HERCA Survey: Use of CT for IHA in Europe - WHO · HERCA Survey: Use of CT for IHA in Europe WHO...

HERCA Survey: Use of CT for

IHA in Europe

WHO International Consultation, 15-17th of October 2014, Munich, Germany

Eva G. Friberg

Norwegian Radiation Protection Authority

HERCA: Heads of the European Radiological protection Competent Authorities

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)


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)


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.


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.

2nd survey in July 2012

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

21 answers Austria

Belgium

Bulgaria

Denmark

Estonia

Finland

France

Germany

Greece

Ireland

Iceland

Lithuania

Luxembourg

Norway

Poland

Romania

Spain

Sweden

Switzerland

The Netherlands

United Kingdom


Question 1

To your knowledge, in your country, are CT

examinations on asymptomatic individuals outside

screening program being performed?

1

2

YES Greece, Austria,

UK, Spain,

Switzerland,

France, Norway,

Germany

NO Belgium*, Finland,

Lithuania, NL,

Sweden, Bulgaria,

Denmark, Iceland,

Ireland, Poland,

Romania, Estonia,

Luxembourg

8

13

* 1 institute under suspicion


Question 2

Does your Authority(ties) actively search for

the existence of these practices?

YES

Lithuania, UK,

Romania,

Norway,

Germany

NO Greece, Belgium,

Finland, Austria, NL,

Sweden, Spain,

Bulgaria, Denmark,

Iceland, Ireland,

Poland, Switzerland,

Estonia, France,

Luxembourg

1

2

16

5


Question 3

Is it or would it be allowed from a legal

point of view / tolerated in your

country?

YES Sweden, UK,

Ireland,

Switzerland

NO Greece, Belgium, Finland,

Austria, Lithuania, NL, Spain,

Bulgaria, Denmark, Iceland,

Poland, Romania, Estonia,

France, Luxembourg, Norway,

Germany

1

2

17

4


Question 3

Is it or would it be allowed from a legal

point of view / tolerated in your

country?

Comments if ‘YES’:

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


Question 4

Does your current regulation mention

exposure to asymptomatic individuals?

YES UK, Bulgaria,

Denmark,

Poland,

Switzerland

NO Greece, Belgium,

Finland, Austria,

Lithuania, NL, Sweden,

Spain, Iceland, Ireland,

Romania, Estonia,

France, Luxembourg,

Norway, Germany

1

2

16

5


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)


Question 6

Are CT examinations on asymptomatic

individuals outside screening program

reimbursed?

1

2

3

Do not know/

not sure

(private companies)

NL, Denmark, Ireland, Austria

NO Greece, Belgium, Finland, Norway, Lithuania, Sweden, UK, Spain**,

Bulgaria, Iceland, Poland, Romania,

Estonia, France, Luxembourg

YES Switzerland,

Germany*

14

2 5

* *Spain « only by some private companies »

* Germany « yes,

after a ‘dedicated’

justification »


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

YES Belgium, Austria,

NL, UK*, Spain,

Switzerland,

Norway**,

Germany***

1

213

8

Small case phenomenon except for :

* A significant budget is spent an national campaigns

**Mainly on CT calcium score

*** Increasing problem


Examples : Spain


Examples : Belgium/NL

www.privatescan.nl or www.bodyscan.nl

www.prescan.be or www.prescan.net

www.prescan.co.uk

www.lichaamscan.nl

www.groupon.com


http://www.prescan.be/

Examples : UK

http://www.lifescanuk.org/about-us?gclid=CN-HgNXstLECFYzbfAod3VcAug

http://www.lifescanuk.org/about-us/partners

+ TV commercials especially on Sky











http://www.prescan.nl/

Examples : Switzerland

http://www.doublecheck.ch/


Examples : France

http://www.american-hospital.org/fr/notre-offre-de-soins/bilans-de-sante-prevention.html


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

Question 8


Example from Belgium

http://www.zuinigmetstraling.be/fr

Medical images are not

family photos. No X rays

without reason


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: www.herca.org


http://www.herca.org/

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