RAPID "Risk Assessment from Policy to Impact Dimension"

survey

Chaired by Gabriel Gulis and Odile Mekel on behalf of the RAPID group

General objectives

Policies and strategies influence the wider determinants of health. These determinants have their impact on a range of different risk factors which then directly affect human health. The main aim of the project is to develop methodologies for conduct of "full chain" risk assessment and implement them on a case study application on selected EC policy and via a series of national workshops.

Strategic relevance and contribution to the public health programme

The proposal addresses the following areas of the health program and annual work plan:

Risk assessment thematic networks and training of risk assessors. The thematic network will address the "full-chain" approach on broad field of determinants of health including all elements of risk management cycle.

Moreover as secondary area our proposal contributes significantly to area 3.3.1 and specifically "Public health capacity building by having academic partners on board who will implement the knowledge developed to their routine public health curricula.

The strategic relevance is given by full-chain approach itself and by geographical coverage of partners.

Methods and means

Each partner will choose a policy and conduct assessment on impact on policy on determinants of health, impact of determinants of health on prevalence of risk factors and impact of risk factors on health effect (top-down approach). Similarly, each partner will choose a health effect and conduct the assessment process up to policies (the  bottom-up approach). Based upon them a merged assessment guidance document will be developed and tested on a case of a European Commission policy. National workshops will be conducted to train experts in participating countries on the developed method.Policy analysis, questionnaire survey (on risk perception), project meetings, focus group discussions, database searches, workshops will be the main methods to conduct the project.

Expected outcomes

Pilot tested model methodologies will be produced for bottom-up and top-down  risk assessment in range of the full chain between policy-health effects. Based upon them, a general assessment methodology will be presented for full-chain approach. In addition, via national workshops a set of national experts will be trained on the developed methods.

Aim of the Project

RAPID grew-out from a previous project “health impact assessment in new member states and accession countries” (HIA NMAC). HIA NMAC identified a lack of risk assessment methods for conducting policy health impact assessments across areas of broad determinants of health.

The main aim of the project is therefore to develop, pilot test and implement risk assessment methodology for full chain risk assessment (policy-determinants of health-risk factors-health effect).

Specific objectives

Establish a policy risk assessor database Conduct risk assessment case studies from policy

to health effect and from health effect to policy Summarize the methodologies from national case

studies and develop a “common methodology guidance”

Implement the new methodology guidance via conducting a case study of a selected EU policy and series of national workshops

General overview

By Ph.D. student Stella R.J. KræmerSDU Esbjerg, Denmark

As first step of the “Risk assessment from Policy to Impact Dimension – RAPID” project the project group aimed to establish a thematic network of risk assessors and develop a database where interested users can find information about those who do risk assessment in partner countries.

The project working group developed a survey tool which has been translated to each participant country language and used for data collection.

The collected data was then entered into a Access database.

359 records Policy oriented risk assessors – 25/359 Public health – 169/359 Policy and public health – 6/359 Research on risk assessment, policy & law, –

71/359

Doing risk assessment within pre-defined disciplines by partner

country, absolute numbersN (% in some cases)

Italy Denmark

Slovenia

Slovak Republic

Hungary

Spain Romania

Gernamy

Poland

Lithuania

Economics 1 1 4 2 1 1 5 6 15 1

Engineering

5 9 3 5 4 5 18 10 14 1

Environment

3 4 6 3 8 9 22 16 16 4

Law & policy

2 (4.1%)

2 (14.2%) 3 (23%) 2 (3.4%) 0 (0) 3 (3.75%) 13 (11.4%) 0 (0) 1 (1.8%) 2 (13.3%)

Social science

5 (20.8%)

0 2 0 1 2 6 9 4 0

Public health

10 1 (7.1%) 7 52 (89.7%) 5 59 22 27 15 12

Toxicology 4 0 1 3 3 9 2 10 13 1

Epidemiology

6 0 2 7 2 9 6 16 3 4

Spatial planning

0 0 1 0 1 0 2 5 1 2

Other 4 2 0 1 4 2 32 11 9 0

Total number of responses

24 14 13 59 18 80 114 58 54 15

Main area of work by partner country, absolute numbers

N (% in some cases)

Italy Denmark Slovenia Slovak Republic

Hungary Spain Romania Germany Poland Lithuania

Government

6 3 0 38 2 58 (72.5%)

