Exposure of the population
to ionising radiationfrom diagnostic medical imaging proceduresin France in 2017

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Table of contents

TABLE OF ILLUSTRATIONS AND TABLES ........................................................................................................................ 3
ABSTRACT........................................................................................................................................................................ 5
Glossary........................................................................................................................................................................ 6

1

INTRODUCTION....................................................................................................................................................... 92

Selecting types of procedures and determining their frequency........................................... 10

2.1

Selecting diagnostic imaging procedures for the study........................................................................................................ 10

2.1.1 Identification of procedures: CCAM classification (social security codes for medical procedures)............................. 10
2.1.2 Combining procedures................................................................................................................................................................... 10
2.2

Estimating the frequency of diagnostic imaging procedures.............................................................................................. 122.2.1 The “Échantillon Généraliste des Bénéficiaires” (EGB)............................................................................................................ 122.2.2 Counting procedures...................................................................................................................................................................... 13
2.2.3 Exporting relevant parameters for the study............................................................................................................................. 13
2.2.4 Extrapolating to the French population...................................................................................................................................... 14

3

Estimating doses associated with diagnostic imaging procedures........................................ 15

3.1

Dosimetric indicator: effective dose.......................................................................................................................................... 15

3.2

Estimated mean effective doses for each type of procedure.............................................................................................. 15

3.2.1 Data transmitted by imaging services when updating diagnostic reference levels.......................................................... 16
3.2.2 Recent studies by professional groups...................................................................................................................................... 16
3.2.3 Guides to procedures published by professional groups....................................................................................................... 17
3.3

Uncertainty for effective doses................................................................................................................................................... 17

4

EXPOSURE FOR THE ENTIRE POPULATION IN 2017....................................................................................... 18

4.1

Distribution of exposure per type of imaging: frequencies of procedures and mean per caput effective doses......... 18

4.1.1 Frequency of procedures per type of imaging according to age and gender.................................................................... 19
4.1.2 Mean effective dose per type of imaging according to age and gender............................................................................. 20
4.2

 istribution of exposure per examination category: frequencies of proceduresDand mean per caput effective doses.......................................................................................................................................... 22

4.2.1 Conventional radiology................................................................................................................................................................... 22
4.2.2 Dental radiology............................................................................................................................................................................... 24
4.2.3 Computed tomography.................................................................................................................................................................. 25
4.2.4 Nuclear medicine............................................................................................................................................................................ 26
4.2.5 Diagnostic interventional radiology............................................................................................................................................. 27

ExPRI study 2017

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5

POPULATION ACTUALLY EXPOSED IN 2017.................................................................................................... 28

5.1

Characterisation of the exposed population............................................................................................................................ 28

5.1.1 Percentage of individuals actually exposed (patients) in the protected population......................................................... 28
5.1.2 Number of procedures per patient.............................................................................................................................................. 30
5.2

Individual effective dose............................................................................................................................................................... 31

5.3

Focus article: The issue of cumulative computed tomography examinations................................................................ 33

6 	
VARIATION IN DIAGNOSTIC MEDICAL EXPOSURE FOR THE FRENCH POPULATIONFROM 2002 TO 2017........................................................................................................................................... 37
6.1

Variation in the mean number of annual procedures............................................................................................................. 37

6.2

Variation in mean annual per caput effective doses.............................................................................................................. 39

6.3

Variation in the distribution of procedures per examination category.............................................................................. 40

7

Conclusions and prospects...................................................................................................................... 43

List of references................................................................................................................................................... 46
Appendix
List of CCAM codes per type of imaging and examination category. Effective dose
per procedure, frequency of procedures and contribution to the mean
per caput annual dose.......................................................................................................................................... 49

2

ExPRI study 2017

Table of illustrations
and tables
Illustrations
Figure 1. Distribution of diagnostic procedures and collective effective dose per type of imaging......................................19
Figure 2. F requency of procedures (all types of imaging) according to age bracket and gender(as a number of procedures for 1000 individuals)..........................................................................................................19
Figure 3. Comparison of frequencies of procedures per type of imaging and age bracket for men and women..............20
Figure 4. Mean annual per caput effective dose according to age and gender.........................................................................20
Figure 5. C omparison of men’s and women’s mean annual per caput effective doses, according to
the type of imaging and age bracket..................................................................................................................................21
Figure 6. C omparison of frequencies of conventional radiological procedures per examination category
and age bracket for men and women................................................................................................................................23
Figure 7. C omparison of frequencies of dental radiological procedures per examination category
and age bracket for men and women................................................................................................................................24
Figure 8. C omparison of frequencies of computed tomography procedures per examination category
and age bracket for men and women................................................................................................................................25
Figure 9. C omparison of frequencies of nuclear medicine procedures per examination category
and age bracket for men and women................................................................................................................................26
Figure 10. Comparison of frequencies of diagnostic interventional radiological procedures
per examination category and age bracket for men and women................................................................................27
Figure 11. Percentage of individuals exposed in 2017 per gender and year of birth..................................................................29
Figure 12. Percentage of individuals exposed in 2017 per gender and year of birth, excluding dental radiology
or mammography...................................................................................................................................................................29
Figure 13. Mean number of diagnostic procedures per patient in 2017, per gender and age..................................................30
Figure 14. Distribution of the mean number of procedures per patient, per age and gender, per type of imaging..............31
Figure 15. Percentage of patients having absorbed a cumulative annual effective dose in the specified interval..............32
Figure 16. Cumulative mean effective dose per patient, according to gender and age.............................................................33
Figure 17. Variation in the cumulative “100mSv+” population over 3 sliding years between 2012 and 2017,(base 100 for 2012-2014).....................................................................................................................................................35
Figure 18. Distribution per age bracket and per gender of patients exposed to more than 100 mSv over the 2012-2017
period. The age is calculated on the date of the first computed tomography scan................................................35
Figure 19. Distribution per anatomical region of CT scans on “100mSv+” patients over the 2012-2017 period..................35
Figure 20. Variation in the number of annual diagnostic procedures between 2002 and 2017, per type of imaging.........38
Figure 21. Variation in the number of annual diagnostic procedures between 2002 and 2017, per type of imaging(excluding dental radiology).................................................................................................................................................38
Figure 22. Variation in the mean annual per caput effective dose between 2002 and 2017, per type of imaging...............39

ExPRI study 20173

Tables

4

Table I.

 xamination categories associated with each type of imaging and number of CCAM (social security)E
codes actually used.........................................................................................................................................................11

Table II.

Number of beneficiaries in the EGB 2017 per gender and year of birth...............................................................12

Table III.

 umber of diagnostic imaging procedures and associated collective effective doses. Rounded values,N
extrapolated for all of France, 2017..............................................................................................................................18

Table IV.

Frequency of procedures according to gender and the type of imaging..............................................................19

Table V.

Mean annual effective dose according to gender and type of imaging, for all ages.........................................21

Table VI.

 istribution of exposure per examination category for conventional radiology: frequencies
Dof procedures and mean per caput effective doses.................................................................................................22

Table VII.

 istribution of exposure per examination category for dental radiology: frequencies of proceduresDand mean per caput effective doses............................................................................................................................24

Table VIII.

 istribution of exposure per computed tomography examination category: frequencies
Dof procedures and mean per caput effective doses.................................................................................................25

Table IX.

 istribution of exposure per examination category for nuclear medicine: frequencies of proceduresDand mean per caput effective doses............................................................................................................................26

Table X.

 istribution of exposure per examination category for diagnostic interventional radiology:Dfrequencies of procedures and mean per caput effective doses...........................................................................27

Table XI.

 ercentage of the sample panel having benefited from at least one diagnostic imaging procedurePin 2017................................................................................................................................................................................28

Table XII.

Statistics on the number of procedures per patient, per gender and per year....................................................30

Table XIII.

 tatistics on cumulative annual effective doses per patient, according to gender, includingSand excluding dental radiological procedures............................................................................................................32

Table XIV.

 umber of diagnostic computed tomography procedures and associated individual effective dose forN
the population of patients exposed to computed tomography and over three cumulative periods...............34

Table XV.

 haracterisation of the population of patients exposed to computed tomography and absorbingC
more than 100 mSv, in terms of number of procedures and associated individual effective dose,over three cumulative periods........................................................................................................................................34

Table XVI.

 istribution of diagnostic procedures in France in 2007, 2012 and 2017 (rounded values) depending onDthe categories defined for the study focusing on 2012 [7]......................................................................................42

Table XVII.

 ffective dose per procedure, frequency of procedures and contribution to the mean per caput annualEdose for CCAM codes for conventional radiology.....................................................................................................49

Table XVIII.

 ffective dose per procedure, frequency of procedures and contribution to the mean per caput annualEdose for CCAM codes for dental radiology.................................................................................................................53

Table XIX.

 ffective dose per procedure, frequency of procedures and contribution to the mean per caput annualEdose for CCAM codes for computed tomography....................................................................................................54

Table XX.

 ffective dose per procedure, frequency of procedures and contribution to the mean per caput annualEdose for CCAM codes for nuclear medicine...............................................................................................................56

Table XXI.

 ffective dose per procedure, frequency of procedures and contribution to the mean per caput annualEdose for CCAM codes for diagnostic interventional radiology...............................................................................58

ExPRI study 2017

Abstract

This report is part of the ExPRI (Exposure of the population to ionising radiation) system launched in 2003, and aims
to establish data on the exposure of the French population to ionising radiation from medical imaging for diagnosis
purposes (conventional, dental and interventional radiology, computed tomography and nuclear medicine) for the year2017 and to analyse variation in such data. The study was performed based on diagnostic imaging procedures taken fromthe échantillon généraliste des bénéficiaires, a sample on a 1/97th scale of the healthcare consumption of the population
covered by the main French health insurance schemes.
The exposure of the French population had not changed significantly in 2017 compared with 2012. Variation detected
in terms of the mean frequency of imaging procedures and the average per caput annual effective dose is generally minor,
excluding dental radiology. In particular, the almost 90% increase recorded between 2002 and 2012 for the average percaput annual effective dose was no longer evident between 2012 and 2017, and levels stabilised at 1.53 mSv per caput(vs. 1.56 mSv in 2012). Nuclear medicine, which ranks number 3 in terms of the collective effective dose, recorded thegreatest increase over this 5-year period, in terms of both frequency and contribution to the collective effective dose.
Computed tomography remains the most significant contribution to the exposure faced by the population (74.2%) by far.
However, the increase in collective effective dose attributable to computed tomography (+2.4%) remains well below thefrequency of these imaging procedures, which increased substantially over the period in question (+17%). The frequency
of dental radiology procedures is falling steeply (-16.8%). However, this variation was driven by major changes to the
CCAM (social security) codes used to record dental radiological imaging over the 2012-2017 period and cannot therefore
be considered as sufficiently reliable.
In 2017, 45.4% of the population was subjected to diagnostic medical imaging procedures one or several times,
representing a slight increase since 2012 (43.8%). This percentage falls to 32.7% if dental examinations are excluded. Onlya small percentage of patients − but representing several hundreds of thousands of patients throughout France −combined multiple computed tomography examinations, leading to high effective doses, potentially exceeding 100 mSv.
Although these patients are very certainly treated for serious pathologies, potential long-term radio-induced effects must
be considered.

KEYWORDS
MEDICAL EXPOSURE, POPULATION, IONISING RADIATION, EFFECTIVE DOSE, RADIOLOGY, COMPUTED TOMOGRAPHY,
NUCLEAR MEDICINE.

ExPRI study 20175

Glossary

ATIH

French technical agency for hospitalisation data

CCAM

Social security codes for medical procedures

CNAM

French health insurance body (CNAMTS prior to 1 January 2018)

CNAMTS
DAP

Dose Area Product

DCIR

SNIIRAM database for individual users

DLP

Dose Length Product

DREES
EGB
EURATOM

Direction de la Recherche et des Etudes Statistiques (Directorate for statistical studies and research)
Generalist sample panel of health insurance beneficiaries
European Atomic Energy Community

ExPRI

Exposure of the population to ionizing radiation

IAEA

International Atomic Energy Agency

ICRP

International Commission on Radiological Protection

INSEEInstitut National de la Statistique et des Etudes Economiques(French Institute of Statistics and Economic Studies)

InVS

Institut de Veille Sanitaire, French institute responsible for monitoring public health and part of
the French public health agency (Agence Nationale de Santé Publique) since May 2016

LMDE

Health insurance for students

	MGD

Mean Glandular Dose	MSA

Social security system for farmers

NGAP

General French nomenclature for professional procedures

NIR

Social security number

DRL

Diagnostic reference levels

OPRI

Office de Protection contre les Rayonnements Ionisants (Office for protection against ionising radiation)

	PET

Positron Emission Tomography

	PMSI

Programme for the medical conversion of information systems

RSI

Social security system for sole traders

SFMN

 ociété Française de Médecine Nucléaire et imagerie moléculaireS(French society for nuclear medicine and molecular imaging)

SFPM

Société Française de Physique Médicale (French society for medical physics)

SFR

Société Française de Radiologie (French society for radiology)

SLM

Local health insurance

SNIIRAM
T2A
UNSCEAR6

French health insurance body for employees (CNAM since 1 January 2018)

ExPRI study 2017

French health insurance information system covering all sectors
Per procedure invoicing system
United Nations Scientific Committee on the Effects of Atomic Radiation

