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Submitted by Prof. Guy Frija, EuroSafe Imaging / European Society of Radiology
   Commenting on behalf of the organisation
Document Diagnostic Reference Levels in Medical Imaging
This comment is submitted by EuroSafe Imaging of the European Society of Radiology (ESR). EuroSafe Imaging welcomes the ICRP document on Diagnostic Reference Levels in Medical Imaging and would like to emphasise some aspects in regard to the concept of DRLs based on recent project work carried out in the field of DRLs and related findings and observations.

There are several issues related to the current concept and use of DRLs, one of them being that DRLs are protocol driven and not always understood and used correctly by the health professionals who have a role in subjecting a patient to a medical exposure.

Different clinical indications often require different image quality and thus different doses, which means that there should be separate specific DRLs for these clinical indications. It is essential to ensure diagnostic image quality. Optimisation must balance image quality and patient dose.

From the patient perspective, DRLs based on clinical indications are most relevant, as they better reflect the dose exposure for a given disease. This will also facilitate patient communication based on patient relevant data.
The ICRP document seems fully aligned with the ESR approach to DRLs based on clinical indications, although different terminology is currently being used (DRLs for a specified medical task vs. DRLs base don clinical indications). A harmonisation of terminology could be considered.

From a professional perspective however, the benefit-risk approach might be more easily endorsed by the referring physician.

For the team of the radiology department benchmarking is like to have a stimulating effect, as it is less abstract than DRLs oriented towards technical protocols.

As a general remark, we would like to point out the practical difficulty in getting enough patient numbers if DRLs are specified for the methodology, the anatomical region, the clinical indication, and for patient sizes deviating from the standard size (i.e. for children, slim or obese patients).

EuroSafe Imaging would like to encourage ICRP to strengthen these aspects in its document and looks forward to continued interaction in regard to the two organisations’ work on DRLs.