1. Reduction of irradiation of the Belgian population which progress has been made? Guy Marchal

2. Strategic committee starting point Over the last years the level of irradiation of the Belgian population has increased dramatically due to diagnostic examinations. As a result Belgium is one of the world champions in this regard.

3. Overall objectives The first objective of the strategic committee is to reduce this growth and to bring the irradiation level back to the level of the neighboring countries. The second objective of the strategic committee is to improve the quality of the examinations performed. Pure cost savings can not be the goal. The money saved will be needed to preserve the quality of the diagnostic imaging service. (equipment that is needed but not fully used) In addition it is important to keep up with the fast technological evolution in medical imaging. The new technologies offer not only new diagnostic possibilities, but are often also less invasive and potentially less irradiating.

4. Strategy To act efficiently, a well defined long term strategy is needed. This strategy is defined by a strategic committee. The strategic committee is composed by representatives of different parties and analyses potential difficulties that could arise during the practical implementation and suggests possible solutions. The strategic committee refers to three subcommittees for the practical implementation of the overall objectives. Members of the strategic committee are also part of the core of the different subcommittees.

5. Subcommittee “guidelines” The task of this subcommittee is to formulate guidelines for the proper use of ionizing irradiation for diagnostic purposes. This group is composed by members of the FOD, the RIZIV, the FANC, the Consilium Radiologicum, BELNUC, representatives of other user groups, and the Belgian society of hospital Physicists. Current members of the committee : Guy Marchal (president), Lodewijk Van Bladel, Wim Janssens, Aldo Perissino and Nils Reynders-Frederix

6. Current situation Initial document: existing French guidelines (2005) Actualization (2010) by – Sections of KBVR – BELNUC Radiology : Differences between Flemish and French versions. Correlation needed as well as complete rewriting of Flemish version. Nuclear medicine: Document not ready yet Further correlation between two documents probably not feasible.

7. Current situation Initial document: existing French guidelines (2005) Actualization (2010) by – Sections of KBVR – BELNUC Radiology : Differences between Flemish and French versions. Correlation needed as well as complete rewriting of Flemish version. Nuclear medicine: Document not ready yet Further correlation between two documents probably not feasible. Potential negative financial impact of guidelines remains a major problem for many to fully collaborate!

8. Proposal for a new prescription order containing – Demographic patient data – Clinical information – Information needed for proper diagnosis or therapy expected from imaging study – Suggested examination – Referring physician – Expected irradiation dose?

9. Proposal for a new prescription order Expected from radiologist – Prescription accepted or changed – Argumentation if changed – Registration number of equipment used – Responsible radiologist – Level of accreditation imaging department?

10. Subcommittee “sensibilisation” The main objective is to increase the awareness of both the radiologist as well as the prescribing physician for the high level of diagnostic irradiation of the Belgian population by a sensibilisation campaign. The ultimate goal of this sensibilisation campaign is to reduce the overall irradiation dose for the population This group is composed by members of the FOD, the RIZIV, the FANC, the Consilium Radiologicum, BELNUC, representatives of other user groups, representatives of the GP’s, “hoge gezondheidsraad”,… Current members of the committee : Aldo Perissino and Wim Janssens (president), Lodewijk Van Bladel, Guy Marchal, Nils Reynders-Frederix, Hilde Engels, Jan Eyckmans and Corinne Souwer.

11. Current situation Sensibilisation of public and patients Information, per specialism about the level of diagnostic irradiation in their region Publicity about the guidelines Relevant individual information of each prescribing physician A change in the procedures and criteria for reimbursement

12. Current situation Sensibilisation of public and patients Information, per specialism about the level of diagnostic irradiation in their region – The level of irradiation per inhabitant – The relative contribution of each specialism in the prescription of the irradiating examinations – The examinations that contribute most to the irradiation per specialism Publicity about the guidelines Relevant individual information of each prescribing physician A change in the procedures and criteria for reimbursement

13. Current situation Sensibilisation of public and patients Information, per specialism about the level of diagnostic irradiation in their region Publicity about the guidelines – Integration in the software of the medical record management (2010 ) – Didactic brochures (2011) – Involvement of medical faculties, high schools medical technology Relevant individual information of each prescribing physician A change in the procedures and criteria for reimbursement

14. Current situation Sensibilisation of public and patients Information, per specialism about the level of diagnostic irradiation in their region Publicity about the guidelines Relevant individual information of each prescribing physician – The principle of precaution – The unnecessary examinations – The useless prescriptions – The erroneous prescriptions A change in the procedures and criteria for reimbursement

15. Current situation Sensibilisation of public and patients Information, per specialism about the level of diagnostic irradiation in their region Publicity about the guidelines Relevant individual information of each prescribing physician A change in the procedures and criteria for reimbursement – Standardized prescription form – Electronic communication of reports towards referring physicians – The patient management software must allow to calculate the cumulative patient dose (2010 ). – Possibility for radiologists to change requests in function of existing guidelines (2010).

16. Subcommittee accreditation and optimalisation This workgroup will try to formulate incentives to motivate the hospitals to promote dose reduction. These incentives are needed to support the use of the guidelines and to reach the strategic goals. This group is composed by members of the FOD, the mutualities, the RIZIV, the FANC, the Consilium Radiologicum, medical physicists. Current members of the committee : Guy Marchal (president), Aldo Perisinno, Greet Haelterman, An Fremout, Pascal Meeus, Nils Reynders-Frederix, Françoise Malchair, Julien Struyven, Denis Tack and Hilde Bosmans.

17. Financial incentives? Alternative for current mainly “fee for service model” towards a larger degree of forfaitarisation? Financial co-responsabilisation of prescribers? Extra financial compensation in function of quality parameters. ….

18. Current situation Optimalisation both by improved techniques as well as better training and optimal use Collaboration between FANC, physicists, academia, radiologists, via working groups, round tables, etc.. Accreditation – COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC RADIOLOGY PRACTICES (IAEA)

19. Proposed audit tool COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC RADIOLOGY PRACTICES: A TOOL FOR QUALITY IMPROVEMENT QUALITY ASSURANCE AUDIT FOR DIAGNOSTIC RADIOLOGY IMPROVEMENT AND LEARNING (QUAADRIL) INTERNATIONAL ATOMIC ENERGY AGENCY VIENNA, 2010

20. COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC RADIOLOGY PRACTICES Document contains 4 chapters: – QUALITY MANAGEMENT PROCEDURES AND INFRASTRUCTURE – PATIENT RELATED PROCEDURES – TECHNICAL PROCEDURES – EDUCATION, TRAINING AND RESEARCH PROGRAMS

21. COMPREHENSIVE CLINICAL AUDITS OF DIAGNOSTIC RADIOLOGY PRACTICES document contains 4 chapters: – QUALITY MANAGEMENT PROCEDURES AND INFRASTRUCTURE – PATIENT RELATED PROCEDURES – TECHNICAL PROCEDURES – EDUCATION, TRAINING AND RESEARCH PROGRAMS The intention is to reduce this audit book towards a for Belgium clinically relevant accreditation instrument (2010)

22. Conclusion There is a clear demand from the authorities to reduce the number of useless examinations There is a positive evolution in the collaboration between the FANC, the radiologists and the medical physicists working towards a more clinically relevant approach. What has to be avoided is too much emphasis on administration and paperwork, useless expenses, and no time left for better patient care.