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Original Investigation
March 30, 2020

Comparison of the Effectiveness of Single-Component and Multicomponent Interventions for Reducing Radiation Doses in Patients Undergoing Computed Tomography: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Radiology and Biomedical Imaging, University of California, San Francisco
  • 2Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
  • 3Department of Epidemiology and Biostatistics, University of California, San Francisco
  • 4Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
  • 5Department of Demography, University of California, Berkeley
  • 6Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
  • 7Department of Radiology, Columbia University Irving Medical Center, New York, New York
  • 8New York–Presbyterian Hospital, New York, New York
  • 9HealthPartners Institute, Minneapolis, Minnesota
  • 10Nicklaus Children’s Hospital, Miami, Florida
  • 11Department of Radiology, University of California, San Diego
  • 12Department of Radiology, City of Hope National Medical Center, Duarte, California
  • 13Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 14Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
  • 15Department of Radiology and Medical Imaging, University of Virginia Health System, Virginia
  • 16Department of Radiology, University of Texas Southwestern Medical Center, Dallas
  • 17Department of Radiology, Einstein Healthcare Network, New York, New York
  • 18Department of Radiology Sciences, Olive View UCLA Medical Center, Los Angeles, California
  • 19Huntsville Hospital System, Huntsville, Alabama
  • 20Center for Diagnostic Imaging, St Louis Park, Minnesota
  • 21Department of Radiology, Cantonal Hospital, Aarau, Aarau, Switzerland
  • 22St Luke's International Hospital, Chuo, Tokyo, Japan
  • 23Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital, Essen, Germany
  • 24Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
  • 25Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
  • 26Kaiser Permanente Washington Health Research Institute, Seattle
JAMA Intern Med. 2020;180(5):666-675. doi:10.1001/jamainternmed.2020.0064
Key Points

Question  Is there an effective intervention to reduce radiation doses in patients undergoing computed tomography (CT) to enhance patient safety?

Findings  In this randomized clinical trial of 864 080 adults undergoing CT at 100 facilities, audit feedback with tailored suggestions, educational seminars, and sharing of best practices was more effective for reducing the organ doses associated with CT compared with audit feedback alone, and radiologists’ satisfaction with CT image quality was unchanged.

Meaning  Medical imaging facilities can use detailed feedback on CT doses combined with specific suggestions and an educational quality improvement program to reduce radiation doses without compromising the quality of images.


Importance  Computed tomography (CT) radiation doses vary across institutions and are often higher than needed.

Objective  To assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT.

Design, Setting, and Participants  This randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018.

Interventions  Imaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention.

Main Outcomes and Measures  Primary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics.

Results  Across 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001; chest: OR, 0.92; 95% CI, 0.86-0.99; P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P < .001; and head: OR, 0.71; 95% CI, 0.66-0.76; P < .001). Reductions in the proportions of high-dose scans were greater when measured using organ doses. The absolute reduction in the proportion of high-dose scans was 6.0% to 17.2%, reflecting 23% to 58% reductions in the proportions of high-dose scans across anatomical areas. Mean effective doses were significantly reduced after multicomponent intervention for abdomen (6% reduction, P < .001), chest (4%, P < .001), and chest and abdomen (14%, P < .001) CT scans. Larger reductions in mean organ doses were 8% to 43% across anatomical areas. Audit feedback alone reduced the proportions of high-dose scans and mean dose, but reductions in observed dose were smaller. Radiologist’s satisfaction with CT image quality was unchanged and high during all periods.

Conclusions and Relevance  For imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest.

Trial Registration  ClinicalTrials.gov Identifier: NCT03000751

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