ORIGINAL ARTICLE

Radiation Dose Reduction in Kidney

Stone CT: A Randomized, Facility-Based
Intervention
Christopher L. Moore, MD a , Mythreyi Bhargavan-Chatfield, PhD b, Melissa M. Shaw, BS c,
Karrin Weisenthal, MD d, Mannudeep K. Kalra, MD e

Abstract

Objective: Kidney stones are common, tend to recur, and afflict a young population. Despite evidence and recommendations,
adoption of reduced-radiation dose CT (RDCT) for kidney stone CT (KSCT) is slow. We sought to design and test an intervention to
improve adoption of RDCT protocols for KSCT using a randomized facility-based intervention.
Methods: Facilities contributing at least 40 KSCTs to the American College of Radiology dose index registry (DIR) during calendar
year 2015 were randomized to intervention or control groups. The Dose Optimization for Stone Evaluation intervention included
customized CME modules, personalized consultation, and protocol recommendations for RDCT. Dose length product (DLP) of all
KSCTs was recorded at baseline (2015) and compared with 2017, 2018, and 2019. Change in mean DLP was compared between
facilities that participated (intervened-on), facilities randomized to intervention that did not participate (intervened-off), and control
facilities. Difference-in-difference between intervened-on and control facilities is reported before and after intervention.
Results: Of 314 eligible facilities, 155 were randomized to intervention and 159 to control. There were 25 intervened-on facilities, 71
intervened-off facilities, and 96 control facilities. From 2015 to 2017, there was a drop of 110 mGy ∙ cm (a 16% reduction) in the mean
DLP in the intervened-on group, which was significantly lower compared with the control group (P < .05). The proportion of RDCTs
increased for each year in the intervened-on group relative to the other groups for all 3 years (P < .01).
Discussion: The Dose Optimization for Stone Evaluation intervention resulted in a significant (P < .05) and persistent reduction in
mean radiation doses for engaged facilities performing KSCTs.
Key Words: CT, kidney stone, radiation dose reduction

J Am Coll Radiol 2021;-:---. Copyright ª 2021 American College of Radiology

INTRODUCTION receiving an average of 1.4 to 1.7 CTs per episode

Kidney stones will afflict as many as 1 in 11 people
in the United States, and more than half of patients
will experience recurrent disease [1-3]. In the United
States, as many of 85% of patients evaluated for
renal colic will undergo CT scanning, with patients
of renal colic [2,4]. CT scanning is thus a relatively
large source of medical radiation in this young
patient population, in which incidence of a first
symptomatic kidney stone peaks at age 30 in males
and age 35 in females [5,6].

a
Chief, Ultrasound Section, Department of Emergency Medicine, Yale
University School of Medicine, New Haven, Connecticut.
b
Executive Vice President for Quality and Safety, American College of
Radiology, Reston, Virginia.
c
Yale University School of Medicine, New Haven, Connecticut.
d
Boston Medical Center, Boston, Massachusetts.
e
Massachusetts General Hospital, Boston, Massachusetts.
Corresponding author and reprints: Christopher L. Moore MD, Yale
University School of Medicine, 464 Congress Avenue Suite 273, New
Haven, CT 06519; e-mail: Chris.moore@yale.edu.
Dr Moore reports grants from Agency for Healthcare Research and Quality,
during the conduct of the study; grants and personal fees from Philips
Healthcare, grants and personal fees from Caption Health Inc, outside the
submitted work. Dr Bhargavan-Chatfield reports grants from Agency for
Healthcare Research and Quality, during the conduct of the study. Ms
Shaw reports grants from Agency for Healthcare Research and Quality,
during the conduct of the study. Dr Kalra reports grants from Agency for
Healthcare Research and Quality, during the conduct of the study; grants
from Siemens Healthineers, grants from Riverain Tech Inc, personal fees
from Globus Medical, outside the submitted work. Dr Weisenthal states
that she has no conflict of interest related to the material discussed in this
article. Dr Moore, Dr Bhargavan-Chatfield, Ms Shaw, Dr Weisenthal, and
Dr Kalra are nonpartner, non–partnership track employees.