ExPRI study 2017

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ExPRI study 2017

1

INTRODUCTION

Medical imaging is a specialist medical field which has repeatedly proven its worth and provides undeniable benefits aspart of patient treatment. Medical imaging makes extensive use of ionising radiation, however it is the main contributor to
the exposure of the French population to artificial ionising radiation [1]. On this basis, it is important to regularly estimate
and characterise this medical exposure, as additionally required by the European Union since 1997 [2]. This requirement
was reinforced in 2013 by the European directive 2013/59/EURATOM [3], which has been recently transposed into Frenchlaw. Article R. 1333-67 of the French Code of Public Health, amended by the decree of 4 June 2018 [4], stipulates that “Meanexposure for type of imaging, in each anatomical region, per age and gender, of the population, to ionising radiation
attributable to diagnostic medical procedures is periodically estimated and analysed by IRSN and described in a public
report available on the IRSN website. “
IRSN has played this role since 2003, the year in which IRSN participated, alongside of Institut de Veille Sanitaire (InVS,
now part of the Agence Nationale de Santé Publique), in the creation of the national ExPRI (Exposure of the population toionising radiation) system, which aims to provide authorities, medical professionals and the public with up-to-date data on
the exposure of the French population to diagnostic medical imaging procedures, in terms of the frequencies and types ofdiagnostic procedures carried out in France, and associated radiation doses and to characterise exposed groups. Since
2010, IRSN has implemented alone the ExPRI system. Three reports have been drafted on the exposure of the French
population, at 5-year intervals (2002, 2007 and 2012) [5]–[7] as well as two reports on the exposure of the paediatricpopulation [8], [9]. In addition to meeting regulatory requirements, the ExPRI system is also used to update the datatransmitted to UNSCEAR as part of its report on the sources and effects of ionising radiation, for which IRSN is the Frenchcorrespondent [10].
This report describes the analysis of the exposure of the population to ionising radiation from diagnostic imaging
procedures in France in 2017, based on the following indicators :• the frequency of each type of diagnostic imaging procedure using ionising radiation;• the percentage of the population actually exposed, i.e. having benefited from at least one diagnostic imaging procedureusing ionising radiation during this period;• the contribution of each type of procedure to the mean per caput annual effective dose and for the “throughout France”
population group;• finally, the annual effective dose absorbed by people actually exposed.
The report starts by covering the methods used to select diagnostic imaging procedures, estimate frequency of use andthe associated doses in chapters 2 and 3. Chapter 4 includes the results obtained for each type of imaging and eachexamination category for the population as a whole. All results are itemised by age and gender. Chapter 5 focuses on
analysing the population actually exposed, using the same indicators. This chapter also focuses on the issue of multiple
computed tomography examinations for some patients. Finally, chapter 6 describes variation in the main indicators since
2002 before reaching conclusions and mentioning a few potential improvements to the ExPRI system.

ExPRI study 20179

2

Selecting types of procedures anddetermining their frequency
This chapter describes how the diagnostic medical imaging procedures included in this study andthe methods used to determine their frequency in 2017 were selected. The general approach used isvery similar to that used for the previous ExPRI study [7].

2.1 Selecting diagnostic imaging proceduresfor the study
This study only includes imaging procedures using
ionising radiation for diagnosis purposes, i.e.:• all conventional radiology procedures, including dental
radiology;• computed tomography procedures1;• nuclear medicine procedures exclusively used for diagnostic
purposes. On this basis, therapeutic procedures are
not covered by this study (unsealed source internal
radiotherapy, transarterial radioembolization, etc.);• interventional radiological procedures for exclusively
diagnostic purposes. On this basis, this study excludes
the following: therapeutic procedures, diagnostic procedures
carried out during a therapeutic procedure (such as
angiographies performed during a coronary angioplasty),
surgical support procedures, etc.
These procedures are hereafter referred to as“diagnostic procedures”. The full list of procedures
covered by the study can be found in appendix, sorted
per type of imaging and per examination category.

2.1.1 Identification of procedures: CCAM
classification (social security codes for medical
procedures)
CCAM codes are unique and cover all medical technicalprocedures for which the cost are paid by the social
security. CCAM codes are used throughout France andbecame mandatory for all general practitioners andspecialists on 31 December 2005 whether outside of
hospitals (clinics, doctor’s surgeries in town), or in public orThis study does not cover biopsies with radiological guidance as theseprocedures depend strongly on the operator and operational difficulties,
therefore representative dosimetric data is rare.

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ExPRI study 2017private hospitals (inpatients and outpatients). These codes
are used to establish pricing and analyse medical activity.
CCAM codes can be used to clearly identify anddifferentiate the different diagnostic procedures. Each
type of procedure is identified by a full description
and a code consisting of four letters and three figures:
e.g. CCAM code ZBQK002 corresponds to the description“Radiography of the thorax”. A keyword search was enteredfor version 49 of the CCAM classification for this study:
632 different codes were found for medical procedures
using ionising radiation. After eliminating therapeutic
procedures, biopsies and ex-vivo examinations, 401 codes
were retained, including 24 new codes added since thestudy on 2012 [7].
It is important to take note that the CCAM codes forprocedures by dental surgeons, which still only coveredsome procedures during the study for 2012, were in
general use in 2017, with 92.5% of dental procedures
assigned a CCAM code for this study. The percentage ofdental radiological procedures without a CCAM code canhowever still be identified using a specific service reference(see section 2.2.3 for more details).

2.1.2 Combining procedures
The selected procedures for this study were combined
into two categories for the purposes of analysis:a. By type of imaging: conventional radiology (excluding
dental radiology), dental radiology, computed tomography,
nuclear medicine and diagnostic interventional radiology.
b. By examination category: diagnostic examination
categories defined in this study are based on medical
practice criteria and generally combine procedures on thesame anatomical region (head and neck, limbs, etc.) or thesame functional system of the human body (digestivetract, nervous system, etc.) when more pertinent,
particularly in nuclear medicine. In some cases, thecombination is based on the type of imaging device whena highly specific device is used (mammography, bonedensity testing, PET). Finally, dental radiological proceduresare broken down into two categories depending onwhether the image receiver is outside of the patient’s
mouth (the extraoral group includes dental panoramicscans, cone-beam CT and skull teleradiography) or placedin the patient’s mouth (the intraoral group includes
retroalveolar, retrocoronary and pelvibuccal radiography).
Table I indicates the examination categories taken into
consideration for each type of imaging, and the number of
CCAM codes actually used for this study (i.e. codes
referring to at least one procedure in 2017 out of the
population sample panel). The full list of CCAM codes
included in this study can be found in appendix.
It is important to specify that the examination
categories covered by this study differ from those used in
the previous ExPRI study [7], for which the method
recommended in European report no. 154 [11] had been
applied. According to the European methodology,
procedure categories are defined in terms of radiation
protection, i.e. considering organs within the field ofradiation. The radiological examination of the lumbar
column, for example, is classified under the abdominal
anatomical region, while this study uses the classification
vertebral column. The method recommended by European
report no. 154 was not used for this study for various
reasons:• Defining procedure categories according to the organs
exposed is pertinent in dosimetric terms if the doses arecalculated in the same manner for all procedures
assigned to this category. This is not the case in thisstudy, for which the doses are calculated using a specificapproach for each procedure (i.e. for each CCAM code,see chapter 3).
• The categories defined in the European report do notcorrespond to the clinical categories which medical
professionals general apply, which could lead todifficulties understanding the figures provided in thisstudy.
• European report no. 154 was issued in 2008. This report
was updated in 2015 by report no.180 [12], however theclassification methodology was not modified. Some ofthe procedure categories defined in the report are now
obsolete, in view of major changes to radiological
techniques over the last decade.

Table I
Examination categories associated with each type of imaging
and number of CCAM (social security) codes actually used.
Type of imaging
Examination category

Number of CCAM codes

Conventional radiology

121

Head and neck8

Vertebral column

19

Limbs

35

Thorax10

Mammography

5

Digestive tract

11

Urogenital system

11

Pelvic bone

11

Bone density testing

3

Other

8

Dental radiology

23

Intraoral

18

Extraoral

5

Computed tomography

49

Head and neck13

Vertebral column

7

Limbs

10

Thorax and heart

3

Abdomen and/or pelvis

7

Multiple regions

5

Other
Nuclear medicine

474

Cardiovascular system

12

Musculoskeletal system

9

Respiratory system

6

Urogenital system

10

Endocrine system

10

Immune & hematopoietic syst.

8

Nervous system

5

PET and oncology

5

Other
Diagnostic interventional radiology

976

Cardiac10

Neurological

10

Biliary duct

7

Vascular

49

Total

343

However, in order to analyse changing medical
practices over time for each type of imaging, the results ofthis study are also presented using the examination
categories for previous studies (and therefore using themethodology recommended in European report no. 154)
in chapter 6.

ExPRI study 201711

2.2 Estimating the frequency of diagnostic
imaging procedures
The estimated frequency of procedures for the“throughout France” population is based on the frequency
recorded for the population included in the “Échantillon
Généraliste des Bénéficiaires” (EGB), the SNIIRAM
generalist sample panel of health insurance beneficiaries,
i.e. the anonymous database managed by CNAM andused to store invoicing data for medical procedures.

2.2.1 The “Échantillon Généraliste desBénéficiaires” (EGB)The SNIIRAM order of 20 June 2005 led to the creationof a national sample panel representing 1/97th of healthinsurance beneficiaries (general cover excluding local
private health insurance), known as the “Échantillon
Généraliste des Bénéficiaires” (EGB). The administrativeand sociodemographic profiles of this permanent sample
panel of beneficiaries are linked to their “use” of medical
procedures over time (which may be none). According
to a study published in 2009 by Roquefeuil et al. [13],the internal validity of the EGB, i.e. its unbiased
representativeness of the beneficiaries of general social
security cover, excluding local health insurances (SLM),
and the healthcare consumption reimbursed tobeneficiaries, has been demonstrated:• t he distribution of the sample panel in terms of genderand age matches that of the entire population ;• the mean expense reimbursed by EGB beneficiary having
received at least one medical procedure during the study
year (2007) is very similar to that of the entire population.
Since this study, in 2011, the sample panel was
extended to the beneficiaries of health insurance forfarmers (MSA) and the social security system for sole
traders (RSI), and in September 2015, the panel was
extended to beneficiaries of 9 local health insurances(SLM)2 and finally in March 2016, to a 10th SLM (Healthinsurance for students - LMDE). The sample panel is now
representative of the health-related behaviour of 95.6% of
the population covered by mandatory French social
security, versus 74.9% at the time of the study by Roquefeuil
et al. The results of this report, based on the generalist
sample panel of beneficiaries for the year 2017, can beextrapolated to the entire French population with a highlevel of confidence.
Mutuelle générale de l’éducation nationale (MGEN), mutuelle générale
(LMG), mutuelle générale de la police (MGP), groupement MFP services,mutuelle nationale des hospitaliers (MNH), Harmonie fonction publique(HFP), mutuelle nationale territoriale (MNT), Intériale, caisse d’assurance
maladie des industries électriques et gazières (CAMIEG).

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ExPRI study 2017

EGB data can be accessed via a secure CNAM internet
portal. Since late 2016, IRSN can permanently access thisdata by decree as part of its public service assignments,
particularly when drafting this report [14].
Slightly over 700,000 beneficiaries were included in thesample panel for 2017. Interestingly for the scope of thisstudy, these beneficiaries may have participated in one orseveral diagnostic procedures, or none at all, in the year
2017. The composition of the sample panel for 2017 is
described in Table II. The population was studied in 5-year
age brackets, as per the recommendations of European
report no. 154 [11], except individuals aged 90 or older,
who are merged into one single age group for statisticalreasons. The paediatric population aged from 0 to 15, forwhich it is particularly important to consider their sensitivity
to ionising radiation, was covered by a specific study
published in 2018 [9].
Table II
Number of beneficiaries in the EGB 2017 per genderand year of birth.
Years of birth

Men

Women

Total

2013-201719,812

18,68238,494

2008-2012

21,852

20,99142,843

2003-2007

21,667

20,742

42,4091998-2002

20,834

19,42440,258

1993-1997

18,174

17,37535,5491988-1992

22,214

22,33244,546

1983-1987

22,341

22,65444,995

1978-1982

23,68623,12146,807

1973-1977

23,227

22,77446,001

1968-1972

24,804

24,12448,928

1963-1967

23,95323,54347,496

1958-1962

21,79822,77044,568

1953-1957

20,131

21,547

41,678

1948-1952

19,368

20,95740,325

1943-1947

14,752

16,462

31,214

1938-1942

9,848

12,07021,918

1933-1937

8,148

11,453

19,601

1928-1932

5,294

9,250

14,5441903-1927

3,201

7,886

11,087345,104

358,157

703,261

Total

2.2.2 Counting procedures
When each beneficiary is subjected to a medical
procedure, this input is periodically added to the sample
panel using SNIIRAM invoicing data. Since June 2011,
SNIIRAM has incorporated reimbursement data for medical
services (non-hospital) and data for public and private
hospitals, by integrating complementary data from the
PMSI (Programme for the medical conversion of
information systems) of the ATIH (French technical agency
for hospitalisation data). CCAM codes are used for theprocedures. Each beneficiary included in the sample panel
is identified by their encoded social security number (NIR)3.
On this basis, medical pathways can be reconstituted while
maintaining anonymous patient data, whether in the private
or public sector, and whether the procedure is received athome, in a doctor’s surgery or at a hospital. The sample
panel can, therefore, be used to count all diagnostic
procedures performed on panel beneficiaries.
When compared with the study on the year 2012 [7],the representativeness of SNIIRAM data available in 2017
has significantly improved in several ways:• PMSI data for public hospitals is far more comprehensive.
The per procedure invoicing system (T2A), introduced in
2004 and gradually extended since that time, are now
almost the only type of financing for medical activities,
surgery, obstetrics and odontology at both public andprivate medical establishments. All of the imaging
procedures performed in these establishments are,therefore, part of the PMSI; on this basis, the programme
can be considered as practically exhaustive for hospital
activities in 2017.
• As beneficiaries for ten SLM have been integrated in thesample panel, it is more representative of the wide rangeof healthcare habits of the French population. In
particular, integrating the health insurance scheme forstudents (LMDE) ensures that students are considered,as student healthcare habits are frequently assumed todiffer from those of the general population.
• The progressive withdrawal of the NGAP codes (General
French nomenclature for professional procedures) for
dental radiological procedures, replaced by CCAM codes,
has greatly boosted the reliability of the data collected.
Over 92.5% of dental radiological procedures areallocated a CCAM code in EGB 2017, ensuring a detailed
description of this sector.
EGB data exports for this study can, therefore, be
considered as sufficiently comprehensive to describe theexposure of the population caused by diagnostic
3

Unique social security number assigned to physical persons.

procedures by independent doctors or as outpatients or
inpatients in a public hospital. However, three points must
be carefully monitored in terms of the reliability of thisdata:
• The representativeness of the sample panel in terms of
the student population remains below that of the rest of
the population. In fact, only one health insurance provider
for students is included in the panel (LMDE) and thisprovider only represents half of the French student
population. The under-representation of this population
is proved by the valley in the panel age structure forbeneficiaries born between 1993 and 2002 (cf. Table II),and therefore between 15 and 24 years old in 2017. It is
important to take note that the integration of other healthinsurance providers for students is not currently underconsideration for technical reasons [15].
• CCAM codes for dental radiology have been extensively
changed. Intraoral radiography codes increased from 5 in2012 to 17 in 2017. 3 codes in particular were introduced
specifically for radiographic images taken during
endodontics therapeutic procedures, including a set rate
for 1 to 3 images. In addition, retroalveolar or retrocoronary
radiography codes are now set rates depending on anumber of dental sectors (groups of 1 to 3 contiguousteeth). These changes to invoicing for radiologicalimages probably had a major impact on how dental
procedures are counted. Comparisons between numbers
and frequencies of procedures between 2012 and 2017
must therefore be taken with caution to avoid incorrectlyinterpreting variation in the number of procedures as
variation in radiological practices4.
• The sample panel represents 1/97th of the population
covered by mandatory French social security, therefore
some infrequent procedures may only be included insmall numbers. Extrapolating to the entire population istherefore unreliable due to the substantial increase instatistical uncertainty.

2.2.3 Exporting relevant parameters for the study
Enquiries were submitted to the SAS Enterprise Guide
7.1 software using the SNIIRAM and PMSI databases inorder to export all diagnostic procedures for the sample
panel between 1 January and 31 December 2017, anddata on the beneficiary (gender and age at the time of theprocedure). In practice, the date of birth of the beneficiaryis not available in sample panel data to avoid any
re-identification, therefore the age of the beneficiary at the
It is important to remember that CCAM codes refer to medical technicalprocedures and are designed for financial purposes. If procedures lead to thecreation of a package of radiological images or if the number of images for one
single procedure changes after a revision, the correspondence between thenumber of procedures and the number of radiological images will be affected.

4

ExPRI study 201713

time of the diagnostic procedure is calculated give or takeone month, rounded up: a child born in February 2016 andrequiring a radiological examination in February 2017 is
considered as 12-months old at the time of theexamination, despite the fact that their real age may be 11
or 12 months depending on whether the date of theexamination is before or after the child’s birthday.
Diagnostic procedures exported include:• procedures in the private sector, i.e. by practitioners in theprivate sector, full-time hospital practitioners in theprivate sector, and practitioners employed by anestablishment applying private rates, which therefore
includes non-hospital procedures and those performed
in private healthcare establishments (inpatients andoutpatients), including dental care if a CCAM code is
assigned to the procedure;• procedures
performed in public medical establishments,
as inpatient or outpatient care;• procedures by dental surgeons in the private sector,
without CCAM codes.
Relevant parameters for each of these procedures forthis study were as follows:• the demographic characteristics of the beneficiary:
encoded NIR, gender, month and year of birth;• characteristics of the procedure:• type of reference service5,•h ealthcare sector (independent, non-CCAM dental,
inpatients and outpatients in public establishments),• CCAM code and description of the procedure, for allprocedures except one part of dental radiology,• month and year of the procedure.
The analysis focused on:• thefrequency of each of these types of diagnostic
procedures in 2017 according to the two classifications
defined in section 2.1.2 (types of imaging and examination
categories), and according to the age and gender of thebeneficiaries;• the
percentage of the population actually exposed in2017, i.e. having benefited from at least one diagnostic
procedure during the year, and characterised by age andgender.
The type of reference service is a variable used to define the type of
healthcare service in SNIIRAM, for procedures in the independent sector. 10
values are assigned to this variable for radiological procedures. In practice,
only 4 codes recorded a number of procedures other than zero (in decreasingorder of number of procedures): 1351 (imaging procedures [excluding
ultrasounds] CCAM), 1331 (radiology procedures), 9423 (oral-dental
prevention – 4-image radiography) and 9422 (oral-dental prevention –2-image radiography). Code 1351 is used for all radiological procedures with
CCAM codes, including dental procedures. Codes 1331, 9422 and 9423 are
exclusively used for dental radiological procedures without a CCAM code.

5

14

ExPRI study 2017

2.2.4 Extrapolating to the French population
The number of diagnostic procedures performed on
the sample panel was extrapolated to the French
population in an identical manner for the public and private
sectors. In fact, as indicated in section 2.2.2, the sample
panel can now be considered as exhaustive for procedures
performed in public hospitals, therefore it is no longer
necessary to differentiate between the public and private
sectors when extrapolating data, unlike previous ExPRI
studies. The reference extrapolation method involves
applying coefficients to each age bracket and each genderof beneficiaries, provided by the CNAM on the basis of theratio between exhaustive SNIIRAM data (DCIR, databasefor individual users) and sample panel data. These
extrapolation coefficients were not available 2017 when
this report was being written, therefore a general
extrapolation process, ignoring the age and gender of thebeneficiary, was applied, considering the representativenessof the sample panel in 2017 (95.6%, see 2.2.1) and the sizeof the panel (1/97th). This method, which is more
approximate than the reference method, remains
acceptable thanks to the significant increase in the
representativeness of the sample panel of the French
population since the study on 2012. However, as indicatedin section 2.2.2, the uncertainty in relation to thisextrapolation method increases substantially if the sample
panel is small. For this reason, the frequencies ofprocedures and contributions to the mean annual effective
dose are not indicated in the tables in appendix for CCAM
codes for which less than 100 procedures were actually
recorded in 2017. In addition, for the reasons also indicatedin section 2.2.2, the sample panel is less representative of
the student population. The results apply for the 18-25 age
bracket must therefore be treated with more precaution
than the other age brackets.
Consequently, the frequencies of procedures andmean annual effective doses indicated in chapter 4 are
all related to the population covered by mandatory Frenchsocial security and not the French population as definedby INSEE. The population covered by mandatory Frenchsocial security, known as the population of beneficiaries, isregistered on one of the social security systems, but does
not necessarily live in France. The French population, as
defined by INSEE, lives in France, but may not be registeredwith the French social security.

3

Estimating doses associated withdiagnostic imaging procedures
3.1 Dosimetric indicator: effective doseIn accordance with the recommendations of European
reports no.154 [11] and 180 [12], the effective dose (inmillisievert, mSv) is used as the dosimetric indicator in thisstudy to evaluate the exposure to ionising radiation ofindividuals due to diagnostic procedures. The effective
dose indicates the risk of long-term damage to health(potential induction of cancers and hereditary disorders)
due to exposure to ionising radiation (stochastic effects).
This indicator can be used to assess the overall risk for theentire body, whether exposed in full or partially, considering
the type and energy of radiation, and the specificradiosensitivity of each body organ exposed [16]. The
effective dose is calculated based on weighting factors
defined for the general population, covering all ages andgenders, and must not be used to quantify a risk for a
specific population in absolute terms, nor, above all, toestimate an individual risk6. In addition, the low effective
doses associated with examinations only affecting asmall part of the body, such as dental radiography or
mammography, must not mask the fact that local
exposure for the salivary glands or the mammary glandin the above cases, can be relatively high.
However, the effective dose is the only available meansof estimating relative radiological risks for imaging
examinations of different anatomic regions or using
different types of imaging for the same anatomical region.
As a standard indicator, the effective dose can also be
used to compare different countries and study variation in
the exposure of the population due to all medical
procedures using ionising radiation or one specific type ofprocedure over time.
The mean effective doses per type of diagnostic
procedure were calculated using the tissue weighting
factors defined in publication 103 of the   International
Commission on Radiological Protection (ICRP) [16], withthe exception of nuclear medicine, for which the most
ICRP publication 103 [16] – «The effective dose for protection purposes isbased on the mean doses in organs or tissues of the human body. […] Thisquantity provides a value which takes account of the given exposure
conditions but not of the characteristics of a specific individual. In particular,
the tissue weighting factors are mean values representing an average overmany individuals of both sexes».

6

recent reference publication [17] systematically refers to
the tissue weighting factors defined in ICRP publication 60[18]. The individual annual effective dose is obtained byadding together the effective doses for the different
procedures performed on one individual patient during theperiod considered.
These mean effective doses per type of procedure
were estimated using various data sources in order toensure that the doses are as representative as possible ofFrench radiology and nuclear medicine practices in 2017.
The mean effective doses per type of procedure can befound in appendix, classified per type of imaging, perexamination category and per CCAM code. These figures
have globally dropped since 2012 [7], to match the
reduction in dosimetric indicators already mentioned in
the recently published IRSN report on the analysis of
updated data for diagnostic reference levels [19].

3.2 Estimated mean effective doses foreach type of procedure
As no individual dosimetric data is available, anddespite the frequent wide variation in doses for the same
type of procedure [19], the exposure of the population isestimated by associating a mean effective dose to eachtype of procedure, defined on the basis of the CCAM code.
These mean effective doses are calculated for an adultpatient with a standard morphology, and are considered tobe constant regardless of the age and gender of thepatient, in accordance with the method recommended at
European level [12]. Unless explicitly indicated otherwise in
the description of this code, the effective doses used inthis study correspond to a complete procedure, as
recommended in the aforementioned European report RP
154. This report defines a complete procedure as «one ora series of x-ray exposures of one anatomical region/organ/organ system, using a single imaging modality(i.e. radiography/fluoroscopy or CT), needed to answer a
specific diagnostic problem or clinical question, during
one visit to the radiology department, hospital or clinic».

ExPRI study 201715

To give just one example, computed tomography of thethorax with the intravenous injection of a contrast medium(code ZBQH001) is a complete procedure which may
include one or several acquisition scans. On this basis, theassociated effective dose is calculated by multiplying thedose for a single thoracic scan by the estimated mean
number of scans for this procedure.
The different data sources used in the previous ExPRI
study [7] were updated to integrate the results of studies
reflecting clinical practices in 2017 as closely as possible,
and are described in the following sections.

3.2.1 Data transmitted by imaging services when
updating diagnostic reference levels
Since 2004, all managers of radiological or nuclear
medicine facilities have been required to carry out anannual dosimetric evaluation for at least two types ofprocedures routinely performed at this facility, selectedfrom a list published by order [20]. This dosimetric
information, which is required by practitioners to evaluate
and optimise their approaches, must also be transmitted
to IRSN, which will publish a periodic analysis for French
entities. The most recent review describes the analysis of
dosimetric data collected over the 2016-2018 period [19],and particularly for adults:• dose area product (DAP) for each conventional radiology
image,• mean
glandular dose (MGD) for each mammography
image,• dose
length product (DLP) for each computed
tomography acquisition,• the activity of the administered radiopharmaceutical for
nuclear medicine.
The mean values of these different dosimetricindicators were especially calculated for the year 2017 forthe purposes of this study.
With conventional radiology, effective doses arecalculated by multiplying the mean DAP of the complete
procedure by the conversion factor for the anatomical
region imaged, if existing [12], or by simulating thediagnostic procedure using PCXMC V2.0 software [21].
With mammography, the effective dose was calculated
by multiplying the cumulative mean glandular dose for thecomplete procedure by the factor WT defined for breasts(or half of this value for unilateral mammography) in ICRP
publication 103 [16].

16

ExPRI study 2017

With computed tomography, the effective dose foreach type of procedure was calculated by multiplying themean DLP of the complete procedure by the conversion
factor for the anatomical region imaged, if existing [12],[22], or by using CT Expo V2.5 software [23].
With nuclear medicine, the mean effective doses were
calculated using the mean activity administered while
applying the conversion factors recently updated by ICRP
[17] for the main radiopharmaceuticals. It is important totake note that these conversion factors are systematicallycalculated on the basis of the tissue weighting factors in
ICRP 60 [18], therefore the mean effective doses per
nuclear medicine procedure are not strictly equivalent to
the mean effective doses per procedure for the other typesof imaging considered in this document, most of which are
based on the tissue weighting factors from ICRP
publication 103 [16]. Conversion factors based on ICRP
publication 103 have been published [24], [25], but have
not yet been formally adopted by ICRP, and are not usedherein.

3.2.2 Recent studies by professional groups
In terms of computed tomography, the national study
led by the SFPM (Société Française de Physique Médicale- French society for medical physics), in coordination with
the SFR (Société Française de Radiologie - French society
for radiology), focusing on clinical doses, included over
6,600 examinations and 53 radiology services andprovided precise and recent data on the most frequent
computed tomography scans [26]. The mean DLP for
complete examinations and the mean number of scans
per examination published in this study were used to
update the mean effective doses for a significant numberof computed tomography procedures.
With interventional cardiology, the multicentric national
RAY-ACT 2 study updated the initial study performed in2010 under the aegis of the Collège national descardiologues des hôpitaux (French group of hospital-based
cardiologists) and included 44 public hospital interventional
cardiology services [27]. The mean effective dose
associated with a coronarography was calculated using
the mean DAP published in this study and the conversion
factor for the anatomical region considered [11].

3.2.3 Guides to procedures published by professionalgroupsWall [32], is in a 20-40% bracket for all proceduresconsidered.

Various learned societies publish guides to procedures
to complement the above data sources, offering asource of key information on technical parameters for
examinations. The following main guides were used toconfirm the estimated mean effective doses as part ofthis report:• The Guide de procédures radiologiques (guide toradiological procedures) published by the SFR and the
OPRI (Office de Protection contre les Rayonnements
Ionisants - Office for protection against ionising radiation)in 2001 and updated in 2014 [28]. This guide wascompleted in 2013 by the Guide pratique d’imagerie
diagnostique (guide to diagnostic imaging practices) for
use by radiologists [29]. These guides propose technicalparameters for these procedures, for the most frequent
procedures, reconciling expected image quality with thelowest possible level of exposure.
• The guide to indications and procedures for radiologicaldental examinations [30].
• SFMN (Société Française de Médecine Nucléaire et
Imagerie Moléculaire - French society for nuclear medicine
and molecular imaging) guides to procedures [31]. These
guides specify the radiopharmaceutical(s) to be used forcertain types of diagnostic nuclear medicine procedures
and the mean activity to be administered. These
documents were used to confirm the effective doses used
for the study.

The uncertainty for the mean annual per caput
effective doses is mainly attributable to the uncertainty forthe mean effective doses for the different types ofprocedures, which is much greater than the uncertainties
for the frequency of the procedures or the size of the
population, for this type of study. European report RP no.
180 [12] estimates that uncertainty for the estimateddoses for the population falls between 12 and 25%
depending on whether the mean effective doses for thedifferent types of procedures are calculated based on
actual clinical practice or estimated using figures from theliterature. The mean effective doses of the different typesof procedures covered in this study are partially calculatedusing actual data (DRL data or specific studies) andpartially extrapolated from the literature, therefore
uncertainty for the mean annual per caput effective doses
calculated in this study should remain within this bracket.

3.3 Uncertainty for effective doses
The main sources of uncertainty when estimating themean effective dose per type of procedure were describedand discussed in the report for 2007 [6]. These points arestill valid for this study and relate to:• the dispersal of effective doses absorbed for a given
type of procedure at national level, considering different
practices and equipment;• potential residual inconsistencies for some types ofprocedures between actual clinical practice and the CCAM
classification;• the scarcity of some types of procedures, which makes
dosimetric evaluation unreliable.
European report RP no.180 [12] estimated uncertainty
for the mean effective doses per type of procedure
calculated for each of the countries participating in the
Dose Datamed 2 study. The mean uncertainty for thisestimation, based on the method proposed by Hart and

ExPRI study 2017

17

4

EXPOSURE FOR THE ENTIRE POPULATION
IN 2017

This chapter describes the results of the study for the entire sample panel population, for all individuals, regardless of whether or not a diagnostic procedure was required. The results can be found in:•n umber of procedures extrapolated to the protected French population7,•c ollective dose extrapolated to the protected French population,• f requency of procedures (number of procedures for 1,000 beneficiaries7),•m ean annual per caput effective doseA total of 834,444 diagnostic procedures were
performed during 2017 on beneficiaries in the sample
panel. By extrapolating to the entire protected French
population, it is estimated that slightly less than 85 million
diagnostic procedures were completed in France in 2017.
A collective effective dose of approximately 110,000
sievert (Sv) is assigned to these procedures as a whole.
These figures correspond to a mean value of 1,187
procedures per 1,000 beneficiaries (exposed or other)and a mean annual per caput effective dose of 1.53 mSv.
These mean values reflect the exposure of the French
population to ionising radiation attributable to medicalcare (excluding therapeutic applications), and can be used
to compare figures for different countries or estimate theexposure of French residents to ionising radiation, from all
sources, as performed periodically by IRSN [1]. Despite
this, the actual exposure of French residents varies widely
as only a fraction of individuals in the sample panel actuallyparticipated in one or several diagnostic procedures in2017. This population of patients who were actually
exposed will be studied in chapter 5.
Table III
Number of diagnostic imaging procedures and associated collective
effective doses.
Rounded values, extrapolated for all of France, 2017.
Type of imaging

Procedures

Coll. effective dose

nomber%mSv%

Conventional radiology

46,681,000

55.1

12,938,000

11.8

Dental radiology

25,023,000

29.6

302,000

0.3

Computed tomography

10,866,000

12.8

81,170,000

74.2

Nuclear medicine

1,662,000

2.0

12,401,000

11.3

435,000

0.5

2,652,000

2.4

84,667,000100

109,463,000

100

Diagnostic interv. radiology
All types of imaging

18

ExPRI study 2017

4.1 Distribution of exposure per type ofimaging: frequencies of procedures andmean per caput effective doses7
Table III and Figure 1 show the number of imaging
procedures and associated collective dose for 2017,
distributed per type of imaging.
Most procedures use conventional radiology,
representing almost 47 million procedures, and this type ofradiology ranks second in terms of contributions to thecollective effective dose. Approximately 25 million dental
radiological procedures were recorded, establishing thistype of imaging as the second contributor to the numberof procedures, but the smallest contributor to the collective
effective dose. On the other hand, computed tomography
only ranks third in terms of frequency of procedures, withjust under 11 million procedures, well behind dental
radiology, but it contributes approximately 75% of thecollective effective dose attributable to the diagnostic
medical imaging sector. Nuclear medicine only representsa small percentage of procedures, but ranks third in termsof contributions to the collective effective dose at over
11%, just behind conventional radiology. Finally, diagnostic
interventional radiology, which represents very few
procedures in terms of number for this study, contributes
2.4% of the collective dose.

The term «protected» refers to the population covered by mandatory
French social security in 2017. The term «beneficiary» is used to refer to one
individual in the protected population (cf. 2.2.4).

7

4.1.1 Frequency of procedures per type of imaging
according to age and gender

Figure 1
Distribution of diagnostic procedures and collective effective dose
per type of imaging.

In addition to the breakdown of the number ofprocedures, it is worthwhile calculating the frequencies ofprocedures, i.e. the number of annual diagnostic
procedures performed on patients of a given age andgender, over the population of this age bracket and gender.
These frequencies differ significantly depending on theage of the individuals and, to a lesser extent, their gender,
as is apparent in Figure 2 which shows frequencies as thenumber of procedures for 1000 individuals of a given
gender and age bracket.

a) Number of diagnostic procedures.         b) Collective effective doseIn %2.0 0.5

2.4
0.3

11.3

12.8

29.6

11.8

55.1

74.2

The frequency of procedures increases with the age ofthe individuals: from approximately 300 procedures for
1,000 children aged under 5 to over 2,000 procedures for
1,000 adults aged 75 - 84. A peak appears for children
aged 10 - 14, and for teenagers aged 15 - 19, as previously
identified in the report on the paediatric population [9],which is available for more details on this population
category. Above the age of 85, the frequency of procedures
drops substantially.

Conventional
radiology

Dental radiology

Computed
tomography

Nuclear medicine

Diag. interv. radiology

Figure 2
Frequency of procedures (all types of imaging) according to age
bracket and gender.

A clear difference is also apparent between men andwomen: procedures are performed more frequently for
women in practically all age brackets, with particularly
contrasting differences for the 40 - 75 age bracket. In
general, considering all ages, the frequency of procedures
is equal to 1,328 procedures for 1,000 women, versus
1,040 procedures for 1,000 men, as indicated in Table IV.

2,500

Men
Women

2,000

1,500

1,000

500

59
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

0
04

Frequency of procedures for 1,000 individuals
in the age bracket

Number of procedures for 1000 individuals.

Age bracket (years)

Table IV
Frequency of procedures according to gender and the type of imaging.
Type of imaging

Men

Women

Overall/1,000 indiv.

%/1,000 indiv.

%/1,000 indiv.

%

Conventional radiology

525

50.5

779

58.7

654

55.1

Dental radiology

327

31.4

374

28.2

351

29.6

Computed tomography

158

15.2

147

11.0

152

12.8

Nuclear medicine

22

2.2

24

1.8

23

2.0

Diagnostic interv. radiology
All types of imaging

8

0.8

4

0.3

6

0.5

1,040

100

1,328

100

1,187

100

ExPRI study 201719

Figure 3
Comparison of frequencies of procedures per type of imaging and age bracket for men and women.

2,000

1,500

1,000

500

0

10
-1
4
15
-1
20 9
-2
4
25
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

Age bracket (years)

Figure 3 indicates the distribution of examinations
according to age and gender, complementing Table IV:•C onventional radiology is far more frequently used withwomen aged 40 to 90 than with men in the same agegroup. This difference is mainly due to mammography,
as discussed later.
• Dental radiology is considerably more frequent for
women, in practically all age brackets.
• The frequency of computed tomographic proceduresis substantially higher for men, particularly over the age

Figure 4

6
5

Men
Women

4
3
2
1

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

59

0
04

Mean annual per caput effective dose (mSv)

Mean annual per caput effective dose according to age andgender.

Age bracket (years)

20

ExPRI study 2017

2,500

2,000

Diag. interv. radiology
Nuclear medicine
Computed tomography
Dental radiology
Conventional radiology

1,500

1,000

500

0

04
59
10
-1
4
15
-1
20 9
-2
4
25
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

Diag. interv. radiology
Nuclear medicine
Computed tomography
Dental radiology
Conventional radiology

Frequency of procedures for 1,000 individuals
in the age bracket

2,500b) Women0459Frequency of procedures for 1,000 individuals
in the age bracketa) MenAge bracket (years)of 55. The frequency of computed tomography as apercentage increases regularly, for both genders, fromthe teenage years, until reaching a peak in the 80’s.
• Nuclear medicine, and diagnostic interventional radiology
even more so, only reach significant frequencies after theage of 40 - 50 and peak in the 70’s.

4.1.2 Mean effective dose per type of imaging
according to age and genderThis section focuses on the distribution of effective
dose according to the age and gender of individuals.
This refers to the mean annual per caput effective dose,
i.e. the total effective dose for the diagnostic procedures
performed on patients of a given age and gender, over the
population of this age bracket and gender. This value
indicates the exposure of the French population as awhole, with no differentiation between the population
exposed to medical radiation and the population not
exposed to medical radiation. The mean effective doseabsorbed if we only consider individuals who are actually
exposed will be studied in chapter 5.
Figure 4 shows mean annual per caput effective
doses per gender and age bracket, in mSv. Doses vary
substantially depending on the age of the individual: fromless than 0.1 mSv per year for children aged under 10 toover 5 mSv for men aged 75 - 85. In general, the dose

Figure 5
Comparison of men’s and women’s mean annual per caput effective doses, according to the typeof imaging and age bracket.
b) Women

6

3
2
1
0

Diag. interv. radiology
Nuclear medicine
Computed tomography
Dental radiology
Conventional radiology

5
4
3
2
1
0

04
59
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

4

Mean annual per caput effective dose (mSv)

5

6

Diag. interv. radiology
Nuclear medicine
Computed tomography
Dental radiology
Conventional radiology

04
59
10
-1
4
15
-1
20 9
-2
4
25
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

Mean annual per caput effective dose (mSv)a) MenAge bracket (years)

Age bracket (years)

tomography, which, as indicated in the previous section, isused more frequently for men, and, to a lesser extent,
nuclear medicine and diagnostic interventional radiology.
Despite this, the contribution of conventional radiology is
far higher for women than men due to mammograms, as
demonstrated in section 4.2.1.

increases more rapidly with age and reaches a maximum
figure in the 75 - 79 age bracket, and then decreases fairly
rapidly. It is important to remember that the mean annual
effective dose of children aged under 1, which is notindicated in this study due to the selected age brackets, issignificantly above the mean annual effective dose ofother children, as explained in the previous report on thepaediatric population [9].

Figure 5 more clearly highlights the contributions ofeach type of imaging according to age and gender,
complementing Table V:• The increasing contribution of computed tomography
with the age of the individual is very clearly visible: mostof the collective effective dose for all age brackets above
15 is attributable to computed tomography procedures,for both genders. However, the contribution of computed
tomography is substantially higher for men above theage of approx. 55.

Unlike apparent trends for the frequencies ofprocedures, the male population aged over 55 absorbs amean effective dose which is significantly greater than thefemale population, as clearly apparent in Figure 4. In
general, considering all ages, the mean annual effective
dose is approximately 1.6 mSv for each man versus
1.47 mSv for each woman, as indicated in Table V. Thisdifference appears to be essentially caused by computed
Table V

Mean annual effective dose according to gender and type of imaging, for all ages.
Type of imaging
Conventional radiology
Dental radiology

Men

Women

OverallµSv/indiv.