68 23 10 9

Industry 1 4 0 1 4 3 18 2 3 0

Medicine 7 1 7 31 3 9 32 9 7 2

University 6 0 1 3 4 10 3 23 17 1

Other research

4 0 1 2 1 6 4 3 30 0

Private business

1 4 2 8 5 2 5 5 5 0

Other 3 4 3 1 2 1 1 5 8 4

Total number of responses

24 14 13 59 18 80 114 58 54 15

Elements of risk assessment by partner country, absolute numbersN (% in some cases)

Italy Denmark Slovenia Slovak Republic

Hungary Spain Romania Germany Poland Lithuania

Hazard identification

9

5 7 32 12 53 70 28 45 2

Hazard characterization

10

4 5 27 12 32 69 0 39 12

Exposure assessment

9

5 5 31 6 40 53 30 34 5

Dose-response 4

1 3 9 4 13 24 23 16 3

Risk characterization

12

8 7 32 9 33 18 30 41 11

Risk management 11

8 4 31 9 37 70 24 31 3

Economic cost-benefit

0

4 4 2 2 5 17 8 12 1

Risk policy &law 7

5 5 3 3 6 19 23 8 1

Health intelligence

3

0 8 33 3 4 15 11 2 10

Quantitative methods

3

4 4 1 2 4 5 23 11 1

Other 3

4 4 1 2 4 5 23 11 1

Total number of responses

24 14 13 59 18 80 114 58 54 15

Level of documentation by partner country, absolute numbers

N (% in some cases)

Italy Denmark Slovenia Slovak Republic

Hungary Spain Romania Germany Poland Lithuania

Strategy 4

4 5 8 7 11 45 25 16 3

Policy 5

2 4 3 3 8 27 13 13 2

Project 16

8 6 25 7 35 42 46 37 11

Plan 8

4 6 14 5 27 30 21 20 6

Concrete action

9

4 3 45 10 46 37 16 37 11

Other 5

0 0 4 3 4 14 16 10 1

Total number of responses

24 14 13 59 18 80 114 58 54 15

Participation in RAPIDItaly Denmark Slovenia Slovak

Republic

Hungary Spain Romania

Germany Poland Lithuania Total

Yes

21 6 12 43 13 73 91 58 54 15 386

% of total

87.5 42.85 92.3 72.88 72.21 91.25 79.8 100 100 100 85.9

Total

24 14 13 59 18 80 114 58 54 15 449

Italy Denmark Slovenia Slovak Republic

Hungary Spain Romania

Germany Poland Lithuania Total

Yes

21 6 12 43 16 55 91 50 43 12 349

% of total

87.5 42.85 92.3 72.88 88.89 88.75 79.8 86.2 79.6 80 77.7

Total

24 14 13 59 18 80 114 58 54 15 449

Interest to participate in workshops in last phase of RAPID

Cross-tabulation of doing risk assessment within public health and policy & law area

Public health policy & law Total

No Yes

No 191 48 239

Yes 178 32 210

Total 369 80 449

7.1% of respondents claimed doing RA on these two areas

Public health RA within different institutional settings, absolute numbers

N (% in some cases)

Italy Denmark Slovenia Slovak Republic

Hungary Spain Romania Germany Poland Lithuania

Government 2 0 0 34 2 48 20 17 5 8

Industry 0 0 0 0 0 1 0 1 1 0

Medicine 6 0 7 30 3 7 3 5 7 1

University 1 0 0 3 2 5 1 8 5 1

Other research

0 0 1 2 0 1 0 2 9 0

Private business

0 0 0 6 0 1 0 1 1 0

Other 1 0 0 1 0 0 0 0 3 3

This table summarizes cases where a respondent answered “yes” both to doing public health risk assessment and within enlisted branches (settings). Most of public health related risk assessment is clearly done within governmental institutions, medicine and universities

The collected data has been made available to the executive agency

Throughout the project risk assessors will be added to this continued improved Database

At the conclusion of the project the Database will be made publically available and maintained

“Risk assessment form policy to impact dimension – RAPID”

project funded by Executive Agency for Health and Consumers (EAHC) of DG SANCO

Risk assessor survey; country differences and similarities

Authors: Joanna Kobza - Silesian Medical University, Public Health Department, Piekarska 18, 41-902 Bytom, Poland

Razvan Chereches - Center for Health Policy and Public Health, Babes-Bolyai University, Cluj, Romania

