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Medical applications of ionising radiation (IR) represent a key component of the diagnosis and treatment of many diseases, guaranteeing efficient health care. The use of IR in medicine, the largest source of general population radiation exposure, is potentially associated with increased risk of cancer and non-cancer diseases, which needs to be evaluated to provide evidence-based input for risk-benefit considerations. Efforts are also needed to improve the safety and efficacy of medical applications through optimisation. The EC Euratom programme enhances research in medical radiation protection. The four complementary multidisciplinary projects presented here contribute to (1) improving knowledge on exposure and effects of diagnostic and therapeutic applications and (2) transferring results into clinical practice. The common aim is to optimise use for individual patients, enhance education and training, ensuring adherence to ethical standards, particularly related to technologies based on artificial intelligence. MEDIRAD, SINFONIA and HARMONIC focus on improving exposure estimation and studying the detrimental effects of diagnostic and therapeutic medical exposures in patients and staff using different endpoints. EURAMED rocc-n-roll brings together the results of the projects and the recommendations generated by them to build, in collaboration with the EU Radiation Protection research platforms, a strategic research agenda and a roadmap for research priorities.

Objective: To describe a methodological approach to explore the concordance of recommendations across guidelines and its application to the case of the WHO recommendations on chest imaging for the diagnosis and management of COVID-19. Study design and setting: We followed a methodological approach applied to a case study that included: defining the 'reference guideline' (i.e., the WHO guidance) and the 'reference recommendations'; searching for 'related guidelines' and identifying 'related recommendations'; constructing the PICO for the recommendations; assessing the matching of the PICO of each related recommendation to the PICO corresponding reference recommendation; and assessing the concordance between the PICO-matching recommendations. Results: We identified a total of 89 related recommendations from 22 related guidelines. Out of the 89 related recommendations, 43 partly matched and 1 entirely matched one of the reference recommendations, and out of these, 8 were concordant with one of the reference recommendations. When considering the seven reference recommendations, they had a median of 12 related recommendations (range 3–17), a median of 7 PICO-matching recommendations (range 0–13), and a median of 1 concordant recommendation (range 0–4). Conclusion: Following a detailed methodological approach, we were able to explore the concordance between our reference recommendations and related recommendations from other guidelines. A relatively low percentage of recommendations was concordant. [ABSTRACT FROM AUTHOR]

The recently implemented European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom lays down core radiation protection standards for European radiology departments, including a mandatory requirement for supporting processes of clinical audit. A repeat survey on behalf of the European Society of Radiology (ESR) was undertaken in February 2021, involving the ESR EuroSafe Imaging Star department network, to re-assess compliance with selected key BSSD requirements following an initial survey in 2018 where variable compliance was demonstrated. 61% (78/128) of eligible departments participated and overall the survey results revealed a mixed picture in terms of implementation of BSSD requirements when compared to the 2018 survey with both improvement and deterioration observed. This pattern was seen also in relation to supporting processes of regulatory audit and re-audit. Higher levels of "skipping" of responses were also observed in 2021. These findings were unexpected in light of the interventions in relation to audit (clinical and regulatory) and radiation protection undertaken by the ESR and other organisations in recent years, but can reasonably be explained by the onset of the COVID-19 pandemic, with consequent significant disruption of radiology services. The 2021 survey results do serve to highlight again the need for co-ordinated intervention involving relevant European bodies, organisations and governmental agencies to address the important issues raised by this survey. The European Commission clinical audit and radiation protection initiatives, QuADRANT, led by the ESR, and SAMIRA will act as important drivers for improvement in patient safety, experience and outcomes across Europe. [ABSTRACT FROM AUTHOR]