%µSv/indiv.

%µSv/indiv.

%

130

8.1

231

15.6

181

11.8

4

0.2

5

0.3

4

0.3

1,224

76.7

1,054

71.5

1,138

74.2

Nuclear medicine

189

11.8

159

10.8

174

11.3

Diagnostic interv. radiology

49

3.1

26

1.7

37

2.4

1,596

100

1,474

100

1,534

100

Computed tomography

All types of imaging

ExPRI study 201721

• The dose attributable to conventional radiology issubstantially higher for women above the age of 10. The
more significant differences between men and womenare apparent in the 50-75 age brackets.
• Dental radiology does not significantly contribute to
the mean effective dose in any age bracket. This due tothe characteristics of this type of diagnostic imaging
procedure (very local exposure of a region with few
radiosensitive organs). This must not mask the fact that
local exposure, particularly of the salivary glands, can be
relatively high; it is therefore important to interpret theseresults with caution (cf. 3.1).
• Nuclear medicine makes a significant contribution to themean effective dose from the age of 45, particularly formen, for which this type of procedure ranks second interms of dose contributions, well ahead of conventional
radiology.
• Finally, diagnostic interventional radiology makes a fairly
significant contribution to the mean effective dose fromthe 55-60 age bracket, an effect which is once again
more visible for men than women.

if anatomical regions are not pertinent. A table summarising
the mean frequencies of procedures and mean annual
effective doses for each group of procedures is provided
for each successive type of imaging, for the entire
population and for each gender. Groups of procedures areclassified per decreasing frequency of procedures for thegeneral population. Frequencies of procedures per age
bracket are then shown by two graphs, for each gender.

4.2.1 Conventional radiology

4.2 Distribution of exposure per examination
category: frequencies of procedures andmean per caput effective doses

Most conventional radiology procedures target limbs
for both men and women: they represent approximately
one third of annual procedures (cf. Table VI). These
procedures are required much more frequently by women.
On the other hand, the effective doses for radiograms oflimbs are very low due to the absence of organs considered
as radiosensitive in the region covered, therefore thecontribution of procedures in this anatomical region to themean annual per caput effective dose is extremely low. As
is the case for dental radiology, this effect is caused by thecharacteristics of these radiographies (very local exposureof a region with few radiosensitive organs) and must notmask the fact that local exposure can be relatively high.
These results must be carefully interpreted (cf. 3.1).

This section studies frequencies per type of imaging
as assigned to groups of procedures. These groups ofprocedures were defined in chapter 2 (cf. Table I) andcorrespond to anatomical regions or types of examinationsThorax radiography is the second most frequentgroup of procedures, for both genders, with approximately
170 procedures for 1,000 individuals. Their contribution to
the mean annual per caput effective dose is significantly

Table VI
Distribution of exposure per examination category for conventional radiology: frequencies of procedures andmean per caput effective doses.
Examination category

Mean annual eff. dose (µSv/indiv.)

Men

Women

Overall

Men

Women

Overall

Limbs

198.2

241.6

220.3

0.28

0.36

0.32

Thorax

174.9

165.0

169.8

9.2

8.3

8.8

Pelvic bone

60.7

93.3

77.3

40.0

61.7

51.0

Mammography

0.5

145.0

74.1

0.2

43.4

22.2

Vertebral column

54.0

82.4

68.5

41.8

61.4

51.8

Digestive tract

14.6

16.7

15.7

27.7

42.3

35.1

Head and neck

10.1

8.8

9.4

2.2

2.6

2.4

Bone density testing

2.1

16.5

9.4

0.002

0.016

0.009

Other

7.8

6.1

6.9

4.7

4.1

4.4

Urogenital system

1.4

3.2

2.3

3.3

5.9

4.6

524.4

778.5

653.8

129.4

230.1

180.7

Total

22

Freq. of procedures (/1,000 indiv.)

ExPRI study 2017

Figure 6
Comparison of frequencies of conventional radiological procedures per examination category andage bracket for men and women.

1,200
1,000
800
600
400
200
0

04
59

Age bracket (years)

1,600

Urogenital system
Other
Bone density testing
Head and neck
Digestive tract
Vertebral column
Mammography
Pelvic boneThorax
Limbs

1,400
1,200
1,000
800
600
400
200
0

10
-1
4
15
-1
20 9
-2
4
25
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

1,400

Frequency of procedures for 1,000 individuals
in the age bracket

Urogenital system
Other
Bone density testing
Head and neck
Digestive tract
Vertebral column
Mammography
Pelvic boneThorax
Limbs

04
59

1,600

b) Women

10
-1
4
15
-1
20 9
-2
4
25
-2
30 9
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

Frequency of procedures for 1,000 individuals
in the age bracketa) MenAge bracket (years)

higher than that of procedures focusing on limbs, but
remains moderate compared with other anatomical
regions such as the pelvis or vertebral column.

proportion of the mean annual effective dose attributable
to conventional radiology, at a similar level to procedures
imaging the pelvic bone.

Procedures imaging the pelvic bone rank 3rd for men
and 4th for women, however such procedures are required
far more frequently for men compared with women, with
an approx. 50% difference. These procedures, with thevertebral column group, represent one of the two groups
with the greatest impact on the mean annual per caput
effective dose.

Procedures focusing on the digestive tract, which areapproximately 10 times less frequent than procedures
focusing on the thorax, do however rank as the 3rdcontributor to the mean annual per caput effective dose,
due to the relatively high effective doses for this type ofradiography.

Mammography is the third most frequent group ofprocedures for women, with a mean annual frequency of
145 procedures for 1,000 individuals. This frequency will
naturally vary widely depending on the age of the women,
as is apparent in Figure 6b. Mammography ranks 3rd interms of contributions to the mean annual effective dose
per women, with slightly over 43 µSv. In the same way as
for radiography on limbs, this figure is partially caused by
the characteristics of these examinations (local exposureof one single radiosensitive organ). This must not mask
the fact that exposure of the mammary gland can be
relatively high; it is therefore important to interpret theseresults with caution (cf. 3.1).
Procedures targeting the vertebral column group rank
4th for men and 5th for women in terms of frequency,
however such procedures are required far more frequently
for women. Such procedures represent the highest

Procedures focusing on other anatomical regions areboth infrequent and do not significantly contribute to themean annual per caput effective dose, particularly bonedensity testing.
Figure 6 highlights significant variation in the
distribution of the locations of radiological procedures
based on age, and certain particularities attributable togender:• Limb radiography is a very frequent procedure for children
aged 10 - 14, and reduces in frequency for adults before
re-increasing once again, particularly for women, andpeaking towards the age of 75.
• The frequency of thorax radiographies increases
proportionally with the age of individuals, and ranks as
the most frequent group of procedures from the age of
55 for men, and 80 for women. Children under the age of
5 are a special case as thorax radiograms rank no. 1 interms of frequency.

ExPRI study 201723

includes dental panoramic imaging and cone-beam CT) for
the final third. These procedures are required far more
frequently for women, for both categories, with a differenceof approximately 15%. Consequently, the mean annual
effective dose per woman attributable to dental radiology isapproximately 18% higher than the same dose for men.
The extraoral group represents approximately two thirds ofthis figure, which is ultimately a very low percentage of thecollective effective dose attributable to diagnostic medical
imaging (0.3%, cf. 4.1).

• The frequency of procedures imaging the pelvic bonealso increase substantially in proportion to age. Pelvis
procedures are required more frequently for women, in all
age brackets.
•M ammography is a special group, as almost exclusively
women require such imaging, and most mammograms
are taken in the 40 - 74 age bracket. Mammography is themost frequent group of procedures for women aged 45- 65.
•V ertebral column imaging is a more frequent group ofprocedures for women than for men, at any age.
Frequency increases with the age of individuals, but to alesser degree than thorax or pelvic bone imaging.

The distribution of the two groups of dental radiologicalprocedures per age bracket is visible in Figure 7. The
frequency of procedures peaks in the 10-14 age bracket,
for both groups of procedures and both genders. Thisfrequency then decreases up to the 20-25 age bracket. The
frequency of extraoral radiography then remains relatively
stable, at approximately 110 procedures for 1,000 men
and 135 procedures for 1,000 women, up to the age of 70,
before rapidly decreasing. The frequency of intraoral
radiography increases progressively from age 25 up to
50-54, at which point it reaches 285 procedures for 1,000
men and 333 procedures for 1,000 women. This frequency
then subsequently slowly decreases, before falling rapidly
after the age of 75 years.

4.2.2 Dental radiology
Dental radiology procedures are split into two groups in
Table VII: intraoral radiography, representing approximately
two thirds of procedures, and extraoral radiography (which
Table VII
Distribution of exposure per examination category for dental radiology:
frequencies of procedures and mean per caput effective doses.
Mean annual eff. dose (µSv/indiv.)

Freq. of procedures (/1,000 indiv.)

Group

Men

Women

Overall

Men

Women

Overall

Intraoral

223.3

253.6

238.7

1.4

1.6

1.5

Extraoral

103.2

120.4

112.0

2.5

3.0

2.7

Total

326.5

374.0

350.7

3.9

4.6

4.2

Figure 7
Comparison of frequencies of dental radiological procedures per examination category and age
bracket for men and women.
a) Menb) Women

400

300

200

100

0

Age bracket (years)

24

ExPRI study 2017

Intraoral

Extraoral

500

400

300

200

100

0

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

500

04
59

Extraoral

Frequency of procedures for 1,000 individuals
in the age bracket

600

Intraoral

04
59
10
-1
4
15
-1
20 9
-2
4
25
-2
9
30
-3
4
35
-3
40 9
-4
4
45
-4
50 9
-5
4
55
-5
60 9
-6
4
65
-6
70 9
-7
4
75
-7
80 9
-8
4
85
-8
9
≥9
0

Frequency of procedures for 1,000 individuals
in the age bracket

600

Age bracket (years)4.2.3 Computed tomography
As shown in Table VIII, the abdominal-pelvic and head& neck anatomical regions are most frequently targeted bycomputed tomography, and frequencies are approximately
equal for men and women. However, the abdominal-pelvic
region contributes six times more to the mean annual per
caput effective dose than the head and neck region, andthis trend is slightly more pronounced in men.
Computed tomography scans of the thorax and heartrank third and those covering multiple regions8 rank 4th.
The frequency of procedures for both of these two groups
is significantly higher in men than in women, and thisdifference increases yet again when we consider the meanannual effective doses, particularly for computed
tomography scans covering multiple regions, which record
a difference of approximately 100 µSv per individual.
Computed tomography of the vertebral column is the
only group where both the frequency of procedures andthe mean annual effective dose are higher for women thanmen.
Computed tomography focusing on the limbs are fairly
infrequent and do not significantly contribute to the meanannual per caput effective dose.

i.e. focusing on at least two of the defined regions, e.g. skull-thorax orthorax-abdomen-pelvis.

8

Figure 8 shows that variation in the frequency ofprocedures with the age of individuals is relatively similar
for all groups of computed tomography procedures. The
frequency of procedures is extremely low before the ageof 15, and increases progressively with age before
reaching a maximum between age 75 and 90, dependingon the anatomical region. Above the age of 90, thefrequency of procedures drops substantially. For all
examination categories, the frequency of procedures forboth men and women is fairly similar for adults in the 20 50 age bracket, the difference increases rapidly above theage of 55, to the benefit of men.

Table VIII
Distribution of exposure per computed tomography examination category:frequencies of procedures and mean per caput effective doses.
Freq. of procedures(/1,000 indiv.)

Anatomic region

Men

Mean annual eff. dose(µSv/indiv.)

Women

Overall

39.5

36.8

Head and neck37.3

Thorax and heart

29.9

Abdomenand/or pelvis

Men

Women

Overall

38.1

382.0

341.6

361.4

38.9

38.1

62.8

61.9

62.3

23.5

26.6

168.4

135.0

151.4

Multiple regions

23.4

17.5

20.4

401.6

301.9

350.8

Vertebral column

15.5

18.4

17.0

147.8

175.4

161.9

Limbs

12.5

11.4

12.0

61.9

37.6

49.5

Other

0.0

0.1

0.0

0.1

0.3

0.2

Total

158.2

146.6

152.3

1,224.5

1,053.8

1,137.5

Figure 8Comparison of frequencies of computed tomography procedures per examination category and age
bracket for men and women.
a) Men

300
250
200
150
100
50

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

0

Age bracket (years)

400
350
300
250
200
150
100
50
0

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

350

Other
Limbs
Vertebral column
Multiple regions
Thorax and heart
Head and neck
Abdomen and/or pelvis

450

04
59

400

500

Frequency of procedures for 1,000 individuals
in the age bracket

Other
Limbs
Vertebral column
Multiple regions
Thorax and heart
Head and neck
Abdomen and/or pelvis

450

04
59

Frequency of procedures for 1,000 individuals
in the age bracket

500b) WomenAge bracket (years)

ExPRI study 201725

4.2.4 Nuclear medicine

caput effective dose: PET and oncology lead the way,followed by cardiovascular system procedures, well aheadof musculoskeletal imaging. Procedures focusing on theendocrine system rank 4th in terms of the frequency ofprocedures and mean annual effective doses. Very low
frequencies are recorded for the other categories ofprocedures.

