HERCA Survey: Use of CT for IHA in Europe

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1 HERCA Survey: Use of CT for IHA in Europe Eva G. Friberg Norwegian Radiation Protection Authority HERCA: Heads of the European Radiological protection Competent Authorities

2 Background Justification of the use of CT for IHA outside screening programs is challenging Commercial services starting to offer IHA using CT Aggressive advertisement often in conflict with the general principle of justification Both EU-BSS and IAEA-BSS proposed requirements for asymptomatic patients in their drafts (now published) Regulatory bodies have an important role in ensuring the implementation of justification for asymptomatic individuals Need for an overview of the situation in Europe about the use of CT for IHA Two European surveys performed (2010 and 2012)

3 Surveys about the situation in Europe regarding the use of CT on asymptomatic individuals outside screening program HERCA WG MA Surveys performed by A. Isambert (France)

4 First survey in May 2010 Survey on radiation exposure of asymptomatic individuals in health care sent to 18 countries involved in HERCA WG MA (13 answers) Regarding health assessment with CT : Positive answers in 2+1 countries : UK, Spain and Germany UK : lung, heart and colon area assessments and combinations of them. Spain : whole body assessments. Germany : advertisements in local newspapers to go to a neighbouring country for such an assessment.

5 2nd survey in July 2012 Background: The issues with regard to unjustified exposures in medicine have been accentuated by recent developments in imaging procedures which belong to preventive health care. A survey was sent to HERCA WG MA members on individual health assessments such as on request CT exams with no clinical indication (individual request) outside screening programs. Eight questions

6 Austria Belgium Bulgaria Denmark Estonia Finland France Germany Greece Ireland Iceland Lithuania Luxembourg Norway Poland Romania Spain Sweden Switzerland The Netherlands United Kingdom 21 answers

7 Question 1 To your knowledge, in your country, are CT examinations on asymptomatic individuals outside screening program being performed? NO Belgium*, Finland, Lithuania, NL, Sweden, Bulgaria, Denmark, Iceland, Ireland, Poland, Romania, Estonia, Luxembourg 13 8 YES Greece, Austria, 1 UK, Spain, 2 Switzerland, France, Norway, Germany * 1 institute under suspicion

8 Question 2 Does your Authority(ties) actively search for the existence of these practices? NO Greece, Belgium, Finland, Austria, NL, Sweden, Spain, Bulgaria, Denmark, Iceland, Ireland, Poland, Switzerland, Estonia, France, Luxembourg 16 5 YES Lithuania, UK, 1 Romania, 2 Norway, Germany

9 Question 3 Is it or would it be allowed from a legal point of view / tolerated in your country? NO Greece, Belgium, Finland, Austria, Lithuania, NL, Spain, Bulgaria, Denmark, Iceland, Poland, Romania, Estonia, France, Luxembourg, Norway, Germany 17 4 YES Sweden, UK, Ireland, Switzerland 1 2

10 Comments if YES : Question 3 Is it or would it be allowed from a legal point of view / tolerated in your country? Ireland : the current legislation does not prohibit it Sweden :An examination could be judged as justified when other factors than clinical symptoms are weighed into the judgment. For example, if a patient is extremely worried about lung cancer, an x-ray of the lungs could be justified to calm the patient Switzerland : not thoroughly regulated yet, will be reviewed in the oncoming revision UK : certain procedures such as virtual colonoscopy and coronary artery calcification scoring are justified in certain circumstances

11 Question 4 Does your current regulation mention exposure to asymptomatic individuals? NO Greece, Belgium, Finland, Austria, Lithuania, NL, Sweden, Spain, Iceland, Ireland, Romania, Estonia, France, Luxembourg, Norway, Germany 16 5 YES UK, Bulgaria, Denmark, Poland, Switzerland 1 2

12 Question 5 How do (did) you react on these practices? (What would you do?) Organisations attention is drawn on the fact that these practices are not justified and therefore not allowed Letter with a demand to stop the practice - Withdrawal of the license if needed Require to account for the justification Would be referred to the Health ministry Inspections by the auditing medical agencies Greece will introduce, during on-site inspections, investigations on the existence of referrals for every patient exposure Norway started of a national project to map the occurrence of these practices UK has commissioned a working party to provide government with up to date guidance following a previous study by the government advisory body (COMARE)

13 Do not know/ not sure (private companies) NL, Denmark, Ireland, Austria NO Question 6 Are CT examinations on asymptomatic individuals outside screening program reimbursed? 14 YES Switzerland, Germany* Greece, Belgium, Finland, Norway, Lithuania, Sweden, UK, Spain**, Bulgaria, Iceland, Poland, Romania, Estonia, France, Luxembourg * *Spain «only by some private companies» 5 2 * Germany «yes, after a dedicated justification»

14 Question 7 Are you aware of some kind of advertisement on this service in your country? NO Greece, Finland, Lithuania, Sweden, Bulgaria, Denmark, Iceland, Ireland, Poland, Romania, Estonia, France, Luxembourg 13 8 YES Belgium, Austria, NL, UK*, Spain, 1 Switzerland, 2 Norway**, Germany*** Small case phenomenon except for : * A significant budget is spent an national campaigns **Mainly on CT calcium score *** Increasing problem

15 Examples : Spain

16 Examples : Belgium/NL or or

17 Examples : UK TV commercials especially on Sky

18 Examples : Switzerland

19 Examples : France

20 Question 8 How would you suggest to create awareness to this focus-group? National awareness campaign on appropriateness in medical imaging, directed at both health care providers and public at large Organize more practical workshops regarding justification, proper use of medical imaging for the people in the working field like doctors, prescribers, nurses, Provide information to patients on benefits and risks regarding CT examinations Implement a independent clinical audit system To strictly regulate that outside approved screening programs such examinations are illegal Common actions with national health and private insurances not to reimburse these kind of CT examinations / create incentives in tarification to reduce the number of such examinations

21 Example from Belgium Medical images are not family photos. No X rays without reason

22 Conclusions CT are used in IHA in at least 8 countries Assumed to be higher (few actively searching) Most countries indicated that IHA are not allowed from a legal point of view IHA mainly not directly mentioned in regulation, but in conflict with general principle of justification Need for an active involvement from the authorities from a legal point of view Survey collected several proposals on how to raise awareness around IHA Identified a need for further work on this topic to prevent further establishment of such practices Publication available at HERCA web-pages: