“Registry data, and in particular the derived indices, will help sites optimize their practice, because you are highlighting practice aspects that might need more attention,” says Kevin A. Wunderle, PhD. The Bulletin recently spoke with Wunderle, diagnostic medical physicist at Cleveland Clinic and associate professor of radiology in the Cleveland Clinic Lerner College of Medicine, and A. Kyle Jones, PhD, lead medical physicist for the ACR’s Dose Index Registry (DIR) Fluoroscopy Education Committee and professor of imaging physics at the University of Texas MD Anderson Cancer Center in Houston, to learn more about the ACR’s new DIR Fluoroscopy module.

The DIR is one of eight registries that comprise the National Radiology Data Registry (NRDR®). The DIR allows participating facilities to compare dose indices against national benchmarks. It also enables facilities to evaluate and compare details about scanner and device performance across participating facilities. The ABR has qualified participation in the DIR as meeting the criteria for practice quality improvement in the ABR Maintenance of Certification program.

Nine facilities piloted the fluoroscopy module before its official launch earlier this year. It is the first of three new DIR modules (with nuclear medicine and digital radiography pilots underway) that build on CT dose indices — which, until now, were the only collected and reported data in the DIR.

Why is the registry such a valuable tool?

Jones: As a physicist, it is really challenging to understand where your site or your practice stands with regards to dose management in fluoroscopy. There is no current normative data set — the best we have is 20 years old. To have any hope of knowing where you are compared to where you want to be, you need to have access to the registry. The fluoroscopy module is now open for enrollment and data submission. Anyone already sending CT data can participate at no cost, and there is minimal extra work involved in submitting fluoroscopy data.

Wunderle: The DIR CT has been extraordinarily successful and has provided an ongoing source of normative clinical data for national and international benchmarking. Participation is a key aspect of a quality assurance program in fluoroscopy. We hope this will ultimately reduce variability in radiation usage for procedures performed using fluoroscopy and promote the adoption of best practices for fluoroscopically-guided procedures.¹

What did you learn through the pilot?

Jones: We wanted to measure the accuracy and consistency of fluoroscopy dose index reporting and report rates of radiation use and safety, trainee participation in procedures, and optional hardware availability at pilot sites. In the past decade, there have been a number of technological advances — radiation dose-reduction techniques — and current fluoroscopic systems have lower default dose rates. There is more awareness of dose-reduction techniques, which we are seeing as we analyze the pilot data. So far, the registry contains information on more than 50,000 procedures — and the ones we have looked at so far show that typical dose indices (e.g., for placement of inferior vena cava filters) are down substantially since the year 2000.

Wunderle: Participation in the DIR Fluoroscopy is an ideal way to identify opportunities for improvement by comparing data to and help promote best practices. The increasing scope and number of fluoroscopically-guided procedures performed each year makes the addition of a fluoroscopy module to the ACR DIR a logical next step to enhancing the safety and quality of patient care.

I think most people understand the enormous benefits that the DIR CT has brought to the radiology table. Our goal is to translate that success and that infrastructure to fluoroscopy as an imaging modality.

Are there any potential challenges when using the DIR?

Jones: We (the pilot group) have done a lot of work updating the ACR Common™ lexicon (a collection of common terms and semantics throughout the specialty) so that everyone using the registry will be using the same language. The quality of the comparisons from the DIR is directly tied to how well a facility maps its terminology to that of ACR Common. If you do a poor job at this, you may not get any useful insight into your practice.

Wunderle: I think most people understand the enormous benefits that the DIR CT has brought to the radiology table. Our goal is to translate that success and that infrastructure to fluoroscopy as an imaging modality.

Where can existing or potential participating sites learn more about the DIR Fluoroscopy?

Jones: The ACR website on DIR Fluoroscopy is constantly updated, and interested registry participants should visit the fluoroscopy webpage at acr.org/DIR-Fluoro to learn more about what is coming down the pike.

Wunderle: A series of webinars on the DIR as a whole, and on individual index modules, is in the works. In addition, while the current DIR Fluoroscopy focuses on IR and neurointerventional radiology, a pilot slated to start by the end of the year will expand that scope to include fluoroscopy in diagnostic radiology.