In recent years, the issue of cumulative effective dose received from recurrent computed tomography examinations has become a subject of increasing concern internationally. Evidence, predominantly from the USA, has shown that a significant number of patients receive a cumulative effective dose of 100 mSv or greater. To obtain a European perspective, EuroSafe Imaging carried out a survey to collect European data on cumulative radiation exposure of patients from recurrent computed tomography examinations. The survey found that a relatively low percentage of patients (0.5%) received a cumulative effective dose equal to or higher than 100 mSv from computed tomography, most of them having an oncological disease. However, there is considerable variation between institutions as these values ranged from 0 to 2.72%, highlighting that local practice or, depending on the institution and its medical focus, local patient conditions are likely to be a significant factor in the levels of cumulative effective dose received, rather than this simply being a global phenomenon. This paper also provides some practical actions to support the management of cumulative effective dose and to refine or improve practice where recurrent examinations are required. These actions are focused around increasing awareness of referring physicians through encouraging local dialogue, actions focused on optimisation where a team approach is critical, better use of modern equipment and the use of Dose Management and Clinical Decision Support Systems together with focused clinical audits. The proper use of cumulative effective dose should be part of training programmes for referrers and practitioners, including what information to give to patients. Patient summary: Radiation is used to the benefit of patients in diagnostic procedures such as CT examinations, and in therapeutic procedures like the external radiation treatment for cancer. However, radiation is also known to increase the risk of cancer. To oversee this risk, the cumulative effective dose (CED) received by a patient from imaging procedures over his or her life is important. In this paper, the authors, on behalf of EuroSafe Imaging, report on a survey carried out in Europe that aims to estimate the proportion of patients that undergo CT examinations and are exposed to a CED of more than 100 mSv. At the same time, the survey enquires about and underlines radiologists' measures and radiology departments' strategies to limit such exposure. Over the period of 2015–2018, respondents reported that 0.5% (0–2.72%) of patients were exposed to a CED of ≥ 100 mSv from imaging procedures. The background radiation dose in Europe depends on the location, but it is around 2.5 mSv per year. It is obvious that patients with cancer, chronic diseases and trauma run the highest risk of having a high CED. However, even if the number of patients exposed to ≥ 100 mSv is relatively low, it is important to lower this number even further. Measures could consist in using procedures that do not necessitate radiation, using very low dose procedures, being very critical in requiring imaging procedures and increasing awareness about the issue. Key Points: • A relatively low percentage of patients (0.5%) received a cumulative effective dose from CT computed tomography equal to or greater than 100 mSv, in Europe, most of them having an oncological disease. • There is a wide range in the number of patients who receive cumulative effective dose equal to or greater than 100 mSv (0–2.72%) and optimisation should be improved. • Increasing the awareness of referring physicians through encouraging local dialogue, concrete actions focused on optimisation and development of dose management systems is suggested. [ABSTRACT FROM AUTHOR]

Value-based radiology (VBR) is rapidly gaining ground as a means of considering the input of radiology practice into individual and societal healthcare, and represents a welcome move away from older metrics focused on counting studies performed, without consideration of whether these studies contributed positively to patient management or to society as a whole. Intrinsic to the process of considering whether radiology activity confers value is recognising the breadth of involvement of radiology in healthcare delivery; previous ESR and multi-society publications have explored this, and have sought to highlight the many ways in which our specialty contributes to patient welfare. This paper is intended to highlight some current ESR activities which already contribute substantially to value creation and delivery, and to outline a selection of practical steps which could be taken by the ESR in the future to enhance value. Patient summary Value-based radiology (VBR) is a conceptual means of looking at the benefits conferred on patients and on society as a whole by provision of radiology services, as opposed to older means of counting numbers of radiology studies performed, without consideration of whether or not those studies contributed overall value. VBR will become increasingly important in the future as a means of determining resources. The ESR has been a leader in advancing VBR concepts and educating radiologists about this novel way of looking at what we do. This paper is designed to highlight current ESR activities which contribute value to healthcare, and to consider other ways in which the ESR could potentially support value enhancement in the future. [ABSTRACT FROM AUTHOR]

