Diagnostic reference levels and median doses for common clinical indications of CT: findings from an international registry
Open accessAbstract
Ob jectives: The European Society of Radiology identified 10 common indications for computed tomography (CT) as part of the European Study on Clinical Diagnostic Reference Levels (DRLs, EUCLID), to help standardize radiation doses. The objective of this study is to generate DRLs and median doses for these indications using data from the UCSF CT International Dose Registry. Methods: Standardized data on 3.7 million CTs in adults were collected between 2016 and 2019 from 161 institutions across seven countries (United States of America (US), Switzerland, Netherlands, Germany, UK, Israel, Japan). DRLs (75th percentile) and median doses for volumetric CT-dose index (CTDI vol ) and dose-length product (DLP) were assessed for each EUCLID category (chronic sinusitis, stroke, cervical spine trauma, coronary calcium scoring, lung cancer, pulmonary embolism, coronary CT angiography, hepatocellular carcinoma (HCC), colic/abdominal pain, appendicitis), and US radiation doses were compared with European. Results: The number of CT scans within EUCLID categories ranged from 8,933 (HCC) to over 1.2 million (stroke). There was greater variation in dose between categories than within categories ( p < .001), and doses were significantly different between categories within anatomic areas. DRLs and median doses were assessed for all categories. DRLs were higher in the US for 9 of the 10 indications (except chronic sinusitis) than in Europe but with a significantly higher sample size in the US. Conclusions: DRLs for CTDI vol and DLP for EUCLID clinical indications from diverse organizations were established and can contribute to dose optimization. These values were usually significantly higher in the US than in Europe. Key Points: • Registry data were used to create benchmarks for 10 common indications for CT identified by the European Society of Radiology. • Observed US radiation doses were higher than European for 9 of 10 indications (except chronic sinusitis). • The presented diagnostic reference levels and median doses highlight potentially unnecessary variation in radiation dose.
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A minimum of 20 to 30 patient-dose entries per procedure per site is advised to guarantee statistical significance, with multi-center surveys favored for the establishment of national or regional DRLs.
“A minimum of 20 to 30 patient-dose entries per procedure per site is advised to guarantee statistical significance, with multi-center surveys favored for the establishment of national or regional DRLs.77”
From Computed Tomography Diagnostic Reference Levels Worldwide and in Jordan: Implications for Patient Dose Reduction (2026) · cites this paper as [77]
The Discussion (page unavailable) says large multicenter studies can help create representative DRLs and describes another survey that collected at least 20 CT examinations per indication from each hospital. It does not advise a minimum of 20–30 entries per procedure per site or say that this number guarantees statistical significance. (LLM, conf=0.88)
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- Authors
- Bos, D., Yu, S., Luong, J., Chu, P., Wang, Y., Einstein, A. J., Starkey, J., Delman, B. N., Duong, P.-A. T., Das, M., Schindera, S., Goode, A. R., MacLeod, F., Wetter, A., Neill, R., Lee, R. K., Roehm, J., Seibert, J. A., Cervantes, L. F., Kasraie, N., Pike, P., Pahwa, A., Jeukens, C. R. L. P. N., & Smith-Bindman, R.
- Affiliations
- Essen University Hospital (DE)
- University of California, San Francisco (US)
- Columbia University Irving Medical Center (US)
- St. Luke's International Hospital (JP)
- Icahn School of Medicine at Mount Sinai (US)
- University of Utah (US)
- Helios Kliniken (DE)
- Kantonsspital Aarau (CH)
- University of Virginia Medical Center (US)
- John Radcliffe Hospital (GB)
- Emory University (US)
- Jefferson Einstein Philadelphia Hospital (US)
- UC Davis Health (US)
- Miami Children's Hospital (US)
- The University of Texas Southwestern Medical Center (US)
- Huntsville Hospital (US)
- Olive View-UCLA Medical Center (US)
- Maastricht University Medical Centre (NL)
- Corresponding author
- Bos, Denise
- ORCID
- Venue
- European Radiology
- Published
- 2021-10-13
- Volume
- 32
- Issue
- 3
- Pages
- 1971-1982
- ISSN
- 0938-7994 (ISSN-L)
- 1432-1084
- PMC
- PMC8831291
- OpenAlex
- W3207097006
- Cited by
- 64
- References
- 36
- Citations by year
- 2026: 16 · 2025: 17 · 2024: 12 · 2023: 15 · 2022: 3 · 2021: 1
- FWCI
- 4.09
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- European Radiology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, cc-by)
- eScholarship (California Digital Library) (submittedVersion, cc-by)
- Informationszentrum Lebenswissenschaften (ZB MED) (submittedVersion, cc-by)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Funders
- National Institutes of Health (R01- CA181191)
- Patient-Centered Outcomes Research Institute (CD-1304-7043, DI-2018C1-11375)
- Deutsche Forschungsgemeinschaft (FU356/12-1)
- Universitätsklinikum Essen
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiation Dose and Imaging
- Physical Sciences › Physics and Astronomy › Radiation › Advanced Radiotherapy Techniques
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiology practices and education
- Keywords
- diagnostic reference levels, CT radiation dose, dose-length product, Euclid, dose optimization, chronic rhinosinusitis, stroke, cervical spine injury, coronary artery calcium score, lung cancer, pulmonary embolism, coronary CT angiography, hepatocellular carcinoma, appendicitis
- MeSH terms
- Diagnostic Reference Levels, Adult, Carcinoma, Hepatocellular, Humans, Liver Neoplasms, Radiation Dosage, Reference Values, Registries, Tomography, X-Ray Computed
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