Copyright ª 2021 American College of Radiology

1546-1440/21/$36.00 n https://doi.org/10.1016/j.jacr.2021.05.004 1
 Visual Abstract
Kidney stones are particularly amenable to detection and
quantification of stone burden using reduced-radiation dose
CT (RDCT). Several studies report high sensitivity, speci-
ficity, and accuracy for kidney stone detection at substantial
radiation dose reduction without adverse effects on diagnosis
or treatment [7,8]. The ACR Appropriateness Criteria
recommend the use of RDCT for renal colic evaluation;
however, as of 2013, only about 2% of kidney stone CTs
(KSCTs) were performed with RDCT protocols [9,10].
RDCT use increased to approximately 8% of KSCTs by
2016, but it remains well below what is “as low as
reasonably achievable” [11,12]. Increased adoption of
RDCT protocols will decrease the overall radiation burden
associated with KSCT, which often requires repeat
imaging in relatively young patients.
We sought to design and test an intervention to improve
adoption of RDCT protocols for KSCT using a randomized
facility-based intervention. Facilities that participated in the
American College of Radiology dose index registry (DIR)
were eligible for randomization. Those randomized to
intervention were invited to participate in the Dose Opti-
mization for Stone Evaluation (DOSE) initiative, a multi-
faceted approach that included education on RDCT
protocols and personalized consultation for dose reduction.
We compared participating facilities to a control group and
nonparticipating facilities at baseline and at 1, 2, and 3 years
after intervention.
2 Journal of the American College of Radiology
METHODS
Facilities and KSCTs
The DIR is a national CT radiation dose registry sponsored
by the American College of Radiology. It was launched in
2011, and as of 2014 included 11.9 million CT examinations
contributed by 642 facilities across the United States [13].
Basic identifying and demographic information are
anonymized during automatic submission of radiation dose
descriptors from CT examinations done at participating
facilities to the DIR. Facilities tag their CT examinations to
a corresponding study descriptor, which is mapped to
Radlex Playbook Identifiers that group similar examinations
together based on test characteristics and body part
scanned. CT dose information includes CT dose index
volume (CTDIvol) (in milligrays) and dose length product
(DLP) (in milligrays per centimeter) with optional size-
specific dose estimate (SSDE) (in milligrays) [14].
Facilities participating in the DIR may contribute
independently (stand-alone) or may be part of a system that
includes multiple independently contributing sites. If there
are multiple facilities contributing from a single site, the
overall site has a master ID that links to each “child” facility
in the system; these are referred to as master and child
facilities. Facilities with multiple imaging locations are
provided a master ID that links associated facilities together
with a child ID to examine data collectively or individually.
Facilities could thus be master, child, or stand-alone. The
Volume - n Number - n Month 2021
term “child” facility has been used by the DIR for some time
and is maintained in this article but does not refer to
pediatric facilities. Any of the facilities (master, child, or
stand-alone) can see any type of patient.
We defined KSCTs based on study descriptor nomen-
clature consistent with stone evaluation (ie, stone, flank
pain, renal colic). Study descriptors associated with multi-
phase or contrast-enhanced examinations and study
descriptors from facilities contributing fewer than 40 KSCT
examinations were excluded. Facilities that contributed at
least 40 KSCTs to the DIR in 2015 were eligible for
randomization to control or intervention groups.
Recorded dose data included DLP, CTDIvol, and SSDE
(milligrays), when available, for each of the following years:
2015, 2017, 2018, and 2019. Facilities that did not have at
least 20 KSCTs in each year for follow-up (2017, 2018,
2019) were excluded from analysis.
DOSE Intervention
Facilities assigned to intervention were recruited to partici-
pate in the DOSE initiative [15]. An initial e-mail invitation
to participate directly was sent from the DIR, with DOSE
team initially blinded to facilities for privacy purposes. In
the initial contact e-mail, facilities were provided
information to access online educational modules free of
charge and invited to visit the DOSE website [15] for
more information on participation in the project. E-mails
were sent to all available persons associated with the
facility in the DIR, which could include the facility
