Comparison of the Effectiveness of Single-Component and Multicomponent Interventions for Reducing Radiation Doses in Patients Undergoing Computed Tomography: A Randomized Clinical Trial
Open accessAbstract
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
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Currently, computed tomography accounts for roughly 15% of diagnostic examinations yet contributes up to 75% of the overall radiation exposure in major hospitals.
“Currently, computed tomography accounts for roughly 15% of diagnostic examinations yet contributes up to 75% of the overall radiation exposure in major hospitals.37–39”
From Computed Tomography Diagnostic Reference Levels Worldwide and in Jordan: Implications for Patient Dose Reduction (2026) · cites this paper as [38]
The introductory passage (section E; page unavailable) says CT doses are much higher than conventional radiography doses and that increased CT use has driven rising exposure to ionizing radiation. It does not give the claimed 15% share of diagnostic examinations or up-to-75% share of radiation exposure in major hospitals. (LLM, conf=0.75)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Computed Tomography — An Increasing Source of Radiation Exposure
Brenner, D. J., & Hall, E. J. (2007) · New England Journal of Medicine · doi:10.1056/nejmra072149 · Cited by 8,738 · see citing works
Pearce, M. S., Salotti, J. A., Little, M. P., McHugh, K., Lee, C., Kim, K. P., Howe, N. L., Ronckers, C. M., Rajaraman, P., Craft, A. W., et al. (2012) · The Lancet · doi:10.1016/s0140-6736(12)60815-0 · Cited by 3,735 · see citing works
Smith‐Bindman, R. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.427 · Cited by 2,467 · see citing works
Self-citationHealth Risks from Exposure to Low Levels of Ionizing Radiation:: BEIR VII Phase 2
Earth, D. O. (2006) · CERN Document Server (European Organization for Nuclear Research) · Cited by 2,190 · see citing works
Projected Cancer Risks From Computed Tomographic Scans Performed in the United States in 2007
de González, A. B. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.440 · Cited by 1,880 · see citing works
Solid Cancer Incidence in Atomic Bomb Survivors: 1958–1998
Preston, D. L., Ron, E., Tokuoka, S., Funamoto, S., Nishi, N., Soda, M., Mabuchi, K., & Kodama, K. (2007) · Radiation Research · doi:10.1667/rr0763.1 · Cited by 1,751 · see citing works
Christner, J. A., Kofler, J. M., & McCollough, C. H. (2010) · American Journal of Roentgenology · doi:10.2214/ajr.09.3462 · Cited by 492 · see citing works
Long-term effects of radiation exposure on health
Kamiya, K., Ozasa, K., Akiba, S., Niwa, O., Kodama, K., Takamura, N., Zaharieva, E. K., Kimura, Y. N., & Wakeford, R. (2015) · The Lancet · doi:10.1016/s0140-6736(15)61167-9 · Cited by 450 · see citing works
Leuraud, K., Richardson, D. B., Cardis, E., Daniels, R. D., Gillies, M., O'Hagan, J. A., Hamra, G. B., Haylock, R., Laurier, D., Moissonnier, M., et al. (2015) · The Lancet Haematology · doi:10.1016/s2352-3026(15)00094-0 · Cited by 442 · see citing works
Are quality improvement collaboratives effective? A systematic review
Wells, S. J., Tamir, O., Gray, J., Naidoo, D., Bekhit, M., & Goldmann, D. A. (2017) · BMJ Quality & Safety · doi:10.1136/bmjqs-2017-006926 · Cited by 440 · see citing works
Richardson, D. B., Cardis, E., Daniels, R. D., Gillies, M., O'Hagan, J. A., Hamra, G. B., Haylock, R., Laurier, D., Leuraud, K., Moissonnier, M., et al. (2015) · BMJ · doi:10.1136/bmj.h5359 · Cited by 379 · see citing works
Managing Radiation Use in Medical Imaging: A Multifaceted Challenge
Hricak, H., Brenner, D. J., Adelstein, S. J., Frush, D. P., Hall, E. J., Howell, R. W., McCollough, C. H., Mettler, F. A., Pearce, M. S., Suleiman, O. H., et al. (2010) · Radiology · doi:10.1148/radiol.10101157 · Cited by 343 · see citing works
de Gonzalez, A. B., Salotti, J. A., McHugh, K., Little, M. P., Harbron, R. W., Lee, C., Ntowe, E., Braganza, M. Z., Parker, L., Rajaraman, P., et al. (2016) · British Journal of Cancer · doi:10.1038/bjc.2015.415 · Cited by 244 · see citing works
Smith‐Bindman, R., Wang, Y., Chu, P., Chung, R., Einstein, A. J., Balcombe, J. N., Cocker, M. R., Das, M., Delman, B. N., Flynn, M., et al. (2019) · BMJ · doi:10.1136/bmj.k4931 · Cited by 244 · see citing works
Self-citationRaff, G. L. (2009) · JAMA · doi:10.1001/jama.2009.814 · Cited by 233 · see citing works
Optimal multivariate matching before randomization.