Piedad Martin-Olmedo & Inés García Sánchez Escuela Andaluza de Salud Pública, Cuesta del Observatorio 4. 18080 Granada, Spain

Presenting author: Joanna Kobza

Background

Public health systems and practices do differ across Europe including differences among EU member states

Summarizing our results we try to find the answer if these differences influence the way how we collect research data and are there differences in approaches to risk assessment

We try to answer these questions by looking at methods used to collect data within risk assessor survey of RAPID project and results of the survey in three countries: Poland, Romania and Spain

MethodsThe RAPID risk assessor survey tool has been employed to collect data administered on electronic way (e-mail and direct online survey tool), translated and retranslated by each partner and collected among risk assessors

The approaches to identify them were different in all partner-countries of the projectRecrutation -Who is a risk assessment expert?

Data were uploaded to a Microsoft Access database and analyzed with STATA statistical software

• Poland identified the risk assessors through the institutions, key for risk assessment, especially in environmental health area and then by individual, personal contact with experts sending e-mails

• Spain used a combined approach of personal contacts and mailing sent around throughout the executive boards of main national scientific societies

• Romania developed a national health and environmental system structure and used it to distribute the survey tool

Poland - chosen institutions

National Institute of Public Health

2 Institutes of Occupational Medicine

Institute for Ecology of Industrial Areas

Central Institute for Labour Protection-National Research Institute

Institute of Environmental Protection

Central Mining Institute

Institute of Agriculture Medicine

Universities

Associations – for ex.: Polrisk (Polish Association of Risk Assessors)

Romania- chosen institutions• Environment Ministry• Environment Guard headquarters• non-governmental organisation• Environmental protection agency• Environmental Direction in the Local County of the Municipality of Cluj-Napoca• Ministry of the Economy• Ministry of Transport, Construction and Tourism• A private company from the top 10 quoted at the Romanian Stock Exchange• Agency for Development North-West• 3 private companies • Ministry of Education and Research• The Institute for the Research of the Quality of Life• The Institute of Sociology of the Romanian Academy• The Faculty of Sociology and Social Work of the University of Bucharest• 1 regional portal based in the Municipality of Cluj-Napoca• Direction of Communication and Public Relations of the Local Council of the

Municipality• Ministry of Health • National School for Public Health and Health Services Management, Bucharest• 4 Institute of Public Health• 3 Public Health Directions based in the residences of the Regional Development

Agencies• 4 hospitals • Presidential Administration• National Agency for Governmental Strategies• 7 County Councils based in the residences of Regional Development Agencies

Spain- chosen institutions

• Spanish Society of Environmental Health

• Spanish Society of Food Safety• Spanish Society of Toxicology• Spanish Society of Epidemiology• Ministry of Health• Regional Health Authorities• Group of experts

Results

The highest percentage of risk assessors who reported to be involved in public health risk assessment at certain extent was identified in: Spain - 73,75% Poland - 27,78% Romania - 19,3%

The extension of risk assessment methodology into policy was more often applied in: Poland - 24,1%Romania - 23,7%Spain – 10%

Results

POLAND ROMANIA SPAIN

56 questionnaire surveys collectedRR=33%

51% of the surveyed are environmental assessors

49% engaged in the financial risk assessment process

80% of surveyed were dealing with health risk assessment

115 questionnaire surveys collectedRR=65%

80 questionnaire surveys collected

58% respondents involved in Environmental Health issues at Governmental Institutions

45-35% respondents are involved in any of the Risk assessment steps, being risk quantification the greatest barrier pointed out

Why differences The differences could be explained partially by the data collection process used in each country but also by important differences on how risk assessment is being understood across Europe, for instance the tradition of education, research in risk assessment domain in each country.

Different approaches existing to refer to Risk Assessment confusion among professionals to identify their role in the process (Spain)

Why differences

Examples:

Poland- risk assessment, risk management in environmental health high developed during decades

public health relatively new sciences/specialization

Poland and Romania –new Member States (perhaps local politicians more open for new strategies)

Romania-

Spain-Risk assessment is being introduced in different policy actions for several years but there is no an official procedure to tackle quantification of health impacts a part from those done by research institutions

Conclusions

The experience gathered via risk assessor survey confirms existing differences in public health systems and approaches across EU member states.