administrators, registry administrators, and any users.
The online educational modules were created collabora-
tively with radiologists from Massachusetts General Hospital
through the RadIQ platform (www.radiq.org). The RadIQ
platform allows incorporation of teaching cases using actual
DICOM images that can be visualized as if looking at images
on a hospital PACS system. The first course, entitled “Inter-
pretation of Low Dose Kidney Stone CT,” was geared toward
radiologists and included 16 cases for 4.0 hours of CME. The
second course, “Optimizing Scan Protocol and Radiation Dose
in Kidney Stone CT,” was appropriate for both radiologists
and CT technicians who may be involved in adjusting CT
protocols. This module offered 19 cases for 4.75 hours of
CME. Both modules were offered free of charge to all
personnel at facilities participating in DOSE.
Facilities who accessed the RadIQ courses or submitted re-
quests for more information through the DOSE website or
other response to e-mail were subsequently contacted by a
DOSE team member. The initial contact was facilitated by the
project director (M.M.S.), who arranged consultation with other
DOSE team members as appropriate. Participating facilities were
encouraged to have all CT technologists, medical physicists, and
radiologists in their department complete the RadIQ modules.
Journal of the American College of Radiology
Moore et al n Radiation Dose Reduction in Kidney Stone CT
In parallel with the RadIQ CME modules, facilities
were provided with a personalized DOSE consultation
regarding CT protocols for kidney stone. The DOSE team
requested information regarding current CT imaging
equipment and protocols for KSCT at each institution.
Baseline protocols were used to provide detailed recom-
mendations for radiation dose reduction as part of a DOSE
consultation report. The DOSE consultation report con-
tained two CT protocols specific to the available brand and
model of CT scanners used that were developed by a radi-
ologist on the DOSE team (MK, radiologist with more than
10 years of experience in CT protocol and radiation dose
optimization). The first protocol was intended for undif-
ferentiated flank pain and had an intermediate radiation
dose reduction compared with their standard noncontrast
abdominal-pelvic CT protocol. The second protocol was
intended for follow-up of known KS or high pretest prob-
ability of KS that further reduced radiation exposure.
Facilities whose current KSCT examination dose index was
relatively higher (zDLP > 900 mGy ∙ cm) were offered
an intermediate LDCT option to optimize KSCT to avoid
drastic image changes for the comfort of those reading
and interpreting the CT images.
After providing the CME and DOSE consultation
report, facilities were contacted by e-mail to set up a call
about the protocols and to address any concerns or ques-
tions. Randomized facilities that did not initially respond
were contacted via subsequent e-mails and telephone calls to
encourage participation. If facilities did not respond after
three e-mails and three telephone calls, they were assumed to
be not interested. Facilities who initially responded but did
not complete any portion of the intervention were excluded.
Participation was defined as completion of at least one CME
module. DOSE participation additionally qualified as a
practice quality improvement measure, and any interested
facilities were supplied an ACR-approved practice quality
improvement template.
Statistical Analysis
Statistical analysis was performed in SAS 9.4 (SAS Institute,
Cary, North Carolina). Mean, SD, median, and 25th and
75th percentiles of DLP for all KSCTs were calculated at
baseline and for calendar years 2017, 2018, and 2019.
Baseline (2015 calendar year data) dose data were collected
for all facilities and compared with 1, 2, and 3 years after
intervention. Median and 25th and 75th percentiles mea-
sures are used to describe typical performance of the facilities
by group and year. Statistical difference-in-difference anal-
ysis used fixed-effect and random-effect model to compare
change in mean DLP before and after intervention in the
facilities that were intervened on to the corresponding
3
change in control facilities. The difference-in-difference
comparisons of the facility means were used to determine
if there was a significant difference between facilities that
were intervened on compared with those that did not
participate and the control group, and if these changes
persisted over time. In an effort to minimize statistical
overtesting in presence of identical trends among CTDIvol
and DLP across different facilities (and because SSDE was