The frequency of nuclear medicine procedures(Table IX) is very similar for three main categories ofprocedures and is substantially higher than for othercategories: with PET and oncology leading the way,followed by the musculoskeletal system and by the
cardiovascular system, almost equally. These three groups
are also the main contributors to the mean annual per

The frequency of procedures for women exceeds
those of men for most groups of procedures, the key
exception being procedures imaging the cardiovascularsystem, where men require 50% more examinations than
women, which globally contributes to a mean annual per
caput effective dose which is generally higher for men
versus women for all nuclear medicine procedures.

Table IX
Distribution of exposure per examination category for nuclear medicine:frequencies of procedures and mean per caput effective doses.
Freq. of procedures(/1,000 indiv.)

Examination
category

Mean annual eff. dose(µSv/indiv.)

Men

Women

Overall

Men

Women

Overall

PET and oncology

7.9

8.4

8.1

102.0

93.6

97.7

Musculoskeletal
system

5.4

6.2

5.8

17.1

19.9

18.6

Cardiovascularsystem

6.8

4.4

5.6

61.6

34.3

47.7

Endocrine system

0.7

1.7

1.2

2.2

4.9

3.6

Respiratory system

0.6

0.9

0.7

1.6

2.2

1.9

Other

0.1

1.3

0.7

0.1

0.4

0.3

Nervous system

0.5

0.5

0.5

3.2

3.0

3.1

Urogenital system

0.3

0.3

0.3

0.3

0.3

0.3

Immune &hematopoiet. syst.

0.2

0.3

0.3

0.6

0.8

0.7

Total

22.5

24.1

23.3

188.7

159.4

173.8

Figure 9 shows that the frequency of nuclear medicine
procedures in men is tightly distributed around the 65-85
age bracket, while this distribution is more spread out for
women, with a relatively high frequency for the 40 - 65 age
bracket for this group for women. The frequency ofprocedures increases significantly over the 35-70 age
bracket for women, and the 45-70 age bracket for men, forthe three most frequent examination categories, before
levelling off and then rapidly decreasing from the age of80, for both genders.

Figure 9Comparison of frequencies of nuclear medicine procedures per examination category and age
bracket for men and women.
a) Men

50
40
30
20
10

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

0

Age bracket (years)

26

ExPRI study 2017

70
60
50
40

Immune and hematopoietic
systems
Urogenital system
Nervous system
Other
Respiratory system
Endocrine system
Cardiovascular system
Musculoskeletal system
PET and oncology

30
20
10
0

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

60

80

04
59

70

Immune and hematopoietic
systems
Urogenital system
Nervous system
Other
Respiratory system
Endocrine system
Cardiovascular system
Musculoskeletal system
PET and oncologyb) Women90

Frequency of procedures for 1,000 individuals
in the age bracket

80

04
59

Frequency of procedures for 1,000 individuals
in the age bracket

90

Age bracket (years)4.2.5 Diagnostic interventional radiology
Table X indicates that most diagnostic interventional
radiological procedures9 are cardiology procedures, which
explains why this category is the main contributor to themean annual effective dose associated with the type ofimaging. Procedures imaging the vascular system rank
second and are approximately three times less frequent
than cardiac procedures. Biliary and neurologicalcategories rank after the above, are infrequent and only
contribute very moderately to the mean annual per caput
effective dose. Procedures are far more frequent for men
than women for the vascular groups, and for cardiac
groups to a greater extent, as well as the associated meanannual effective doses.
It is important to remember that diagnostic
interventional radiological procedures are very frequently
associated with a therapeutic procedure and, on this basis,are not systematically assigned a specific CCAM code.
This study probably, therefore, excludes a high number ofdiagnostic procedures. On this basis, these figures mustnot be considered as representative of clinical practice.

refer to section 2.1 for the definition of diagnostic interventional radiology.

Table X
Distribution of exposure per examination category for diagnostic interventional radiology: frequencies of procedures and mean per caput
effective doses.
Freq. of procedures(/1,000 indiv.)

Examination
category

Mean annual eff. dose(µSv/indiv.)

Men

Women

Overall

Men

Women

Overall

Cardiac

5.8

2.8

4.3

32.3

15.9

23.9

Vascular

1.9

1.1

1.5

14.2

7.2

10.6

Biliary duct

0.4

0.4

0.4

0.7

0.6

0.6

Neurological

0.3

0.4

0.3

2.6

2.6

2.6

Total

8.3

4.7

6.5

49.7

26.3

37.8

Figure 10
Comparison of frequencies of diagnostic interventional radiological procedures per examination
category and age bracket for men and women.
a) Men25

Frequency of procedures for 1,000 individuals
in the age bracket

Neurological
Biliary duct
Vascular
Cardiac30b) Women
35

20
15
10
5

04
59

10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

0

Age bracket (years)

30

Neurological
Biliary duct
Vascular
Cardiac

25
20
15
10
5
0

04
59
10
-1
4
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
85
-8
9
≥9
0

35

Frequency of procedures for 1,000 individuals
in the age bracket

9

As indicated in Figure 10, cardiology procedures occur
extremely infrequently up to the age of 35-40, and thenincrease rapidly in men, and at a slower rate in women,
until reaching a peak between 75 and 84. This variation
with age is approximately identical in other categories ofdiagnostic interventional radiological procedures, even
if the interpretation is unreliable due to the low numbersof procedures recorded, particularly for the biliary or
neurological groups.

Age bracket (years)

ExPRI study 201727

5

POPULATION ACTUALLY EXPOSED IN 2017

Sample panel data is provided by both SNIIRAM in the private sector and PMSI for inpatients andoutpatients in the public sector, therefore the percentage of the population studied actually exposed, i.e.
individuals who actually participated in a diagnostic imaging procedure using ionising radiation during
the year, can be determined. On this basis, this chapter focuses on the population actually exposed in2017. Exposed individuals in this population will hereafter be called patients. Patient exposure will becharacterised in terms of the number and type of procedures, and the individual annual effective dose.

5.1 Characterisation of the exposed
population
5.1.1 Percentage of individuals actually exposed(patients) in the protected population
319,187 of the 703,261 individuals in the sample
panel in 2017, i.e. 45.4%, participated in one or several
diagnostic procedures in 2017. As is apparent in Table XI,
this percentage varies substantially depending on thegender of the individuals: a much higher percentage ofwomen is exposed than men: 50.2% versus 40.4%.
However, this difference is reduced by half if mammography
is excluded from the list of diagnostic proceduresconsidered. Even without considering this procedure,
which is almost exclusively required for women10, we canconclude that women require a diagnostic imaging
procedure more often than men, with a difference ofalmost 5 percent. When dental radiological procedures,
which have a very minor contribution to the collective
effective dose, are excluded, the percentage of exposed
Table XI
Percentage of the sample panel having benefited from at least one
diagnostic imaging procedure in 2017.
Men

Women

Overall

(%)

(%)

(%)

All types of imaging

40.4

50.2

45.4

Excluding dental radiology

27.3

37.9

32.7

Excluding mammography

40.4

45.3

42.9

183 mammography procedures were performed on men, versus 51,947
on women in the sample panel in 2017.

1028

ExPRI study 2017individuals in the population falls steeply: 32.7%, i.e. a
decrease of almost 13 percent. On this basis, we canconsider that one third of the French population
participated in at least one diagnostic procedure in 2017,
excluding dental radiology.
The percentage of exposed individuals in the
population also depends strongly on age, as shown in
Figure 11. The percentage of the population having
benefited from at least once diagnostic procedure isindicated, per bracket of year of birth, as a percentage ofthe male and female populations respectively. The age ofthe individuals in the sample panel will necessarily vary by
one year over the course of a year, therefore it is morereliable to calculate the percentage of individuals exposed
according to the year of birth rather than age. Brackets foryears of birth were selected to match the age brackets
used in this report as far as possible.
It is important to take note that the percentage ofwomen exposed is higher than the percentage of men for
all years of birth. This difference is particularly apparent for
women born between 1940 and 1980 (aged 36-77 in2017). This effect is mostly due to mammography, as
shown in Figure 12b, which excludes this type of
examination. One exception applies for children born after
2013 (aged 4 or less in 2017) for whom the percentage ofyoung boys exposed is higher than the percentage ofyoung girls. This matches previous observations in thereport on the paediatric population [9] and is probably
caused by health problems which mostly affect the maleperinatal population more than the female perinatal
population, as proven by the higher level of perinatal
mortality for young boys compared with young girls.

(aged 9-19 in 2017), which confirms the observations in
the aforementioned report [9, p. 19] and is very probably
due to the mandatory preventive oral-dental examination
at the age of 12 defined in the French Code of Public
Health.

Figure 11
Percentage of individuals exposed in 2017 per gender and yearof birth.
Percentage of individuals exposed in 2017

80%

Men
Women

70%

Figure 12a shows the percentage of individuals
exposed to at least one imaging procedure, excluding
dental radiology. The general reduction in the percentage
of individuals exposed has very little effect on the overall
age distribution, with one key exception for the years
corresponding to children and teenagers aged 10-20 in2017, for whom this percentage is halved. This category of
the population is in fact characterised by extensive use of
dental radiology, as indicated in the previous chapter. By
comparing Figure 11 and Figure 12a, it appears that thedifference between the percentages of exposed men andwomen, which is most noticeable for people born between
1940 and 1980, is partially attributable to dental radiology,
as this difference is even greater if this type of imaging is
excluded. This point would appear to indicate that moremen in this age bracket exclusively participate in this typeof radiological examination (dental radiology) than women
during the year. On the other hand, it appears that more
women born between 1983 and 2007 exclusively
participate in this type of examination than men during theyear, as the differences shown in Figure 11 are almost nonexistent in Figure 12a for these years of birth.

60%
50%
40%
30%
20%
10%

[2

[2

01
32
00 0178][2 -20
00 12
3]
2
[1
99 0078][1 -2099 02
3][1 -1998 97
8][1 -19
98 92
3]
[1 19
97 87
8]
[1 19
97 82
3]
[1 19
96 77
8]
[1 19
96 72
3]
[1 19
95 67
8]
[1 19
95 62
3]
1
[1
94 957
8][1 -1994 52
3][1 -1993 47
8][1 -19
93 42
3]
[1 19
92 37
8]
[1 19
90 32
319 ]
27
]

0%

Years of birth

The percentage of individuals exposed in the
population increases with age, from approximately 15%
for very young children to slightly less than 70% for womenborn in the 1940’s (aged approx. 65-75 in 2017) andapprox. 55% for men born in the 1930’s and 1940’s (agedapprox. 65-85 in 2017). A higher percentage is recorded forchildren and teenagers born between 1998 and 2007

Figure 12
Percentage of individuals exposed in 2017 per gender and year of birth, excluding dental radiology or mammography.

Men
Women

50%
40%
30%
20%
10%

01
3
[2 -2000
17
8[2 -20 ]00
12
3[1 -20 ]
99
0
8- 7]
2
[1
99 00
3- 2]
1
[1
98 99
7
8
[1 -19 ]
98
9
3- 2]
1
[1
97 98
7
8
[1 -19 ]97
82
3[1 -19 ]96
77
8[1 -19 ]96
72
3[1 -19 ]
95
6
8- 7]
1
[1
95 96
2
3
[1 -19 ]
94
5
8- 7]
1
[1
94 95
2
3
[1 -19 ]
93
4
8- 7]
1
[1
93 94
2
3
[1 -19 ]
92
3
8- 7]
1
[1
90 93
3- 2]
19
27
]

0%

Years of birth

70%
60%

Men
Women

50%
40%
30%
20%
10%
0%

[2
01
3
[2 -20
00
1
8- 7]
2
[2
00 01
2
3
[1 -20 ]
99
0
8- 7]
2
[1
99 00
2
3
[1 -19 ]98
97
8[1 -19 ]98
92
3[1 -19 ]97
87
8[1 -19 ]97
82
3[1 -19 ]
96
7
8- 7]
1
[1
96 97
2
3
[1 -19 ]
95
6
8- 7]
1
[1
95 96
2
3
[1 -19 ]94
57
8[1 -19 ]94
52
3[1 -19 ]93
47
8[1 -19 ]93
42
3[1 -19 ]
92
3
8- 7]
1
[1
90 93
3- 2]
19
27
]

60%

b) Excluding mammography
Percentage of individuals exposed in 2017

70%

[2

Percentage of individuals exposed in 2017a) Excluding dental radiology

Years of birth

ExPRI study 201729

Table XII
Statistics on the number of procedures per patient, per gender andper year.
Number of procedures per patient

Men

Women

Overall

Mean

2.57

2.65

2.61

Mean (dental radiol. excl.)

2.61

2.52

2.56

th

25 percentile

1

1

1

Median22275th percentile

3

3

3

95 percentile

7

7

th

Maximum

7
132

Figure 13
Mean number of diagnostic procedures per patient in 2017,
per gender and age.

Men
Women

3.5
3
2.5
2
1.5
1
0.5
0
[5

[0

-4
]
-9
[1 ]
01
[1 4]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

Mean number of procedures per patient

4

Completed age (years)

5.1.2 Number of procedures per patient
The 319,187 individuals on the sample panel exposed
to at least one imaging procedure in 2017 participated in
834,444 imaging procedures, representing a mean figureof 2.61 procedures per patient. Table XII shows detailsof the different statistics for the number of procedures
involving patients each year. On average, female patients
participated in slightly more examinations than malepatients. This trend is reversed if dental radiology is notconsidered when determining the exposed population.
The distribution of the number of procedures is highly
asymmetrical, as shown by the different percentiles
calculated in Table XII: 50% of patients benefitted fromone or two annual procedures, 75% of patients from one
to three procedures, and 5% from over 7 diagnostic
procedures in 2017. 132 is the maximum number ofprocedures recorded in the sample panel for one single
patient. It is important to realise that this distribution
remains constant if dental radiology is excluded.