This review presents basic information on the dosimetric quantities used in medical imaging for reporting patient doses and establishing diagnostic reference levels. The proper use of the radiation protection quantity "effective dose" to compare doses delivered by different radiological procedures and different imaging modalities with its uncertainties and limitations, is summarised. The estimates of population doses required by the European Directive on Basic Safety Standards is commented on. Referrers and radiologists should be familiar with the dose quantities to inform patients about radiation risks and benefits. The application of effective dose on the cumulative doses from recurrent imaging procedures is also discussed. Patient summary: Basic information on the measurement units (dosimetric quantities) used in medical imaging for reporting radiation doses should be understandable to patients. The Working Group on "Dosimetry for imaging in clinical practice" recommended that a brief explanation on the used dosimetric quantities and units included in the examination imaging report, should be available for patients. The use of the quantity "effective dose" to compare doses to which patients are exposed to from different radiological procedures and its uncertainties and limitations, should also be explained in plain language. This is also relevant for the dialog on to the cumulative doses from recurrent imaging procedures. The paper summarises these concepts, including the need to estimate the population doses required by the European Directive on Basic Safety Standards. Referrers and radiologists should be familiar with the dose quantities to inform patients about radiation risks and benefits. [ABSTRACT FROM AUTHOR]

The European Directive 2013/59/Euratom requires member states of the European Union to ensure justification and optimisation of radiological procedures and store information on patient exposure for analysis and quality assurance. The EuroSafe Imaging campaign of the European Society of Radiology created a working group (WG) on "Dose Management" with the aim to provide European recommendations on the implementation of dose management systems (DMS) in clinical practice. The WG follows Action 4: "Promote dose management systems to establish local, national, and European diagnostic reference levels (DRL)" of the EuroSafe Imaging Call for Action 2018. DMS are designed for medical practitioners, radiographers, medical physics experts (MPE) and other health professionals involved in imaging to support their tasks and duties of radiation protection in accordance with local and national requirements. The WG analysed requirements and critical points when installing a DMS and classified the individual functions at different performance levels. Key Points: • DMS are very helpful software tools for monitoring patient exposure, optimisation, compliance with DRLs and quality assurance. • DMS can help to fulfil dosimetric aspects of the European Directive 2013/59/Euratom. • The EuroSafe WG analyses DMS requirements and gives recommendations for users. [ABSTRACT FROM AUTHOR]

This article introduces the European Society of Radiology's EuroSafe Imaging initiative in the year of its 6th anniversary. The European and global radiation protection frameworks are outlined and the role of the EuroSafe Imaging initiative's Call for Action in successfully achieving international radiation protection goals as set out by those frameworks is detailed. [ABSTRACT FROM AUTHOR]

Rationale and methodology: A survey of patients was carried out between January and June 2019, to better understand how patients interpret value in relation to radiology as a means to refining the concept of Value-Based Radiology (VBR) in Europe, ensure radiology's value is properly weighted in Value-Based Health Care (VBH) metrics, and maximise the value of radiological services to patients. The survey was disseminated via various heads of radiology departments, ESR officers, patient organisations, and ESR website and social media channels. Results: Responses were received from 400 patients from 22 countries. Whilst most expressed general satisfaction with the radiological services they received, certain aspects of the radiological services they received left room for improvement. Thirty-six percent of respondents reported that they were not satisfied with the information provided about the risks and benefits of procedures, and thirty-three percent reported not being satisfied with the availability of radiologists for consultation, potentially suggesting that some patients lack sufficient information to participate fully in treatment decisions. Patients were often unaware of what information they were entitled to receive. Over eighty percent of respondents were unfamiliar with the concepts of Value-Based Radiology and/or Value-Based Health Care. Conclusion: In addition to procedural correctness (correct diagnosis, appropriate procedures performed), patients highly value information and communication with their radiologist (information provided about procedures, explanation of results, personal consultation). Lack of communication was found to be a cause of dissatisfaction in many cases. This could suggest a means of improving patient outcomes as measured by Value-Based Health Care metrics. [ABSTRACT FROM AUTHOR]