incompletely reported), we limit our results to DLP as it is
the most commonly reported dose descriptor in prior
publications on RDCT use for KSCT protocols [12].
Distribution of examinations by DLP categories are
reported for all years in the analysis. Percent of examinations
with DLP below 400 is used as an indicator of RDCTs;
generalized mixed modeling was used to assess significance
of the difference-in-difference in this measure.
Institutional Review Board
As a quality improvement project involving anonymized
data this project was exempt from institutional review board
approval.
RESULTS
Out of 161,293 study descriptors in the DIR, there were
481 study descriptors consistent with KSCT that mapped to
41 Radlex Playbook Identifiers. From 1,512 active
facilities in the DIR, there were 380 facilities contributing
at least 40 KSCTs in calendar year 2015 (baseline). There
were 314 child and stand-alone facilities, of which 155
facilities were randomized to intervention and 159 were
in the control group (Fig. 1). Of the 155 facilities
Fig 1. Enrollment diagram with exclusions. “Master” facilities refers to IDs associated with facilities that are made up of
multiple “child” facilities (child meaning below master, not pediatric). The master IDs are used to link the child facility IDs
together but do not contain unique data. These were excluded to avoid duplicate counting of results. KSCT ¼ kidney
stone CT.
4 Journal of the American College of Radiology
randomized to intervention, 38 initially responded,
although only 25 actually engaged in the intervention
(completed at least one CME module). For the final
analysis, there were 96 control facilities and 96 test
facilities including 25 that participated in the intervention
(“intervened-on”) and 71 that did not participate despite
repeated attempts to include them (“intervened-off”).
Facility demographics and number of KSCT per year are
summarized in Table 1.
Ultimately, there were 32 dual protocols (one for
baseline or initial KSCT and the other for follow-up KSCT)
developed for the four major manufacturers: Siemens (15),
GE (11), Philips (3), Toshiba (3). The distribution of ma-
chines was based on whatever equipment and models were
available at each site, and could be reused at different sites
that had the same equipment. These protocols are available
on the DOSE website [15].
Overall, there were 422,039 KSCTs across 4 years from
the 192 facilities included in the analysis. Overall mean and
median DLP, CTDIvol, SSDE, and proportion of exami-
nations stratified by DLP is shown in Table 1. Baseline
mean DLP (SD) in 2015 was 691 (202) mGy ∙ cm in
the control group, 689 (297) mGy ∙ cm in the
intervened-on group, and 663 (223) mGy ∙ cm in the
intervened-off group. From 2015 to 2017, the mean DLP in
the intervened-on group dropped 110 mGy ∙ cm (a 16%
reduction; Fig. 2). Regression analyses adjusting for facility
random effects showed the decrease in DLP between 2015
and 2017 using a difference-in-difference comparison was
significantly different for the intervened-on group than for
the control group (P < .05). Figure 2 shows the persistence
of dose reduction in each group over subsequent years.
Volume - n Number - n Month 2021
 The proportion of studies that could be considered reduced
dose (DLP < 400 mGy ∙ cm) increased in the “intervened-on”
group from 22% in 2015 to 33% in 2017 and 36% in 2019
(Figure 3), a higher proportion than in the other groups. The
change in the intervened-on group over time is significantly
different from the control group in 2017, 2018, and 2019
relative to 2015 (P < .01 for all three comparisons).
DISCUSSION
To our knowledge, this is the first intervention performed at
a national facility level to measure the effects of an inter-
vention to reduce CT radiation dose specific to kidney stone
imaging. The mean reduction in radiation dose for KSCTs
was significant (P < .05) in facilities that participated in the
DOSE intervention when compared both with the control
group and facilities that opted not to participate, and the
radiation dose reduction persisted over 3 years of observa-
tion. Although mean facility DLP in the control group did
drift down over time, the drop in the intervened-on group
occurred more quickly and drifted up only slightly over
time, remaining lower in 2019 than either other group, even
though it started higher than the group that declined
intervention. This suggests that sustainable radiation dose
reduction through education is feasible and can promote
sustainable change.
We are aware of one other initiative at the facility level
for a broad array of CT scanning applications that showed