This implies a need for careful planning of methodology development and training content and method selection expected in last phase of the

RAPID project

Thank you for your attention

HIA framework to investigate additional cancer risk from Ionizing

Radiation in Medical Imaging

Top-Down case study – Italian partner

Nunzia Linzalone, Elisa Bustaffa, Liliana Cori, Fabrizio Bianchi and IFC cardio-staff

Prepared for the project

Risk Assessment from Policy to Impact Dimension (RAPID) 2009-2012EU (DG-SANCO) Grant agreement No 20081105

HIA framework

• To develop effective precautionary

policies, policy-makers and

stakeholders need evidences based on

an integrated risk assessment

• To match this need RAPID project have

included a case study to develop and

test a framework and methodology for

“full chain” impact assessment

• The aim of this work is to incorporate

existing models of risk management

and quantitative risk assessment, into

a framework of health impact

assessment

POLICY SELECTIONPatient Safety from Ionizing Radiation (IR)

• European directive 97/43 (D. Lgs. 187/00)• Legislative Decree 187/00 • Regional Health Plan 2008-2010• Tuscan Region funded projects on

medical use of IR– “Communication of patient dose” – “Stop Useless Ionizing Testing in

Heart Disease” (SUITheart) • Guidelines

– EU, 2001 – Italy, 2006 last update – American College of Radiology 2007, – International Atomic Energy Agency 2008

Reducing Environmental Cancer Risk, What We Can Do Now :

2008-2009 Annual Report, President’s Cancer Panel

FOCUS ON CARDIOVACULAR IMAGINGAn emerging concern at local and international level

Computed tomography (CT) was introduced into medical imaging in the 1970s and has grown exponentially particularly in cardiovascular clinical test for a wide variety of cardiovascular conditions. Cardiovascular CT use has recently been tempered by a string of high-impact publications raising concern about the increase in radiation exposure to the population from medical procedures and the potential cancer risk.

The current cardiological practice is based on a deregulated, radiation-insensitive, and imaging prescription policy. (Brenner, 2007)

PolicyPolicy

Determinants of healthDeterminants of health

Risk factorsRisk factors

Health outcomesHealth outcomes

Medical practice

Medical practice

Environmental, , Biological, Clinical, Economic determinants

Environmental, , Biological, Clinical, Economic determinants

Com

mun

icati

on a

nd c

onsu

ltatio

nCo

mm

unic

ation

and

con

sulta

tion

Greatest social

benefit at

lowest cost

Greatest social

benefit at

lowest cost

Pediatric and adult population

Pediatric and adult population

Gender, age, diagnosisGender, age, diagnosis

RAPIDTop-down risk assessment

model

• Core determinants of health influenced by the policy

• Risk factors linked to determinants of health

• Health effects linked to selected risk factor

• Risk perception and communication on each level

Ionizing radiation in medical practice: exposure and health

• Medical imaging is the largest controllable source of radiation exposure in the population of industrialized countries

• One out of two examinations is completely or partially inappropriate (i.e. risk outweighs benefit) and cardiologists are often unaware of the radiological dose of the examination they prescribe or practice

• This avoidable exposure is associated with increased, significant cancer risk at both the individual and population levels

• Exposure can be minimized through a knowledge-based intervention targeted to increasing radiological awareness of prescribers and practitioners.

Risk-benefit balance• Exposures for medical purposes account for a variable percentage

of cases of cancer between 1 and 3 per cent of all those observed in developed countries (underestimated risk)

• 30% of tests involving ionizing radiation are inappropriate—that is, patients take a long term risk without a commensurate acute benefit.

• Need to know the risk for each test and balance it with the benefits of diagnosis

• Better knowledge of risks will help to avoid small individual risks translating into substantial population risks.

Population riskIndividual risk

RAPID Model: the full chain assessment

• How do different policies,

focused to the issue of

awareness in diagnostic use of

ionizing radiation, correspond

to changes in individual

exposure to cumulative dose?

• How do they account for the

associated attributable long

term cancer risk.

• Is estimated individual risk

comprehensive of cumulative

exposures?

Tuscany Policy on Radiprotection 2008-2010Tuscany Policy on Radiprotection 2008-2010

Proximal health determinants (physical environment)Proximal health determinants (physical environment)

Cumulative individual dose, working tasks, technologies availability, co-morbidity,…

Cumulative individual dose, working tasks, technologies availability, co-morbidity,…

Fatal and non fatal cancer, other non cancer outcomesFatal and non fatal cancer, other non cancer outcomes

Current guideline, technological updating,

continuing training, patient and operator awareness,

etc…….

