title: Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS).
abstract: OBJECTIVE
  To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose.
  
  
  RESULTS
  We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs.
  
  
  CONCLUSIONS
  Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally.
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA andrew.einstein@columbia.edu.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Einstein
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Thomas N B
authors.initials: TN
authors.lastname: Pascual
authors.affiliation: Division of Cardiology, Department of Medicine, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA.
authors.forename: Mathew
authors.initials: M
authors.lastname: Mercuri
authors.affiliation: Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ganesan
authors.initials: G
authors.lastname: Karthikeyan
authors.affiliation: Quanta Diagnóstico & Terapia, Curitiba, Brazil.
authors.forename: João V
authors.initials: JV
authors.lastname: Vitola
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Mahmarian
authors.affiliation: Department of Nuclear Medicine, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia.
authors.forename: Nathan
authors.initials: N
authors.lastname: Better
authors.affiliation: Centre Hospitalo-Universitaire de Bab El Ouéd, Alger, Algeria.
authors.forename: Salah E
authors.initials: SE
authors.lastname: Bouyoucef
authors.affiliation: Department of Nuclear Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.
authors.forename: Henry
authors.initials: H
authors.lastname: Hee-Seung Bom
authors.affiliation: Department of Nuclear Medicine and PET-CT, Jaslok Hospital and Research Centre, Mumbai, India.
authors.forename: Vikram
authors.initials: V
authors.lastname: Lele
authors.affiliation: Department of Physical Sciences and Mathematics, University of the Philippines, Philippines Department of Nuclear Medicine, University of Santo Tomas Hospital, Manila, Philippines.
authors.forename: V Peter C
authors.initials: VP
authors.lastname: Magboo
authors.affiliation: Departamento de Cardiología Nuclear, Instituto Nacional de Cardiología 'Ignacio Chávez', Mexico, Mexico.
authors.forename: Erick
authors.initials: E
authors.lastname: Alexánderson
authors.affiliation: Cardiology Department, Al Azhar University, Cairo, Egypt.
authors.forename: Adel H
authors.initials: AH
authors.lastname: Allam
authors.affiliation: Division of Advanced Cardiac Imaging, King Saud bin Abdulaziz University for Health Sciences, Riyad, Saudi Arabia.
authors.forename: Mouaz H
authors.initials: MH
authors.lastname: Al-Mallah
authors.affiliation: Nuclear Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Albert
authors.initials: A
authors.lastname: Flotats
authors.affiliation: Intersocietal Accreditation Commission, Ellicott City, MD, USA Division of Cardiology, University of Maryland, Baltimore, MD, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Jerome
authors.affiliation: Department of Nuclear Medicine and Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
authors.forename: Philipp A
authors.initials: PA
authors.lastname: Kaufmann
authors.affiliation: Medical Technology and Infrastructure Administration, Ministry of Health, Jerusalem, Israel Israeli Center for Technology Assessment in Health Care, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel.
authors.forename: Osnat
authors.initials: O
authors.lastname: Luxenburg
authors.affiliation: Division of Cardiology, Department of Medicine, and Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.affiliation: National Heart and Lung Institute, Imperial College London, UK Department of Nuclear Medicine, Royal Brompton and Harefield Hospitals, London, UK.
authors.forename: S Richard
authors.initials: SR
authors.lastname: Underwood
authors.affiliation: Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Madan M
authors.initials: MM
authors.lastname: Rehani
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Ravi
authors.initials: R
authors.lastname: Kashyap
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Diana
authors.initials: D
authors.lastname: Paez
authors.affiliation: Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Dondi
mesh_terms: D000368:Aged; D002309:Cardiology / Q000592:standards; D002985:Clinical Protocols / Q000592:standards; D003430:Cross-Sectional Studies; D005260:Female; D014943:Global Health; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000592:standards / Q000706:statistics & numerical data*; D049268:Positron-Emission Tomography / Q000592:standards / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic / Q000592:standards*; D011364:Professional Practice / Q000592:standards / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data; D011829:Radiation Dosage; D000069079:Radiation Exposure / Q000032:analysis*; D012044:Regression Analysis; D015899:Tomography, Emission-Computed, Single-Photon / Q000592:standards / Q000706:statistics & numerical data
keywords: Best practices; Nuclear cardiology; PET; Quality of care; Radiation dose; SPECT