Table 1. Facility demographics and KSCT examinations performed by year

Demographic and Year All (n ¼ 192) Control (n ¼ 96) Intervened-on (m ¼ 25) Intervened-off (n ¼ 71)

Environment*
Urban 48.1% (91) 43.2% (41) 52.0% (13) 53.6% (37)
Suburban 39.7% (75) 42.1% (40) 44.0% (11) 34.8% (24)
Rural 12.2% (23) 14.7% (14) 4.0% (1) 11.6% (8)

Academic 17% (34) 16.7% (16) 8.0% (2) 22.5% (16)

Trauma level
Level I 17.2% (33) 17.7% (17) 8.0% (2) 19.7% (14)
Level II 14.6% (28) 13.5% (13) 8.0% (2) 18.3% (13)
Other 68.2% (131) 68.8% (66) 84.0% (21) 62.0% (44)

Location
Northeast 22.4% (43) 20.8% (20) 20.0% (5) 25.4% (34)
South 25.5% (49) 33.3% (32) 24.0% (6) 15.5% (11)
Midwest 40.6% (78) 34.4% (33) 44.0% (11) 47.9% (34)
West 11.5% (22) 11.5% (11) 12.0% (3) 11.3% (11)

Facility type
Stand-alone 28.1% (54) 33.3% (32) 20.0% (5) 23.9% (17)
Child 71.9% (138) 66.7% (64) 80.0% (20) 76.1% (54)

KSCT examinations per year mean (SD)

Year
2015 519 (567) 514 (515) 602 (689) 497 (593)
2017 584 (676) 573 (647) 617 (711) 586 (709)
2018 550 (596) 547 (602) 692 (811) 505 (492)
2019 545 (660) 568 (742) 695 (852) 461 (418)

KSCT examinations per year median (interquartile range)

Year
2015 393 (119,687) 405 (119,706) 277 (611,143) 384 (133,677)
2017 361 (127,782) 371 (130,724) 500 (78,961) 354 (166,908)
2018 333 (146,779) 331 (149,723) 425 (56,1217) 332 (177,768)
2019 311 (127,793) 362 (127,784) 242 (52,1249) 278 (160,674)

Note that “child” facilities refers to facilities that are part of a larger group, and “stand-alone” facilities are independent. KSCT ¼ kidney stone CT.
*Three facilities did not report.

