Jenia Vassileva. National Centre of Radiobiology and Radiation Protection Sofia, Bulgaria
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1 How to determine examination frequencies and population dose estimates for X-rays and NM? Jenia Vassileva National Centre of Radiobiology and Radiation Protection Sofia, Bulgaria
2 Population dose estimates Country A, B, C, D, Annual numbers of: all examinations (N 1, N 2, N 3,..) per 1000 population N E i i i Examinations 1, 2, 3, i Mean effective dose per examination E 1, E 2, E 3,. countries Annual collective dose - total - per 1000 population - per caputa Collective dose of the European population
3 Number of categories of examinations 225 specific types of examination or procedure covering 4 radiological modalities and based on regions 70 broad categories of examinations based on regions 20 examinations with highest contribution to the population dose
4 Top 20 approach (X-ray) Frequency % Collective dose 70-90% Top 20 Top 20
5 28 NM examinations
6
7 Information on the annual numbers of examinations conducted in a country can be obtained: Method A: Sample survey from a sample of hospitals, clinics or practices and then scaled up to cover the whole country. Method B: Central statistics survey from central statistics held by government departments or insurance companies for all (or at least a large proportion) of radiology practice in the country.
8 Method A: Sample survey 1. Representativeness Steps to ensure that the sample is as representative of national radiology practice as possible. All types of hospital and radiological practice should be included in the sample in similar proportions to those occurring nationally. Which health care providers might offer medical radiology services? Which are the most important contributors to national radiology practice?
9 Method A: Sample survey 1. Representativeness
10 Method A: Sample survey 1. Representativeness Are dental radiology conducted by dentists in Dental Practices is included in the population dose assessments or not? little impact on the collective dose but a big impact on the frequency examinations (account for at least 1/3 of all x-ray examinations in most countries)
11 Example Bulgaria Finland: 7,6 million inhabitants 5,3 million inhabitants 480 intraoral dental systems 4565 intraoral dental systems 96 OPG 673 OPG 62.3/1000 exams 469.4/1000 exams UA HU RO BG PT CR SK UK LI FR CZ NO BE DE FI DK LU AT CH 1409
12 Method A: Sample survey 1. Representativeness little impact on the completeness of the frequency data because of the insignificant contribution:
13 Example: Ukraine Chest radiography (142/1000) exams Effective dose 0.1 msv 652 mansv Fluorography (499/1000) Effective dose 3.3 msv film; 0.42 msv digital mansv
14 Method A: Sample survey 2. Standardized categorization of exams and sources of information: RIS: National coding system RIS: Different coding system in different hospitals PACS/RIS (electronic) or paper registers
15 Method A: Sample survey 2. Standardized categorization of exams and sources of information. The accuracy of the frequency data depends on how reliably the coded information stored in the RIS can be translated into actual numbers of examinations. Coding system may vary with time Cooperation between those responsible for assessing the population dose and the designers of examination code systems
16 Method A: Sample survey 3. Scaling up to the whole country: based on different approaches, depending on what data are available: the relative numbers of radiology service providers; the relative numbers of patients; the total numbers of x-ray examinations in the sample the whole country
17 Method A: Sample survey 3. Scaling up to the whole country: UK Sample 38 trusts in 2 different regions (16% of English exams) Switzerland 11 big hosp; 2 week survey in 274 medium & small hosp & 2787 practices Sweden Denmark From licence holders covering 25% of population. Directly from national hosps. Chiro 39 clinics (95% survey) Scaled by Total no. of x-ray exams per trust No. of hospitals & practices with x-ray unit Multiply by 4 Multiply by 1.05 Netherlands 90% of hospitals No. of hospital admissions
18 Method A: Sample survey Example from this survey: Switzerland National survey to collect the 2008 data: developed an online database ( All healthcare providers invited to participate by sending their annual frequency data for more than 225 examinations. Data from about 3,500 users were collected (42% response rate; 45% in terms of X-ray units) Extrapolated to cover the whole country according to the number of X-ray units, taking also into account the type of healthcare provider.