Current guideline, technological updating,

continuing training, patient and operator awareness,

etc…….

Workplace environment and community

environment

Workplace environment and community

environment

Com

mun

icati

on a

nd c

onsu

ltatio

nCo

mm

unic

ation

and

con

sulta

tion

Greates

t social

benefit at

lowest cost

Greates

t social

benefit at

lowest cost

Pediatric and adult population

Pediatric and adult population

Gender, age, diagnosis

Gender, age, diagnosis

Levels of investigation

1. Main factors in the causation chain.

2. Percent of cancers avoided depending on the different medical practice used in the context of heart disease (IFC – SUIT Heart Project).

The inquiry methodology

1. Main factors in the causation chain

To make an overall assessment of the policy effects on health, most important determinants and risk factors are identified by:– Review of literature– Experts consultation

1.1. Review of literature

• What?– Higher Impact Factor Scientific Journal focused to MI

and/or CT use– Scientific Association Guidelines and

Recommandations

• How many?– Selected references are primary study or most

updated reviews, published from 2004 to 2010. They totally sum to #69

1.2. Experts consultation

• Who are they?– Inner resources from IFC-

CNR and collaborative consultants from University and Helth care Dept.s

• What they are requested to do?– Identify and rank the most

important determinants and risk factors. A scoring system helps to prioritize them from “high relevant” to “not relevant”.

– Cardiologist (Senior Researcher, ICP-NRC Pisa-Italy)

– Radiologist (Technical Consultant, ICP-NRC Pisa-Italy)

– Hemodynamist (Research Director, ICP-NRC Pisa-Italy)

– Pulmonologist (Researcher, ICP-NRC Pisa-Italy)

– Nuclear physicist (Principal Investigator, ICP-NRC Pisa-Italy)

– Geneticist (Researcher, ICP-NRC Pisa-Italy)

– GP (Generic Physician)– Manager and Scientific Coordinator,

Physical co-worker (USL Lucca, Livorno – Italy

Informing policy actions

Health determinants Present medical practice Training strategies 19Technological updating Age (p) 17Training strategies Technological updating 15Patient/operator awareness Present medical practice 11Workplace environment Gender (p) 11Community environment Age (a) 11Commercial/Economic reasons Patient/operator awareness 8

Risk factors Workplace environment 7Pediatric population Age Gender (a) 7

Gender Diagnosis (a) 5Diagnosis Diagnosis (p) 1Other (Familiarity) Commercial/Economic reasons -3

Adult population Age Other (Familiarity) -3Gender Community Environment -5DiagnosisOther (Familiarity)

Health determinants Present medical practice Training strategies 19Technological updating Age (p) 17Training strategies Technological updating 15Patient/operator awareness Present medical practice 11Workplace environment Gender (p) 11Community environment Age (a) 11Commercial/Economic reasons Patient/operator awareness 8

Risk factors Workplace environment 7Pediatric population Age Gender (a) 7

Gender Diagnosis (a) 5Diagnosis Diagnosis (p) 1Other (Familiarity) Commercial/Economic reasons -3

Adult population Age Other (Familiarity) -3Gender Community Environment -5DiagnosisOther (Familiarity)

very relevant

relevantmoderate

slight effect

not relevant

Are determinants of health as relevant as already known risk

factors?Main cathegories

The inquiry methodology

2. Percent of cancers avoided

The risk of cancer associated with diagnostic imaging is quantified by:– A developed software based on three main sub-

components of exposure: natural,diagnostic, professional. The result is the amount of cumulative risk.

– The simulated risk is associated with current indications of appropriateness.

2.1. RADIORISK Software – IFC Tool

Awareness of radiological risk is

low among cardiologists, who

prescribe the majority (60-80%)

of ionizing test examinations

(totaling today the dose

equivalent of about 150 chest x-

rays per head per year) and are

the most exposed among health

professionals (250-300 chest x-

rays per head per year for most

active interventional

cardiologists)

SUITStopUseless

Imaging Testing

Project of the Institute of Clinical Physiology and of the Tuscany Region

to search new strategies to reduce inappropriate use of Imaging Testing

RadioRiskSoftware to calculate and communicate radiological risk to patients and doctors

Dose reference and Cancer Risk estimates

• Reference European guideline (2001)