Journal of the American College of Radiology 5

Moore et al n Radiation Dose Reduction in Kidney Stone CT
Fig 2. Change in mean facility dose length product in mGy ∙ cm by group.
that tailored intervention is more effective than simple
auditing [16]. Auditing would also occur in the control and
intervened-off groups that we followed in our study as part
of their participation in the DIR. Our results reinforce that
tailored intervention is more effective than auditing, and
demonstrate that examination-specific tailored education
can be effective.
It is the shared responsibility of medical users of
radiation dose or radiation dose-based imaging tests
such as CT to ensure use of as low as reasonably
achievable radiation doses. This is particularly true for
an indication such as KSCT, in which there is un-
equivocal evidence that RDCT can be employed
without adverse effects. KSCT is a particularly attractive
target for radiation dose reduction because high-contrast
kidney stones can be detected and quantified for stone
burden despite high image noise content and artifacts
associated with LDCT [7].
Despite the dramatic increase in use of CT scanning for
the diagnosis of renal colic over the last several decades,
6 Journal of the American College of Radiology
there is little evidence that CT has impacted rates of
diagnosis, admission, or intervention [4,17,18]. Approaches
that forego CT and utilize ultrasound first have been shown
to be safe and effective [19]. The vast majority of kidney
stones will pass spontaneously, and those that are larger
and more likely to require intervention are readily
detectable using reduced radiation dose [20,21].
Although statistically significant, the reduction in dose
was relatively modest, demonstrating the difficulty in
achieving and maintaining substantial change in this area.
Despite repeated attempts to provide free resources to
facilitate radiation dose reduction, a minority of facilities
randomized to intervention opted to participate. Notably,
these facilities exhibited less radiation dose reduction over
time when compared with controls, suggesting these facil-
ities may have overall been less interested or motivated to
adjust protocols to decrease radiation dose. There could be
several reasons for a reluctance to adopt RDCT recom-
mendation despite specific recommendations from national
societies and our DOSE initiatives.
Volume - n Number - n Month 2021
Fig 3. Proportion of reduced-radiation dose kidney stone CTs (DLP < 400 mGy∙ cm) each year by group. DLP ¼ dose length
product.
Unfortunately, the lack of adoption of RDCT is not
unique to KSCT. A recent study of dose descriptors from 72
US facilities found that up to 65% (47 of 72) facilities had
median doses above the ACR guidelines for RDCT in lung
cancer screening [22]. Both KSCT and lung cancer screening
share similar imaging attributes of high inherent lesion
contrast between the anticipated lesions (kidney stones or
pulmonary nodules) and the background organ parenchyma
that offers fertile basis for RDCT. These observations are
in stark contrast to multisite, multiyear data on
mammography in the United States that document mean
glandular dose to the breasts well below the compliance
limit of 3 mGy for a single craniocaudal view of the breast
set in the congressionally enacted Mammography Quality
Standards Act of 1992, suggesting that legislation rather
than voluntary participation is likely more effective [23].
Our results were certainly limited by the relatively low
response of facilities who were willing to participate, which
is likely related to the lack of factors to encourage motivation
for change. Although we made multiple attempts to contact
facilities via e-mail and telephone, the response rate was low.
It is also possible we were simply unable to get in touch with
personnel who may have been willing to participate.
Notably, the proportion of academic facilities that partici-
pated was lower than nonacademic (17% of facilities but
only 8% of participation) for unclear reasons, perhaps
because they felt they had more resources to do this on their
own or had other priorities. Although we counted a facility
as having participated if they completed at least one CME
module, it is likely that change was more impacted by
facilities who completed the full intervention. However,
although the absolute reductions in radiation dose in our
study were modest, given the number of KSCTs performed
Journal of the American College of Radiology
Moore et al n Radiation Dose Reduction in Kidney Stone CT
year over year at these facilities, the population effect of a
modest change is still potentially important [24].
The measure of radiation dose used in this project is
DLP, which is what is consistently reported by facilities to the
DIR. DLP is a measure of delivered radiation along the length
of the patient and does not take patient size into account. An
SSDE would be a better measure of absorbed dose [14]. As of
2015, in many cases the SSDE was reported in fewer than
half of the CTs (Table 2). Although this did increase to
more than three-quarters of CTs by 2019, using SSDE
alone would have provided an incomplete picture. It is likely
that the change in DLP is representative of the change in
absorbed dose as long as patient characteristics are relatively
constant year over year. The changes in CTDIvol were fairly
similar to the changes in DLP (Table 2), although in some
cases our protocol suggestions included a shorter scan
length, which could reduce delivered (and absorbed) dose at
the same CTDIvol, so we felt that DLP represented the
best measure of radiation to report in this case.
We are unable to tell if changes in CT protocols affected
diagnostic accuracy. However, multiple prior studies
(including a meta-analysis) have demonstrated that diag-
nostic accuracy is maintained even with substantial radiation
dose reduction [7,8,20]. It is very likely that diagnostic
accuracy is well maintained given the relatively modest
effects achieved in this intervention.
As CT imaging equipment and algorithms improve,
there is a move toward radiation dose reduction over time
even without intervention, as seen particularly in the control
group that received no attempt at intervention. All facilities
in our study were already participating in the ACR DIR
initiative, which does provide feedback and may help facil-
ities adjust their protocols to be more in line with other
7
 8