This discussion paper has been produced within the context of the European Society of Radiology EuroSafe Imaging initiative and considers primarily the issues and challenges associated with justification of medical exposures using ionising radiation for individual patient diagnostic imaging procedures. It addresses both regulatory requirements and practical considerations and discusses approaches that are intended to improve justification. [ABSTRACT FROM AUTHOR]

In 2013, the new European Basic Safety Standards Directive 2013/59/Euratom (BSS Directive), which defines the new legal framework for the use of ionising radiation in medical imaging and radiotherapy, was published. In 2014, the ESR EuroSafe Imaging Initiative was founded with a goal in mind "to support and strengthen medical radiation protection across Europe following a holistic, inclusive approach". To support radiology departments in developing a programme of clinical audit, the ESR developed a Guide to Clinical Audit and an accompanying audit tool in 2017, with an expanded second edition released in 2019 and published under the name of Esperanto – ESR Guide to Clinical Audit in Radiology and the ESR Clinical Audit Tool, 2019. Audits represent specific aspects at a certain point in time, usually with retrospective evaluation of data. Key performance indicators (KPIs), on the other hand, are intended to enable continuous monitoring of relevant parameters, for example to provide warnings or a dashboard. KPIs, which can, for example, be recorded automatically and visualised in dashboards, are suitable for this purpose. This paper will discuss a selection of indicators covering different areas and include suggestions for their implementation. [ABSTRACT FROM AUTHOR]

The European Directive 2013/59/EURATOM requires member states of the European Union to ensure justification and optimisation of the radiological procedures and to include information on patient exposure as part of the report of the examinations. The EuroSafe Imaging campaign of the European Society of Radiology created a working group (WG) on "Dosimetry for imaging in clinical practice" with the aim to help with the dosimetry aspects required by European and national regulations. The primary focus topics were selected and a survey among the experts of the WG, allowed suggesting some initial consensus approaches. For information on patient exposure, it was agreed to include the dosimetric values reported by the imaging modalities (validated by a medical physics expert). It was also suggested to prepare educational material on dosimetric quantities for patients. Individual optimisation was considered a challenge, especially for interventional procedures. In these cases, patient and occupational doses should be part of the global optimisation process and trigger levels should be defined to avoid skin radiation injuries. Diagnostic Reference Levels (DRLs) always need to be considered for comparison with periodic patient dose audits. In the case of accidental or unintended exposures, a report should be produced for the Quality Assurance programme, together with an educational note to avoid the repetition of incidents. Dose registry and management systems should allow fulfilling the regulatory requirements of national and European regulations. In a second step, and after the initial experience with the Directive implementation, a wider survey will be considered. [ABSTRACT FROM AUTHOR]

Clinical audit "according to national procedures" is a legal requirement as defined within the recently implemented European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom. A survey was undertaken in 2019 to assess the current status of clinical audit in European radiology departments and for feedback on the recently published "ESR Guide to Clinical Audit in Radiology" and the "ESR Clinical Audit Tool (Esperanto)". The survey was distributed within the European Society of Radiology (ESR) EuroSafe Imaging Star network and also to European national radiological societies which are institutional members of the ESR. A total of 47/116 (41%) EuroSafe Imaging Star departments responded, and responses were received from 43 radiology departments from 16/48 national radiological societies. Survey findings demonstrated a low awareness of recent key ESR audit-related publications (Esperanto), a lack of clinical audit infrastructure for BSSD compliance and by inference a poorly developed local/national communication and audit infrastructure in many cases. Key stakeholders, including the ESR and the European national radiological societies, will need to continue to work with other bodies to further promote, integrate and to encourage resourcing of clinical audit at all levels, facilitating BSSD compliance and improving patient care. [ABSTRACT FROM AUTHOR]