Greevy, R., Lu, B., Silber, J., & Rosenbaum, P. (2004) · Biostatistics · doi:10.1093/biostatistics/5.2.263 · Cited by 233 · see citing works
Cancer Risks After Radiation Exposure in Middle Age
Shuryak, I., Sachs, R. K., & Brenner, D. J. (2010) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/djq346 · Cited by 182 · see citing works
Determinants of success of quality improvement collaboratives: what does the literature show?
Hulscher, M., Schouten, L. M. T., Grol, R. P. T. M., & Buchan, H. (2012) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000651 · Cited by 158 · see citing works
Optimizing Radiation Doses for Computed Tomography Across Institutions
Demb, J., Chu, P., Nelson, T. R., et al. (2017) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2017.0445 · Cited by 51 · see citing works
Self-citationICRP and IAEA actions on radiation protection in computed tomography
Rehani, M. M. (2012) · Annals of the ICRP · doi:10.1016/j.icrp.2012.06.029 · Cited by 47 · see citing works
How Tracking Radiologic Procedures and Dose Helps: Experience From Finland
Seuri, R. M., Rehani, M. M., & Kortesniemi, M. (2013) · American Journal of Roentgenology · doi:10.2214/ajr.12.10112 · Cited by 45 · see citing works
Siegelman, J., & Gress, D. A. (2013) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2012.12.008 · Cited by 40 · see citing works
Tack, D., Jahnen, A., Kohler, S., et al. (2013) · European Radiology · doi:10.1007/s00330-013-2994-8 · Cited by 35 · see citing works
Reweighted Mahalanobis distance matching for cluster‐randomized trials with missing data
Greevy, R. A., Grijalva, C. G., Roumie, C. L., Beck, C., Hung, A. M., Murff, H. J., Liu, X., & Griffin, M. R. (2012) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.3260 · Cited by 32 · see citing works
CT Radiation Dose Optimization and Tracking Program at a Large Quaternary-Care Health Care System
Goenka, A. H., Dong, F. F., Wildman, B., et al. (2015) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2015.03.037 · Cited by 20 · see citing works
Personalized Technologist Dose Audit Feedback for Reducing Patient Radiation Exposure From CT
Miglioretti, D. L., Zhang, Y., Johnson, E., et al. (2014) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2013.10.017 · Cited by 16 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 1
- International Agency for Research on Cancer. A Review of Human Carcinogenesis. Lyon, France: International Agency for Research on Cancer; 2012:100D:7-303. IARC monographs on the evaluation of carcinogenic risks to humans.
Cited by
Sorted by citations
Oglat, A., Shdaifat, S., Sayah, M., Abukonna, A., & Khogali, W. (2026) · Drug, Healthcare and Patient Safety · doi:10.2147/dhps.s595721
- Authors
- Smith-Bindman, R., Chu, P., Wang, Y., Chung, R., Lopez-Solano, N., Einstein, A. J., Solberg, L., Cervantes, L. F., Nelson, T. R., Boswell, W., Delman, B. N., Duong, P.-A., Goode, A. R., Kasraie, N., Lee, R. K., Neill, R., Pahwa, A., Pike, P., Roehm, J., Schindera, S., Starkey, J., Suntharalingam, S., Jeukens, C. R. L. P. N., & Miglioretti, D. L.
- Affiliations
- Department of Radiology and Biomedical Imaging, University of California, San Francisco
- University of California, San Francisco (US)
- University of California, Berkeley (US)
- NewYork–Presbyterian Hospital (US)
- HealthPartners (US)
- Miami Children's Hospital (US)
- University of California San Diego (US)
- City Of Hope National Medical Center (US)
- Icahn School of Medicine at Mount Sinai (US)
- Emory University (US)
- University of Virginia Health System (US)
- The University of Texas Southwestern Medical Center (US)
- Einstein Healthcare Network (US)
- University of California, Los Angeles (US)
- Huntsville Hospital (US)
- Center for Diagnostic Imaging, St Louis Park, Minnesota
- Kantonsspital Aarau (CH)
- St. Luke's International Hospital (JP)
- Essen University Hospital (DE)
- Maastricht University Medical Centre (NL)
- Kaiser Permanente Washington Health Research Institute (US)
- ORCID
- Venue
- JAMA Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2020-05-01
- Volume
- 180
- Issue
- 5
- Pages
- 666
- ISSN
- 2168-6106 (ISSN-L)
- PMC
- PMC7105953
- OpenAlex
- W3013480718
- Cited by
- 23
- References
- 27
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 4 · 2023: 5 · 2022: 2 · 2021: 5
- FWCI
- 1.58
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Internal Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- Patient-Centered Outcomes Research Institute (CD-1304-7043)
- National Institutes of Health
- Office of the President, University of California
- National Cancer Institute (R01CA181191)
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiation Dose and Imaging
- Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiology practices and education
- Keywords
- audit and feedback, multicomponent intervention, quality improvement collaborative, best practice sharing, effective dose, organ dose, CT dose optimization
- MeSH terms
- Abdomen, Adolescent, Adult, Aged, Aged, 80 and over, Female, Head, Humans, Male, Middle Aged, Radiation Dosage, Thorax, Tomography, X-Ray Computed, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