Table 2. Detailed CT radiation dose results by group and year

Characteristic or Category 2015 % 2017 % 2018 % 2019 %

Control (n ¼ 96)
DLP (in mGy ∙ cm)
No. of CT examinations with information 49,330 54,995 52,481 54,543
Mean (SD) 691 (202) 662 (205) 642 (207) 649 (221)
Median (IQR) 712 (551,814) 645 (519,791) 640 (501,793) 612 (515,797)
No. of CT examinations in DLP ranges (mGy ∙ cm)
<200 2,385 4.8 3,729 6.8 3,478 6.6 3,577 6.6
200-399 4,329 8.8 6,111 11.1 6,206 11.8 6,956 12.8
300-399 5,883 11.9 7,517 13.7 7,585 14.5 8,125 14.9
400-499 5,867 11.9 6,750 12.3 6,906 13.2 7,062 12.9
500-599 5,526 11.2 6,025 11.0 5,870 11.2 5,995 11.0
600-699 4,846 9.8 5,254 9.6 4,875 9.3 4,853 8.9
700-799 4,086 8.3 4,166 7.6 3,987 7.6 3,892 7.1
800-899 3,244 6.6 3,422 6.2 3,148 6.0 3,342 6.1
900-999 2,893 5.9 2,983 5.4 2,604 5.0 2,639 4.8
1,000 10,271 20.8 9,038 16.4 7,822 14.9 8,102 14.9
Dose (CTDIvol) in mGy
No. of CT examinations with information 49,330 54,995 52,481 54,543
Mean (SD) 14.3 (4.2) 13.4 (4.2) 13.1 (4.4) 13.1 (4.6)
Median (IQR) 14.3 (11.2,17.3) 13.2 (10.5,16.2) 13.1 (10.3,15.9) 12.0 (10.3,15.9)
Journal of the American College of Radiology

SSDE in (mGy)
No. of CT examinations with information 26,411 32,955 32,334 35,122
% of total CT examinations with SSDE 54 60 62 64
Mean (SD) 15.4 (4.9) 13.6 (4.2) 13.1 (5.0) 13.4 (5.0)
Volume - n Number - n Month 2021

Median (IQR) 15.3 (11.8,18.3) 13.6 (9.8,15.8) 13.6 (9.8,15.8) 13.2 (10.1,15.6)

Intervened-on (n ¼ 25)
DLP (in mGy ∙ cm)
No. of CT examinations with information 15,053 15,433 17,304 17,368
Mean (SD) 689 (297) 582 (176) 585 (171) 593 (168)
Median (IQR) 678 (534,731) 569 (508,714) 583 (519,673) 583 (509,692)
No. of CT examinations in DLP ranges (mGy ∙ cm)
<200 700 4.7 1,076 7.0 942 5.4 905 5.2
200-399 1,188 7.9 1,820 11.8 2,269 13.1 2,417 13.9
300-399 1,464 9.7 2,219 14.4 2,749 15.9 2,848 16.4
Moore et al n Radiation Dose Reduction in Kidney Stone CT
Journal of the American College of Radiology

400-499 1,970 13.1 2,294 14.9 2,558 14.8 2,573 14.8

500-599 1,950 13.0 1,897 12.3 2,038 11.8 1,958 11.3
600-699 1,793 11.9 1,418 9.2 1,545 8.9 1,442 8.3
700-799 1,247 8.3 1,137 7.4 1,244 7.2 1,139 6.6
800-899 1,280 8.5 904 5.9 988 5.7 990 5.7
900-999 1,057 7.0 771 5.0 778 4.5 807 4.6
1,000 2,404 16.0 1,897 12.3 2,193 12.7 2,289 13.2
Dose (CTDIvol) in mGy
No. of CT examinations with information 15,053 15,433 17,304 17,368
Mean (SD) 14.3 (5.8) 12.0 (3.4) 11.9 (3.2) 12.0 (3.2)
Median (IQR) 13.1 (12.0,15.2) 12.1 (10.1,14.6) 12.1 (9.9,13.9) 12.1 (9.9,13.9)
SSDE (in mGy)
No. of CT examinations with information 6,142 8,969 12,926 13,017
% of total CT examinations with SSDE 41 58 75 75
Mean (SD) 14.7 (5.7) 12.4 (2.9) 12.2 (3.0) 12.6 (3.0)
Median (IQR) 13.5 (12.0,17.0) 12.2 (10.7,14.9) 12.4 (11.0,17.7) 14.3 (11.0,17.7)