30

The distribution of the mean number of diagnostic
procedures depends on the age of the patient, as illustrated
in Figure 13: on average, young children (age < 10)participate in less than 2 procedures annually; on average,
the elderly (≥ 75) participate in approx. 3.5 procedures. The
mean number of procedures increases almost linearlywith age, except the 1-14 age bracket, and, to a lesser
extent, the 15-39 age brackets for men, for whom a higher
level of procedures is recorded. The mean number ofprocedures stabilises above the age of 75 for men and
80 for women.

ExPRI study 2017

The distribution of the number of procedures according
to age and gender clearly differs depending on the typeof imaging performed, as shown in Figure 14 for fourtypes:• The mean number of conventional radiologicalprocedures (Figure 14a) is relatively high for the youngest
children11 (1.5 per patient for children aged under 5) andthen stabilises around 1, up to the age of 40. A significant
difference is recorded in these age brackets between
women and men, to the benefit of the latter12. From theage of 40, the mean number of procedures increases
almost linearly up to the highest ages. This increase isparticularly noticeable for women, who participate inmore annual examinations than men, on average, for all
age brackets. This observation is clearly dependent onscreening mammography for breast cancer.
•T he distribution of the mean number of dental radiology
procedures (Figure 14b) follows the reverse trend toconventional radiology: on average, the youngest patients(except children aged under 5) participate inapproximately one dental procedure in the year, and thisvalue then steadily decreases with age, with a steeper
drop from age 85. It also appears that, on average, young
female patients benefit from slightly more dental
radiological examinations than young male patients, withthe trend reversing from the age of 35.
• With computed tomography (Figure 14c), the distributionof the mean number of procedures is noticeably offset
towards older ages, particularly for men. Before the ageof 15, the mean number of computed tomography
procedures per patient is very low (between approx. 0.03
and 0.06); this figure then increases slowly, before
adopting a steeper trend and reaching a maximum of
0.7 for women and 0.9 for men in the oldest patients.
The difference between men and women peaks for the
Probably due to chronic pathologies affecting young children (bronchiolitis,etc.).

11

This figure must be compared with the higher frequency of radiography
procedures of the limbs of young men (cf. Figure 6), probably due totraumatology.

12

60-75 age brackets: male patients benefit from 1.8 times
more computed tomography examinations than female
patients.
• Finally, the distribution for nuclear medicine (Figure 14d)
is also strongly centred on more elderly patients. The
mean number of procedures is very low before the age of
35-40, and then rapidly rises to peak between 70 and 80,
and then falls off. The difference between men andwomen reaches significant values in the 55+ age bracket.
Due to the inadequate number of procedures in thesample panel, the results obtained for diagnostic
interventional radiology are not shown here.

5.2 Individual effective dose
If the cumulative effective dose calculated for 2017 iscompared with the number of patients (reminder: patientsare considered as individuals in the sample panel who are
actually exposed), a cumulative mean individual effective
dose of approx. 3.4 mSv is obtained. To a greater extent
than for the number of procedures, the dose distribution
varies widely (cf. Table XIII): half of patients absorb a dose
which is less than or equal to 0.1 mSv, 75% absorb 1.5 mSv
or less, while 5% of the most exposed patients absorb adose of greater than 18.1 mSv, with a maximum value of
380 mSv recorded for a given patient in this study.

Figure 14
Distribution of the mean number of procedures per patient, per age and gender, per type of imaging.

Men
Women

2.5

b) Dental radiology
Mean number of procedures per patient

2
1.5
1
0.5

Men
Women

1
0.8
0.6
0.4
0.2

]

-9

-4

[1

[1

[1

[1

[5

[0

]

]
014
]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

-9

-4

Completed age (years)c) Computed tomographyd) Nuclear medicine
0.18

Mean number of procedures per patient

Men
Women

0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1

0.14
0.12
0.1
0.08
0.06
0.04
0.02

[5

Completed age (years)

-4

]
-9
]
[1
01
[1 4]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

0

-4
]
-9
[1 ]
01
[1 4]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

0

Men
Women

0.16

[5

[0

[5

Completed age (years)

1
0.9

[0

]
014
]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

0

0

Mean number of procedures per patient

1.2

[0

Mean number of procedures per patienta) Conventional radiology
3Completed age (years)

ExPRI study 201731

Table XIII
Statistics on cumulative annual effective doses per patient, according to gender, including and excluding dental
radiological procedures.
Including dental

Annual effective dose
per patient (mSv)

Men

Excluding dental

Women

Overall

Women

Overall

Mean value

3.95

2.94

3.38

5.84

3.88

4.68

th

25 percentile

0.009

0.019

0.014

0.010

0.068

0.058

Median

0.04

0.31

0.10

0.61

0.31

0.33

75 percentile

1.60

1.40

1.53

5.85

2.45

3.80

95th percentile

20.3

15.5

18.1

27.6

18.6

21.4

th

Maximum value

Men

380

Unlike the conclusions of section 5.1.2 on the numberof procedures, a very noticeable difference is apparent inTable XIII between men and women in terms of cumulative
individual effective dose: men absorbed approx. 1 mSv
more than women in 2017 on average. By analysing thedifferent percentiles, we can confirm that the distribution
for the effective dose of men is clearly offset towards
higher dose levels compared to women. This observationmust be compared with the mean number of computed
tomography and nuclear medicine procedures per patient,which is higher for men (cf. Figure 14c & d): these two
types of imaging record the highest effective doses foreach examination, therefore it is logical for the cumulative
effective dose per patient to be higher for men than for
women.
The contribution of dental radiology to the collective
effective dose is very low (see chapter 4), therefore it is380

worthwhile characterising the cumulative effective dose
per patient integrating all imaging procedures other thandental radiology. This approach will reduce the populationconsidered as exposed (n = 229,790 instead of 319,187)
as patients having exclusively participated in dental
radiological procedures during 2017 are not included. The
mean cumulative effective dose for this reduced population
increases significantly (+38%), and reaches approximately
4.7 mSv. Differences previously recorded between the
exposure of men and women are confirmed and enhanced:
the mean cumulative effective dose per male patient isalmost 2 mSv higher than for female patients.
Figure 15 shows another means of approaching the
distribution of cumulative annual effective doses per
patient. The percentage of patients having absorbed acumulative dose in a specified dose interval is shownin this figure, with a logarithmic scale, covering bothFigure 15
Percentage of patients having absorbed a cumulative annual effective dose in the specified interval.
b) By gender
100%

0,2%

Cumulative annual effective dose interval (mSv)

32

ExPRI study 2017

9,1%

1%

1%

0,5%
0,2%
0,1%

0.1%
-1
0]
]1

11]
]0
,

]

]
]1
00
-+

010
0]
]5

050
]
]1

0]
]1
-1

]0
,1
-1

]

0.1%

11,4%

Cumulative annual effective dose interval (mSv)

]

0,7%

Men
Women

18,7% 19,6%

9,3%

10%

0,
1

1%

27,7%

]1
00
-+

10,1%

10%

43%

]5
010
0]

19,2%

]0
-

19,6%

59,4%

]1
050
]

50,2%

Percentage of patients (logarithmic scale)

100%

]0
-0
,1
]

Percentage of patients (logarithmic scale)a) Total

The cumulative mean effective dose also depends on
the age of the patients, and to an even greater extent, asshown in Figure 16. This figure shows the distribution ofthis dose according to age bracket for each gender. This
distribution varies in a very similar manner for men andwomen up to the age of around 40: less than 1 mSv forchildren and very young adults (0.6 mSv before the age of5; approx. 0.4 mSv between 5 and 15; 0.9 mSv before theage of 20), without any noticeable difference between
boys and girls, climbing with age to reach approximately 2
mSv before the age of 40. Above this age, on average,
annual exposure will be substantially higher for men thanfor women (approx. 9 mSv vs 5 mSv between the ages of
70 and 74). This difference is explained by the results givenin the previous chapter, which particularly demonstratethat men participate in more computed tomography andnuclear medicine procedures than women after the age of
45. In fact, most of the effective doses associated withcomputed tomography and diagnostic nuclear medicine
procedures exceed the effective doses associated withconventional radiology examinations.

5.3 Focus article: The issue of cumulative
computed tomography examinations
As indicated in chapter 4, computed tomography is
the type of imaging with the greatest contribution to
the collective effective dose in France. This observation
is valid for all countries with a similar healthcare system
to France. The cumulative effective dose for patients

Cumulative mean effective dose per patient, according to genderand age.
10

Men

9

Women

8
7
6
5
4
3
2
1

[5

-4
]
-9
[1 ]
01
[1 4]
519
[2 ]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

0

[0

The distribution of the cumulative effective dose clearly
differs depending on gender as shown in Figure 15b:
three times more women absorb a cumulative annual
dose of between 0.1 and 1 mSv, which corresponds to the
mammography dose range. In the highest dose intervals,
the percentage of men is the double of that of women, due
to their more frequent need for computed tomography andnuclear medicine.

Figure 16

Cumulative mean effective dose
per patient (mSv)

genders (a) and per gender (b). It appears that roughly
half (50.2%) of patients absorbed a cumulative effective
dose of less than or equal to 0.1 mSv in 2017. Slightly
under 20% of patients absorbed a cumulative effective
dose of between 0.1 and 1 mSv, and an additional 20%
absorbed a dose between 1 and 10 mSv. Finally, 10.1% of
patients absorbed between 10 and 50 mSv and 0.9% over
50 mSv. These figures illustrate one point that the meandose per patient alone tends to mask: most (81.6%
precisely) patients absorbed a dose of less than themean dose of 3.4 mSv in 2017.

Completed age (years)

participating in several computed tomography
examinations must therefore be considered at international
level. A recent study by the Massachusetts General
Hospital in Boston [33] concluded that 1.3% of patients
having benefitted from at least one computed tomography
examination over a period of 1 to 5 years had absorbed acumulative effective dose in excess of 100 mSv. Similar
conclusions were reached by an international study led
by the International Atomic Energy Agency (IAEA) [34].
On this basis, this section of the ExPRI study focuseson patients having participated in at least one diagnostic
computed tomography procedure (as previously explainedin chapter 2, interventional procedures and computed
tomography used for radiotherapy planning purposes are
not taken into consideration), in 2017 and, retrospectively,
over a cumulative 3- and 6-year period. Table XIV shows
various statistics for the number of computed tomography
procedures and associated individual effective dose. It is
important to specify that any doses absorbed in imaging
procedures other than computed tomography are notconsidered. Depending on the cumulative durationconsidered, on average, patients benefitted from between
1.64 and 2.56 computed tomography examinations forperiods of 1 and 6 year respectively, corresponding to amean cumulative effective dose of 12 to 18 mSv. Most
patients by far undergo computed tomography
examinations infrequently: 75% of patients recorded amaximum of two examinations over one or three years,
and three over six years, with cumulative effective dosesof less than 15 mSv, 18 mSv and 20 mSv, respectively.
However, it also appears that, within the population foreach of the periods considered, 1% of patients participated

ExPRI study 201733

Table XIV
Number of diagnostic computed tomography procedures and associated individual effective dose for the populationof patients exposed to computed tomography and over three cumulative periods.
Percentiles
Cumulative period considered2017 (1 year)

2015-2017 (3 years)

2012-2017 (6 years)

Mean value

Median75th

95th

National population*of the 99th percentile

99th

N° of procedures

1.64

1

2

4

7

Effective dose (mSv)

12.2

9.3

14.6

37.8

77.0

N° of procedures

2.10

1

2

6

11

Effective dose (mSv)

15.4

9.7

18.0

51.7

117.7

N° of procedures

2.56

2

3

8

14

Effective dose (mSv)

18.2

10.0

20.0

62.8

145.0

67,000148,000

225,000* Estimated national population, rounded to the nearest thousand.

“100mSv+”. In 2017, approximately 0.5% of patients
having participated in at least one computed tomographyscan absorbed a cumulative effective dose of more than
100 mSv, which represents approximately 33,000
patients at national level. Over the 2012-2017 period, i.e.
a total of 6 years, this percentage reached 2.25%, whichis slightly over 500,000 patients throughout France. The
mean effective dose absorbed by patients represented
approx. 130 mSv for 2017 and 160 mSv in total over 6
years. The maximum values recorded for the sample panel
represented 30 computed tomography procedures and acumulative 313 mSv in 2017 and 65 computed tomography
procedures and cumulative 694 mSv over 6 years in the
2012-2017 period. Due to the limited representativeness ofthe sample panel, the maximum values at national levelare very probably higher than the peak panel values.

in more than 7 examinations in 2017, 11 examinations
between 2015 and 2017 and 14 examinations between
2012 and 2017, which leads to cumulative effective doses
in excess of 77 mSv, 118 mSv and 145 mSv, respectively.
The national population corresponding to this 1% of
patients having benefitted from computed tomography
procedures is indicated, rounded to the nearest thousand,in Table XIV: it represents over 200,000 patients over 6
cumulative years.
It would be worth considering patients having
accumulated an effective dose in excess of 100 mSv fromthe population having benefitted from computed
tomography procedures during the cumulative periods
studied. In fact, the various international organisations
such as ICRP [16] or UNSCEAR [10] have reached aconsensus on considering that above this effective dose,
stochastic risks exist for ionising radiation. Table XV
shows a few characteristics of this population of patientssubject to high exposure, hereafter referred to as

Figure 17 shows some characteristics of the “100mSv+” population over a cumulative 3-year period,
compared with base 100 in 2012-2014, showing variation

Table XV
Characterisation of the population of patients exposed to computed tomography and absorbing more than 100 mSv,
in terms of number of procedures and associated individual effective dose, over three cumulative periods.
Percentiles
Cumulative period considered2017 (1 year)

2015-2017 (3 years)

2012-2017 (6 years)

Mean value

Median

75

th

95th

N° of procedures

10.1

9

12

18

Effective dose (mSv)

133.5

122.6

144.0

199.7

N° of procedures

12.2

11

15

22

Effective dose (mSv)

153.0

134.6

172.1

270.6

N° of procedures

14.1

13

17

26

Effective dose (mSv)

160.0

138.2

179.5

296.2

% patients
exposed*National
population#

0.49

33,0001.44

212,000

2.25

506,000* Compared with the population having benefited from at least one diagnostic computed tomography procedure in the period studied.
# Estimated national population, rounded to the nearest thousand.

