Andalusia
Andalusia (Fig. 1) is an autonomous community in southern Spain. It is the most populous, and the second largest autonomous community in Spain. The Andalusian autonomous community is of- ficially recognised as a "historical nationality".
The territory is divided into eight provinces: Almería, Cádiz, Córdoba, Granada, Huelva, Jaén, Málaga and Seville. Its capital is the city of Seville.
Andalusia ranks first by population among the 17 autonomous communities of Spain. The official number of inhabitants was estimated in 2019 as 8,414,240, of whom 4,147,167 were men and 4,267,073 were women. Fig. 2
The population is mainly concentrated in the provincial capitals and along the coasts, so that the level of urbanization is quite high; half the population is concentrated in the 28 cities of more than 50,000 inhabitants. The population is aging, although the process of immigration is countering the inversion of the population pyramid.
Healthcare in Andalusia Fig. 3
Responsibility for healthcare jurisdictions was devolved from the Spanish government to Andalusia with the enactment of the Statute of Autonomy. Thus, the Andalusian Health Service (Servicio Andaluz de Salud - SAS -) currently manages almost all public health resources of the Community.
Functions of the SAS
Article 13.3 of 18 May establishes the functions of the SAS:
“Management of health services in the field of promotion and protection of health, prevention of disease, health care and rehabilitation as applicable to the territory of the Autonomous Community of Andalusia.”
The Andalusian Service of Healthcare provides both primary and specialty care.
Specialty Care
The second level of health care takes care of patients who need hospitalized medical assistance. In hospitals there are also outpatient care and peripheral centers.
The “Servicio Andaluz de Salud” has 49 hospitals all over Andalusia.
Specialty care is defined under Ley 2/1998 as the second level of care. Specialty care provides the technical and human capabilities appropriate to diagnosis, treatment and rehabilitation for conditions that cannot be handled at the primary
level.
Hospital care includes all the medical and surgical processes, from simplest to more complex. Some of them are the stroke assistance, global care in oncologic patient, heart acute and chronic disease or specialized care in pediatric population. In all of them, imaging techniques play a main role, specially CT imaging. It is unusual that a patient included in any of these processes has no CT imaging during his o her medical care.
CT and Ionizating Radiation Fig. 4
- The main non natural source of ionizing dose in the population is CT (Brenner, 2007) .
- Worldwide, the average annual per-capita effective dose from medicine (about 0.6 mSv of the total 3.0 mSv received from all sources) has approximately doubled in the past 10–15 years .
- From 1980 to 2006, the number of radiologic and nuclear medicine procedures has increased about 10-fold and 2.5-fold, respectively. Worldwide, the frequency of CT scanning increased from one to three procedures per 1000 population during 1977–1980 to about 35 procedures per 1000 population during 1997–2007.
- Currently, CT represents about 7% of all radiologic procedures in the world but accounts for more than 40% of the collective effective dose. (Mettler et al, 2009).
Having a modern technology and optimized protocols ensures dose optimization.
Technological renewal is complex due to the need for large investments.
The new European Directive 2013/59/Euratom was unanimously adopted by the Council of the European Union (EU) on 5 December 2013 after 4 years of work by different European scientific and technical committees. According to the new Directive (ESR, 2015), a high level of competence and a clear definition of responsibilities and tasks among all professionals involved in medical exposure are fundamental to ensure adequate protection of patients undergoing medical radiodiagnostic and radiotherapeutic procedures.
Article 60.3 (equipment) underlines the responsibility of Member States to ensure that:
- Any equipment used for interventional radiology and computed tomography and any new equipment used for planning, guiding and verification purposes have a device or a feature informing the practitioner, at the end of the procedure, of relevant parameters for assessing the patient dose.
- Equipment used for interventional radiology and computed tomography has the capacity to transfer the information required under 3(d) to the record of the examination. Equipment installed prior to 6 February 2018 may be exempted from this requirement.
Spanish translation of the European Directive was published last October as a Real Decreto 601/2019, and is to be followed since November 1st, 2019.
There are many factors responsible for the increase of radiation applied to patients. One of them is the use of heterogeneous equipment and protocols. It has been proved that reducing unnecessary variation in CT radiation dose can be done fairly easily by getting radiology professionals together to share best practices. This was the result in a healthcare system as large as the University of California's (UC). This way, one goal is to get homogeneous equipment and protocols in Andalusia, also a big community. This will, probably, reduce the population radiation dose.
Another study (Tonkopi, 2018) proved that establishing provincial DRLs allows an effective reduction in patient dose without resulting in degradation of image quality.
New CT equipment include different technologies which, altogether, can reduce the radiation dose up to 30 to 80 %, related to five year old CT machines. (Willemink, 2014).
Taking all these factors into account, the Health Andalusian Service designed and published a concourse to supply a CT service, with the following main purposes:
- All the equipment should optimize the “energy print” so that all and every patient should receive the lowest radiation dose while getting optimized and diagnostic images.
- These new equipments should be available all over Andalusia. The purpose is to get a population dose decrease, while following the purposes of the Andalusian Service of Healthcare.
- The expense should be limited, and even could be a waste saver, as many patients would be studied in public hospitals.