Intervened-off (n¼71)
DLP (in mGy ∙ cm)
No. of CT examinations with information 35,275 41,611 35,890 32,756
Mean (SD) 663 (223) 654 (216) 646 (222) 649 (222)
Median (IQR) 648(507,821) 658 (494,781) 637 (478,794) 649 (489,786)
No. of CT examinations in DLP ranges (mGy ∙ cm)
<200 2,042 5.8 2,709 6.5 2,248 6.3 1,847 5.6
200-399 3,798 10.8 3,937 9.5 3,643 10.2 3,256 9.9
300-399 4,177 11.8 4,386 10.5 4,158 11.6 4,373 13.4
400-499 4,353 12.3 4,923 11.8 4,489 12.5 4,347 13.3
500-599 3,797 10.8 4,561 11.0 4,274 11.9 3,910 11.9
600-699 3,282 9.3 4,119 9.9 3,339 9.3 3,029 9.2
700-799 2,569 7.3 3,193 7.7 2,608 7.3 2,327 7.1
800-899 2,221 6.3 2,617 6.3 2,033 5.7 1,752 5.3
900-999 1,890 5.4 2,253 5.4 1,749 4.9 1,610 4.9
1,000 7,146 20.3 8,913 21.4 7,349 20.5 6,305 19.2
Dose (CTDIvol) in mGy
No. of CT examinations with information 35,275 41,611 35,890 32,756
Mean (SD) 13.8 (4.5) 13.5 (4.3) 13.3 (4.4) 13.4 (4.6)
Median (IQR) 13.2 (10.8,17.1) 13.6 (10.0,16.7) 13.6 (9.4,15.5) 13.6 (9.5,16.0)
SSDE (in mGy)
(continued)
9
 institutions that are achieving lower radiation doses for

%
similar studies. It is likely that if our results were compared
with institutions that do not participate in the DIR, the
differences would be even greater. However, as this study

13.8 (9.8,16.8)
demonstrates, with appropriate education and attention to
13.8 (4.8)
27,138

protocols, this reduction can be enhanced and maintained.

2019

83

The DOSE initiative for radiation dose reduction in KSCT

has developed and maintained resources that may be useful
to facilities interested in optimizing their protocols for CT
in kidney stone. These include the two CME modules on
RadIQ and the CT scanning protocols on the DOSE
%

website [15,25,26].
13.7 (10.3,16.0)

TAKE-HOME POINTS
13.6 (4.3)
29,129
2018

81

- This analysis included 422,039 KSCTs from 192

facilities during 2015, 2017, 2018, and 2019.
- This randomized, controlled intervention achieved a
substantial reduction of 110 mGy ∙ cm in mean DLP
CTDIvol ¼ CT dose index volume; DLP ¼ dose length product; IQR ¼ interquartile range; SSDE ¼ size-specific dose estimate.
%

for KSCTs done by participating facilities compared

with control facilities.
- The proportion of reduced dose CTs increased in
13.6 (11.4,16.8)

participating facilities for all years postintervention.

13.8 (4.5)
35,010
2017

84

ACKNOWLEDGMENTS
This study was funded by the Agency for Healthcare
Research and Quality, R18HS023778. This research was
supported by the American College of Radiology’s National
%

Radiology Data Registry (NRDR). The authors thank ACR

staff for assistance in preparation of the data and acknowl-
edge guidance and input by the NRDR steering committee
14.3 (11.0,17.7)
14.6 (5.3)

for this analysis.

21,226
2015

60

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