19 Method A: Sample survey Example from this survey: Italy The survey included 5 Italian regions, accounting for approximately 30% of the population. The included radiology procedures in 2006 (reference year) For each procedure were requested to each region both the frequency and the dose. When a region was not able to provide data for a specific examination, the results were interpolated on the basis of the other regions data. Data were extrapolated to the entire Italian population
20 Method A: Sample survey 10 countries used questionnaire sent to ALL departments using X-ray Response rate: Finland 98% Greece 20% Estonia 53% Iceland 90% FYR of Macedonia 97% Montenegro 100% Norway 100% Slovenia 75% (90% of the workload) Serbia 40% Ukraine 85%
21 Method A: Sample survey Most often used method for collection of frequency data of NM examinations in this survey. Questionnaire sent to ALL NM departments
22 Method A: Sample survey Results collected and analyzed by the coordinating institution (authority, institute, etc) Response rate of NM departments: Bulgaria 100% Lithuania 100% Estonia 100% Finland 100% Latvia 100% FYR of Macedonia 100% Montenegro 100% Norway 100% Slovenia 100% Ukraine 100% Iceland 90% Greece 70% Serbia 71% Portugal 73% Belgium 66% UK 66% Scaling up to the whole country
23 Method B: Central statistics survey Central statistics held by: insurance companies government departments for all (or at least a large proportion) of radiology practice in the country. usually for a large proportion or even the total of radiology practice in the country scaling up to cover the whole country may be still necessary
24 Method B: Central statistics survey Sample Germany From statutory health insurance: 89%; private health insurance: 9%; other kinds of / no health insurance: 2% for about 80% of x-ray exams (out patients) Scaled by Scaling factors to estimate inpatient data Luxemburg Belgium Annual nos from Nat Health Ins (99% survey) Annual nos from Nat Health Ins Inst (97-100% survey) No scaling necessary No scaling necessary
25 Method B: Central statistics survey Using health insurance data: Belgium, Germany, Examples from this survey Croatia (+ direct survey in 7/9 major NM dept, 5 interventional cardiology departments and one University hospital ) Central government department statistics: Bulgaria (Ministry of Health) for X-ray procedures
26 Method B: Central statistics survey Using both: Examples from this survey Czech Republic - Health insurance company + Institute of Health Information and Statistics Slovakia - National Health Information Centre and the main Slovak Health Insurance Companies, covering about 80% of all X-ray and NM exams
27 Method B: Central statistics survey Scaling up to the whole country Example: Romania Number of procedures reported to the regional Ionizing Radiation Hygiene Laboratory, and they send data to the National Institute of Public Health. In 2010: reported 29 out of 41 counties; Scaling up to the whole population: take into account the number of X-ray units per type in different regions, e.g.: "m" is the total number of reported CT examinations from M" CT units; "N" is the real number of CT units at country level; "c" - the estimated number of CT examination at country level: c = m N / M
28 France Mixed method A & B Survey conducted in 2007 by the Institute for radiation protection and nuclear safety (IRSN) and the National institute for public health surveillance (InVS). The frequency data was obtained from two sources: for private practice : from the national health insurance data for a representative sample of 1% of the population (about persons), for public practice: 2 surveys in public hospitals: in radiology - 50 hospitals (about 12% of the public hospitals). in NM, a questionnaire has been sent to the 127 public NM departments (response rate 72%).
29 Portugal Mixed method A & B Frequency data from the Civil Servants' reimbursement system (10% of exams); frequency data from the reimbursements of the exams performed under the "conventioned" regime (roughly 20%); hospital survey by a questionnaire to obtain the annual frequency of the exams performed in the "general regime" i.e. reimbursed on a hospital basis); 23% representation. For Angiography and PTCA: information from Portuguese Association of Cardiovascular Intervention summed the values The remainder of the exams (~5% ) not considered
30 Sources of frequency data N/A 32% Questionnaire 22% RIS/PACS 15% Others 7% Insurance 12% Health authorities 12%
31 Using Top 20 approach to estimate overall total collective effective dose Frequency % Collective dose 70-90% Top 20 Top 20
32 Extrapolation from Top 20 to the total 12 countries reported total frequency of Top 20 examinations and overall total frequency from all X-ray examinations. Average correction factor calculated (total overall/total TOP 20) for each main group of x-ray procedures (plain radiography, fluoroscopy, CT and interventional radiology) Correction factors used to estimate overall total frequencies from the total frequencies evaluated by TOP 20 approach Frequency correction factors Overall total/top 20 total Plain radiography Fluoroscopy Computed tomography Interventional radiology 2,13 2,12 1,12 2,73
33 Extrapolation from Top 20 to the total 6 countries reported total collective effective dose of Top 20 examinations and overall total collective effective dose from all X-ray examinations. Average correction factor calculated (total overall/total TOP 20) for each main group of x-ray procedures (plain radiography, fluoroscopy, CT and interventional radiology) Correction factors used to estimate overall collective effective dose from the total evaluated by TOP 20 approach Correction factors Overall total/top 20 total Plain radiography Fluoroscopy CT IR 1,12 1,55 1,18 2,61
34
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