‘Highly generalizable’ initiative lowers radiation exposure in Michigan cath labs
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Key takeaways:
- An initiative reduced patient and cath lab staff exposure to procedural radiation during PCI.
- Air kerma may be a favorable quality metric for PCI centers.
An initiative in Michigan successfully reduced patient, physician and staff exposure to procedural radiation during percutaneous coronary intervention, and may be generalizable in other states, researchers reported.
“Owing to the risks associated with radiation exposure among patients and catheterization laboratory personnel, it is strongly recommended that PCI be performed with radiation doses that are as low as reasonably achievable,” Ryan D. Madder, MD, interventional cardiologist at the Frederik Meijer Heart and Vascular Institute at Corewell Health in Grand Rapids, Michigan, and colleagues wrote.
In 2017, the Blue Cross Blue Shield of Michigan Cardiovascular Collaborative (BMC2) launched an initiative to improve catheterization laboratory radiation safety practices in the state. The initiative included radiation safety education for physicians and staff, increased focus on radiation data analysis, best practices documentation for radiation safety in the catheterization laboratory, comparative institutional-level radiation reporting and implementation of radiation dose performance metrics.
“The purpose of the present study was to assess the temporal trend in procedural air kerma during PCI concurrent with the initiation and conduct of the statewide radiation safety quality improvement initiative,” the researchers wrote.
For the present study, Madder and colleagues analyzed radiation data from 131,619 PCI procedures performed from July 1, 2016, to July 1, 2022, documented in the BMC2 registry.
Their findings were published in Circulation: Cardiovascular Interventions.
Reducing PCI radiation exposure
From 2016, the researchers observed a reduction of air kerma during PCI from a median dose of 1.46 Gy (interquartile range [IQR], 0.86-2.37) to 0.97 Gy (IQR, 0.56-1.64) in 2022 (P < .001).
After adjusting for variables that could affect radiation dose during PCI, every year since the start of the initiative, procedural air kerma was reduced on average by 7.61% (95% CI, 7.38-7.84; P < .0001).
In addition, the proportion of PCIs with an air kerma of 5 Gy or more — a threshold above which patients were counseled about risk for radiation-related skin injury — declined from 4.24% in 2016 to 0.86% in 2022 (P < .0001).
Despite the observed reduction in procedural air kerma over time, during the same period, Madder and colleagues noted an increase in fluoroscopy time from a median of 13.7 minutes to 16.2 minutes.
“Because fluoroscopy uses considerably less radiation than cineangiography, it is possible, and may even be favorable, to reduce total procedural radiation dose by using cineangiography more judiciously, in favor of using more fluoroscopy,” the researchers wrote. “Additionally, a reduction in the fluoroscopic frame rate from 15 to 7.5 frames per second would be expected to be half the radiation dose when using fluoroscopy, which could more than offset any marginal increase in the fluoroscopy time.
“Regardless of whether a skin injury threshold is reached, the overall radiation dose is also an important metric because doses at any level have implications for the risk of stochastic events,” they wrote. “In addition to making PCI safer for patients in Michigan, the reduction in patient radiation doses observed would be expected to reduce the amount of scatter radiation, thereby reducing occupational radiation doses to the physicians and catheterization laboratory staff members.”
‘Old dogs’ and ‘new tricks’
In a related editorial, Stephanie S. Colello, MD, fellow in the division of cardiovascular medicine at the University of Pennsylvania Perelman School of Medicine, and colleagues discussed the implications of these results on clinical practice.
“The findings reported by Madder et al indicate that the program achieved its objectives,” the authors wrote. “In particular, the observation that the overall dose rates decreased over time while both procedure complexity and fluoroscopy time increased is consistent with the conclusion that the program operators (old dogs) successfully implemented these dose-sparing practices (new tricks).
“The BMC2 program promotes radiation dose as a quality metric,” they wrote. “This is a valuable addition to invasive cardiology’s culture and should be promoted to all practitioners. The good news is that the findings reported by Madder et al are highly generalizable. It would be constructive to make the curriculum of the BMC2 program widely available so that regions other than Michigan could adopt it.”
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