Tailoring CT Dose to Patient Size: Implementation of the Updated 2017 ACR Size-specific Diagnostic Reference Levels

Rationale and Objectives: To use an automatic computed tomography (CT) dose monitoring system to analyze the institutional chest and abdominopelvic CT dose data as regards the updated 2017 American College of Radiology (ACR) diagnostic reference levels (DRLs) based on water-equivalent diameter (Dw) and dose estimates (SSDE) to detect patient size subgroups in which CT dose can be optimized. Materials and Methods: All chest CT examinations performed between July 2016 and April 2017 with and without contrast material, CT of the pulmonary arteries, and abdominopelvic CT with and without contrast material were included in this retrospective study. Dw and SSDE were automatically calculated for all scans using a previously validated in-house developed Matlab software and stored into our CT dose monitoring system. CT dose data were analyzed as regards the updated ACR DRLs (size groups: 21-25 cm, 25-29 cm, 29-33 cm, 33-37 cm, 37-41 cm). SSDE and volumetric computed tomography dose index (CTDlvol) were used as CT dose parameter. Results: Overall, 30,002 CT examinations were performed in the study period, 3860 of which were included in the analysis (mean age 62.1 +/- 16.4 years, Dw 29.0 +/- 3.3 cm; n = 577 chest CT without contrast material, n = 628 chest CT with contrast material, n = 346 CT of chest pulmonary, n = 563 abdominopelvic CT without contrast material, n = 1746 abdominopelvic CT with contrast material). Mean SSDE and CTDlvol relative to the updated DRLs were 43.3 +/- 26.4 and 45.1 +/- 27.9% for noncontrast chest CT, 52.3 +/- 23.1 and 52.0 +/- 23.1% for contrast-enhanced chest CT, 68.8 +/- 29.5 and 70.0 +/- 31.0% for CT of pulmonary arteries, 41.9 +/- 29.2 and 43.3 +/- 31.3% for noncontrast abdominopelvic CT, and 56.8 +/- 22.2 and 58.8 +/- 24.4% for contrast-enhanced abdominopelvic CT. Lowest dose compared to the DRLs was found for the Dw group of 21-25 cm in noncontrast abdominopelvic CT (SSDE 30.4 +/- 21.8%, CTDlvol 30.8 +/- 21.4%). Solely the group of patients with a Dw of 37-41 cm undergoing noncontrast abdominopelvic CT exceeded the ACR DRL (SSDE 100.3 +/- 59.0%, CTDlvol 107.1 +/- 63.5%). Conclusions: On average, mean SSDE and CTDlvol of our institutional chest and abdominopelvic CT protocols were lower than the updated 2017 ACR DRLs. Size-specific subgroup analysis revealed a wide variability of SSDE and CTDlvol across CT protocols and patient size groups with a transgression of DRLs in noncontrast abdominopelvic CT of large patients (Dw 37-41 cm).