• Guidelines of Italian Minister of Health

• Peer reviewed journal

• Government Agency

• From each exam data file (if available)

BEIR VII, 2006• The estimation is base on 100000 studies, including 87000 Hiroshima and

407000 nuclear workers

• 2 to 3 confidence intervals of attributable risks estimate

• X-rays and gamma-rays are a proven carcinogen (WHO’s International Agency of Research of Cancer)

• Epidemiological evidence up to now above 50 mSv

• Re-affirm Linear No-Threshold hypothesis

History of exposure to ionizing radiation

Exposure, charts, risk estimationIndividual informations

Table of risk and extra cancer risk from

medical exposure

Risk report: cancer incidence and mortality

Communication of risk

Comparison to other risks: all data are transferred into images Cigarette smokingTravelling by car Rock climbing

Coal miner workingStay near Hiroshima

on 6 August 1945

2.2. Considerations on appropriateness

• Why to reduce useless imaging– Economic

• cut direct costs• reducing waiting lists• avoid radiation risks

– Biology• teratogenesis• cancer• hereditary defects

– Ethic• misunderstood risk percepion• “disinformed” consent• underestimation of doses to patient

Decision-making in Clinical Practice

LV function: Echo or MRI or MSCT or RNA (Canadian 2006)

Myocardial viability: Echo or MRI or Scinty or PET (ESC, 2004)

Cardiac Stress Imaging in pediatric patients: Echo or MRI or CT or Nuclear (AHA guidelines, 2006)

Standard approach in guidelines:

The same for physicians, not for patient or the society!

Risk of cancer

Echo: Echocardiography or EchocardiogramMRI: Magnetic Resonance ImagingCT: Computed Tomography

MSCT: Multisclice Computed TomographyPET: Positron Emission TomographyScinty: ScintigraphyRNA: Radionuclide Angiography

Legend:

more conservative less conservative

Clinical Practice (CP) CP 2CP 1 CP 3

Disclosing “medical practice” box

Scintigrafy  Sestamibi Tc-99m

Incidence 58.1  (45,6-74,2)        

1/1721 (1/2193 - 1/1348)

Mortality 33,2 (26,0-41,0)         

1/3012  (1/3846 - 1/2439

Scintigrafy  Tallium

Incidence 264,9   (207,9-337,8)     

1/378 (1/481-1/296)

Mortality 151,5 (118,5-186,6)        

1/662 (1/844 - 1/538)

• Same individual: different possible diagnostic approach– Reduction in cumulative dose

TC-chest

Incidence 45.2  (35,5-57,7)      1/2212 (1/2817 - 1/1733)

Mortality 25,9 (20,2-31,9)        1/3861 (1/4951 - 1/3135)

Choosing the right test for the right patient, and performing it with the lowest possible radiation dose

• Different individual: different possible diagnostic pathway– Free from radiation possible

EX: differences in cancer risks Sample 100000 personsAge 40-50    Males 50 %Females 50%

Integrating levels of knowledge

Regional Health Plan 2008-2010on radioprotection

Medical Referral Guide lines Business leverage

Medical Lobbies Tecnological updating

Volume of prescription by centers

Trained/skilled operators

Education on risks

Research in a third level referral medical center

Patient survey and data storing

Individual mean dose

levels

Volume of MIprescriptions

Individual extra risk for

long term cancer

Profiling risks to population

Medical equipe shift

Research communication

Assessing impacts in a socio-environmental context

Risk factors

Working environment

regulation

Health determinants

Air flights duration

Financial local trends

Updated form forInformed consent

Risk perseption in medical staff

Place of residence

Professional exposure

Free time activities

Suspected diagnosis Medical practice

Health outcomes

Social and health equity

Pediatric/adultpopulation

Age Gender

Exposure estimates

Dose response

model

All cancers patterns in the populationDetermininstic effects

Advice on the Regional Health Plan 2010-2012

• Further recommendations and guidelines fueled by IFC research on: level of appropriateness of the main ionizing cardiological

examinations in a high-tech tertiary care referral center; calculation of the patient and population dose from reference

and actual radiological exposures al local level; user-friendly software for dose and risk calculation by patient; preparation of an informative, transparent template of informed

consent form for radiological examinations; estimate of the number of avoidable cancers produced by

current levels of inappropriate testing.

RAPID key features

• Literature consultation• Experts rating• Risk estimates comparison • Overall consideration for best practice• Reinforcement of communication on

risks