et al. Current CT practice in Germany: Results and implications of a nationwide survey. Eur J Radiol 2017; 90: 114-128
    CrossrefPubMedGoogle Scholar
  • 21 International commission on radiological protection (ICRP). Adult reference computational phantoms. ICRP Publication 110. Ann ICRP 2009; 39: 1-165
    PubMedGoogle Scholar
  • 22 International commission on radiological protection (ICRP). Recommendations of the international commission on radiological protection. ICRP Publication 103. Ann ICRP 2007; 37: 1-123
    PubMedGoogle Scholar
  • 23 Stamm G, Nagel HD. CT-Expo – a novel program for dose evaluation in CT. Fortschr Röntgenstr 2002; 174: 1570-1576
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 24 STUK – Radiation and nuclear safety authority Helsinki. PCXMC dose calculations. 2.0.1 ed2008
    PubMedGoogle Scholar
  • 25 Bundesärztekammer. Leitlinie der Bundesärztekammer zur Qualitätssicherung in der Computertomographie. 2007
    PubMedGoogle Scholar
  • 26 Bundesärztekammer. Leitlinie der Bundesärztekammer zur Qualitätssicherung in der Röntgendiagnostik – Qualitätskriterien röntgendiagnostischer Untersuchungen 2007.
    PubMedGoogle Scholar
  • 27 Khelassi-Toutaoui N, Berkani Y, Tsapaki V. et al. Experimental evaluation of PCXMC and prepare codes used in conventional radiology. Radiation Protection Dosimetry 2008; 131: 374-378
    CrossrefPubMedGoogle Scholar
  • 28 Brix G, Lechel U, Veit R. et al. Assessment of a theoretical formalism for dose estimation in CT: an anthropomorphic phantom study. Eur Radiol 2004; 14: 1275-1284
    PubMedGoogle Scholar
  • 29 National council on radiation protection and measurement (NCRP). Ionizing Radiation Exposure of the Population of the United States. 2009 Report 160
    PubMedGoogle Scholar
  • 30 European commission. Guidance for protection of unborn children and infants irradiated due to parental medical exposures. Radiation Protection 1998 100
    PubMedGoogle Scholar
  • 31 European commission. European guidelines on diagnostic reference levels for paediatric imaging. Radiation protection 2018 185
    PubMedGoogle Scholar
  • 32 International commission on radiological protection (ICRP). Basic anatomical and physiological data for use in radiological protection reference values. ICRP Publication 89. Ann ICRP 2002; 32: 1-165
    CrossrefPubMedGoogle Scholar
  • 33 Galanski M, Nagel HD, Stamm G. Pediatric CT exposure practice in the federal republic of Germany. BMUB Forschungsvorhaben 2006; StSch 4470
    PubMedGoogle Scholar
  • 34 Kiljunen T, Järvinen H, Savolainen S. Diagnostic reference levels for thorax X-ray examinations of paediatric patients. Br J Radiol 2007; 80: 452-459
    CrossrefPubMedGoogle Scholar
  • 35 Council of the European Union. 97/43/Euratom on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure and repealing Directive 84/466/Euratom. Official Journal of the EU 1997; L180: 22-27
    PubMedGoogle Scholar
  • 36 Council of the European Union. 2013/59/Euratom on basic safety standards for protection against the dangers arising from exposure to ionising radiation and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the EU 2014; L13: 1-73
    PubMedGoogle Scholar
  • 37 Renger B, Brieskorn C, Toth V. et al. Evaluation of dose reduction potentials of a novel scatter correction software for bedside chest x-Ray imaging. Radiat Prot Dosimetry 2016; 169: 60-67
    CrossrefPubMedGoogle Scholar
  • 38 Wang KC, Patel JB, Vyas B. et al. Use of radiology procedure codes in health care: the need for standardization and structure. RadioGraphics 2017; 37: 1099-1110
    CrossrefPubMedGoogle Scholar
  • 39 Mayo J, Thakur Y. Pulmonary CT angiography as first-line imaging for PE: image quality and radiation cose considerations. Am J Roentgenol 2012; 200: 522-528
    PubMedGoogle Scholar
  • 40 Atalay MK, Walle NL, Grand DJ. et al. Scan length optimization for pulmonary embolism at CT angiography: analysis based on the three-dimensional spatial distribution of 370 emboli in 100 patients. Clinical Radiology 2011; 66: 405-411
    CrossrefPubMedGoogle Scholar
  • 41 Schweizerisches Bundesamt für Gesundheit (BAG). Diagnostische Referenzwerte in der Computertomographie, Wegleitung. R-06-06wd (2018).
    PubMedGoogle Scholar
  • 42 Nagel HD, Hering KG, Hieckel HG. et al. Mitteilung der DRG: Protokollempfehlung der AG DRauE zur Durchführung von Low-Dose-Volument-HRCT-Untersuchungen der Lunge. Fortschr Röntgenstr 2017; 189: 553-575
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 43 Heilmaier C, Zuber N, Berthold C. et al. Establishing local diagnostic reference levels in IR procedures with dose management software. Journal of Vascular and Interventional Radiology 2017; 28: 429-441
    CrossrefPubMedGoogle Scholar
  • 44 McFadden S, Hughes C, D'Helft C. et al. The establishment of local diagnostic reference levels for paediatric interventional cardiology. Radiography 2013; 19: 295-301
    CrossrefPubMedGoogle Scholar
  • 45 Boos J, Meineke A, Bethge OT. et al. Dose monitoring in radiology departments: Status quo and future perspectives. Fortschr Röntgenstr 2016; 188: 443-450
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 46 Gress DA, Dickinson RL, Erwin WD. et al. AAPM medical physics practice guideline 6.a.: Performance characteristics of radiation dose index monitoring systems. Journal of Applied Clinical Medical Physics 2017; 18: 12-22
    CrossrefPubMedGoogle Scholar
  • 47 Heilmaier C, Niklaus Z, Berthold C. et al. Improving patient Safety: implementing dose monitoring software in fluoroscopically guided interventions. Journal of Vascular and Interventional Radiology 2015; 26: 1699-1709
    CrossrefPubMedGoogle Scholar
  • 48 Heilmaier C, Zuber N, Weishaupt D. Implementation of a patient dose monitoring system in conventional digital X-ray imaging: initial experiences. Eur Radiol 2017; 27: 1021-1031
    CrossrefPubMedGoogle Scholar
  • 49 Schäfer S, Alejandre-Lafont E, Schmidt T. et al. Dose management for x-ray and CT: systematic comparison of exposition values from two institutes to diagnostic reference levels and use of results for optimisation of exposition. Fortschr Röntgenstr 2014; 186: 785-794
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 50 American Association of Physicists in Medicine (Task Group 204). AAPM report: size-specific dose estimates (SSDE) in pediatric and adult body CT examinations. College Park, MD 20740-3846: American Association of Physicists in Medicine 2011
    PubMedGoogle Scholar
  • 51 Christner JA, Braun NN, Jacobsen M. et al. Size-specific dose estimates for adult patients at CT of the torso. Radiology 2012; 265: 841-847
    CrossrefPubMedGoogle Scholar
  • 52 Menke J. Comparison of different body size parameters for individual dose adaptation in body CT of adults. Radiology 2005; 236: 565-571
    CrossrefPubMedGoogle Scholar