34

ExPRI study 2017

In %

2.5
2.9

0.03

28.9

130

1.28%

120
110

153 mSv

1.13%
146 mSv

142 mSv

20
17

20
15
20
13
-

20
14
20
12
-

12.2

11.7

11.8

90

20
15
-

1.02%
140 mSv
12.5

20
16

100

1.44%

20
14
-

Variation (base 100 in 2012-2014)

Percentage of "100mSv+"
Mean number of CT per patient
Mean cumulative effective dose
per patient (mSv)

140

Cumulative period

Figure 18
Distribution per age bracket and per gender of patients exposed
to more than 100 mSv over the 2012-2017 period.
The age is calculated on the date of the first computed tomography scan.
12%

Men
Women

10%
8%
6%
4%
2%
0%

-4
]
-9
[1 ]
01
[1 4]
51
[2 9]
02
[2 4]
52
[3 9]
03
[3 4]
53
[4 9]
04
[4 4]
54
[5 9]
05
[5 4]
55
[6 9]
06
[6 4]
56
[7 9]
07
[7 4]
57
[8 9]
08
[8 4]
589
]
≥9
0

Distribution per anatomical region of CT scanson “100mSv+” patients over the 2012-2017
period.

150[5Figure 19

Variation in the cumulative “100mSv+” population over 3 sliding
years between 2012 and 2017 (base 100 for 2012-2014).

[0

The mean age13 of the “100mSv+” patient sub-groupover the 2012-2017 period is approximately 62. Most of
this sub-population is male (60.5% men versus 39.5%
women). Figure 18 shows the age pyramid for this subgroup. No significant difference between men and women
is apparent in the age distribution. Half of patients are
aged between 55 and 71 at the time of the first computed
tomography examination. However, this strongly exposed
sub-group includes a small, but significant, percentage ofyoung patients. The general shape of this age pyramid canFigure 17

Percentage of the "100 mSv+" patient sub-groupover time. The percentage of “100 mSv+” patients in the
population having benefitted from at least one computed
tomography procedure in the period considered (red line)
increased by 40% from 1.01% in 2012-2014 (for around
136,000 patients) to 1.44% in 2015-2017 (for around
212,000 patients). Over the same period, the cumulative
mean effective dose for these same patients (green line)
increased by around 10%, to reach approximately 153 mSv.
The mean number of computed tomography examinations
for these patients (blue line) is relatively stable at around
12 examinations over 3 years. These results appear toindicate that the population exposed to over 100 mSv due
to cumulative computed tomography examinations has
steadily and relatively rapidly increased, since 2012

Completed age (years)

38. 4
8.0
19.3

Abdomen and/or pelvis

Vertebral column

Head and neck

Limbs

Thorax and heart

Other

Multiple regions

be extrapolated at national level, however, it is important toshow caution with the youngest patients due to theinherent statistical uncertainty for a panel-based study,
including if the panel is fairly large, as is the case here. In
particular, the “100 mSv+” sub-group only includes
9 children aged under 15, which implies high levels of
uncertainty for any extrapolation to the national level.

The age of the patient is calculated on the date of the first computed
tomography examination in the cumulative period considered.

13

ExPRI study 201735

Figure 19 shows the anatomical regions covered by
the computed tomography procedures performed on
patients in the “100mSv+” sub-group during the 2012-2017
period. The distribution of these procedures is very clearly
different to that recorded for the entire sample panel(cf. chapter 4.2.3). In particular, the percentage ofcomputed tomography scans imaging multiple regions(mostly thorax-abdomen-pelvis) has almost tripled (38.4%
vs 13.4%). Abdominal and/or pelvic imaging procedures
are also slightly more frequent (29% vs 25%), as well as
thorax and cardiac imaging (19.3% vs 17.5%). On the other
hand, computed tomography examinations of the headand neck (8% vs 25%), and of the vertebral column andlimbs, are much rarer than for the general population.
To conclude, a population estimated at over 30,000
patients nationwide was exposed to a cumulative effective

36

ExPRI study 2017

dose of over 100 mSv in 2017 due to multiple computed
tomography examinations. This figure rises to 500,000 if acumulative period of 6 years is considered. This strongly
exposed population appears to be steadily increasing
since 2012. Most members of this population are elderly,
however one quarter is aged under 55. On this basis,
potential long-term radio-induced effects must be
considered for this specific population. It is worth
remembering that these patients are very certainly treatedfor serious pathologies, and that computed tomography
examinations are probably an essential part of thistreatment. Specific investigations would be required toconfirm this point and potentially identify any unnecessaryor redundant examinations. The description of this groupof patients strongly exposed to medical examinations
requiring ionising radiation could be rendered more precise
by considering other types of diagnostic procedures.

6

VARIATION IN DIAGNOSTIC MEDICAL EXPOSURE
FOR THE FRENCH POPULATION FROM 2002
TO 2017
This study follows on from the three previous studies focusing on 2002, 2007 and 2012 [5]–[7]. The
method used to estimate the number of diagnostic procedures changed significantly between the different studies.
For the year 2002, the EGB sample panel was not yet available and the number of procedures wastherefore determined based on multiple data sources: CNAMTS, DREES, regional hospitalisation agency for greater Paris, etc.
For the year 2007, the EGB sample panel was used for procedures in the private sector, howeverdata for the public sector was not yet included in this sample panel. Public sector data was therefore
extrapolated based on a survey of 50 public healthcare establishments. In addition, dental radiology
data had not been updated and data from 2002, obtained during a CNAM survey, had been re-used.
The same method was used in 2012 as for the current study. However, the progressive withdrawalof the NGAP codes for dental radiological procedures, replaced by CCAM codes, has greatly boosted
the reliability of the data collected. In addition, dental CCAM codes have been extensively modified (cf.
section 2.2.2). For both of these reasons, comparing figures for this type of imaging between 2017 andprevious years is a delicate process.
The mean effective doses for each type of procedure in this study were updated compared to theprevious study for 2012, mainly on the basis of the analysis of diagnostic reference levels data, to matchchanging medical practices. However, the same method was used for this study and previous editions.
This chapter compares the results for 2017 with the results of previous studies, and comments onchanges, considering changing methods.

6.1 Variation in the mean number of annual
procedures
The mean number of annual procedures decreased
from 1,247 to 1,187 for 1,000 beneficiaries between 2012
and 2017, which is a 4.8% decrease. However, the mean
number of annual procedures, excluding dental radiology(836 for 1,000 beneficiaries) is 1.3% higher than in 2012.
Details of variation since 2002 for each type of imaging
can be found in Figure 20. It appears that the frequency ofdental procedures varies widely between the different
studies, which strongly affects total figures for diagnostic
procedures. In fact, this type of imaging is generally

responsible for the reduction in the mean annual numberof diagnostic procedures between 2012 and 2017. The
frequency of dental procedures indeed fell steeply (by16.8%), over 5 years. However, it is important to consider
these figures with plenty of caution. On the one hand, as
explained in the corresponding ExPRI report [6], dental
data for 2007 is very probably underestimated14. On theother hand, two major changes occurred during the 20122017 period: the percentage of dental radiology procedureswith CCAM codes increased substantially as dental
surgeons switched from NGAP codes to CCAM codes;
new CCAM codes were introduced, some covering several
The number of intra-oral dental procedures in 2007 was taken as equal to
the 2002 figure, as no more recent data was available [6, tab. III].

14

ExPRI study 201737

Figure 20
Variation in the number of annual diagnostic procedures between 2002 and 2017, per type of imaging.
b) in relative values

1,400
1,200

1,200
97

1,247
1,170

Percentage of the total number of annual procedures

Mean number of annual procedures for 1000 indiv.

a) in absolute values

1,187

130

118

152

1,000
300

289

421

800

351

600
400

774

737

673

654

200
0

2002

2007

Conventional radiology

2012

2017

Dental radiology

100%
90%
80%

As shown in Figure 21, if dental procedures are
excluded, the downward trend in the number of procedures,

10,1%

25,0%

24,7%

70%

10,4%

12,8%

33,8%

29,6%

54,0%

55,1%

2012

2017

60%
50%
40%
30%

64,5%

63,0%

20%
10%
2002

Computed tomography

images (cf. section 2.2.2 for more detailed explanations).
Comparing the frequency of dental procedures between
2012 and 2017 is therefore affected by these sourcesof uncertainty and reliability must be considered as
inadequate. For this reason, it is more appropriate to
exclude dental radiology when considering variation indiagnostic procedures.

8,1%

2007

Nuclear medicine

Diag. interv. radiology

recorded since 2002, disappears in 2017: the mean
number of annual procedures, excluding dental radiology(836 for 1,000 beneficiaries) is 1.3% higher than in 2012.
The frequency of conventional radiological procedures
dropped by 2.8% (a smaller decrease than in previous
periods) and still represent the vast majority (78.3%) of
all annual examinations, excluding dental radiology.
Computed tomography expanded substantially over theperiod, climbing from 130 to 152 annual procedures for
1,000 beneficiaries, i.e. a 17% increase. The percentage of

Figure 21
Variation in the number of annual diagnostic procedures between 2002 and 2017, per type of imaging (excluding
dental radiology).
1,000
900
800

899
97

881
826

836

118
130

700

152

600
500
400

774

737

300

673

654

200
100
0

2002

2007

Conventional radiology

38b) in relative values

ExPRI study 2017

2012

2017

Computed tomography

Percentage of the total number of annual procedures

Mean number of annual procedures for 1000 indiva) in absolute values

100%
90%

1,5%

2,1%

2,0%

10,8%

13,4%

15,7%

86,1%

83,7%

81,6%

78,3%

2002

2007

2012

2017

2,8%
18,2%

80%
70%
60%
50%
40%
30%
20%
10%
0%

Nuclear medicine

Diag. interv. radiology

computed tomography versus all diagnostic procedures,
excluding dental procedures, has been constantly risingsince 2002, from 10.8% to 18.2% over 15 years. Nuclear
medicine procedures remain infrequent (23 for 1,000
beneficiaries), but have expanded strongly byapproximately 44% since 2012, and the percentage versus
all non-dental diagnostic procedures (2.8%) has almost
doubled in 15 years. The frequency of diagnostic
interventional radiological procedures has not varied
substantially (6 for 1,000 beneficiaries in 2017). Due to thislow figure and existing limitations already mentioned (cf.
section 4.2.5) for this type of imaging in this study, no
conclusions can be reached with respect to variation inthis type of imaging since 2002.
It is worth comparing these figures with the periodic
review by the CNAM of the activity of independent doctors.
The last edition of this review focuses on 2016 [35]. The
decrease in the relative share of conventional radiology
is also mentioned: “the percentage of conventional
radiology in imaging as a whole15 dropped from 25% in 2012
to 22% in 2016”. Variation in nuclear medicine andcomputed tomography procedures also matches these
conclusions: “scintigraphy (reimbursements up +7.2% in2016) and, to a lesser extent, computed tomography,
contribute to the overall increase in imaging procedures”.
The increase in imaging procedures (excluding dental
procedures) recorded in this study is more moderate than
the increase indicated in the CNAM review: “Between 2007
and 2016, reimbursements for imaging recorded meanannual growth of 2.4%”. It is, however, important to takenote that this study excludes all types of imaging which do
not use ionising radiation, such as ultrasound, which
represents over 40% of imaging procedures, and MRI,
which is rapidly expanding in use (+7 % between 2015
and 2016). In addition, the comparison is limited as
the procedures performed in the public sector are notintegrated in the CNAM review.

6.2 Variation in mean annual per caput
effective doses
If we consider variation in the mean annual effective
doses associated with diagnostic procedures during thedifferent ExPRI studies (cf. Figure 22), it appears that theincrease recorded between 2002 and 2012 (+88 %)disappears between 2012 and 2017: the mean annual
per caput effective dose decreased by 1.9% from 1.56 to
1.53 mSv between 2012 and 2017. This decrease ismainly attributable to conventional radiology, for which
the contribution (0.18 mSv in 2017) dropped by over 34%,
which substantially exceeds the 2.8% reduction in thefrequency of procedures recorded over this period. The
contribution of computed tomography to the annual
effective dose increases moderately (+2.4%) whencompared with the increase of over 17% recorded for thefrequency of this type of imaging procedure. The
contribution of nuclear medicine to the annual effective
dose increased by around 44% from 0.12 mSv to 0.17 mSv,

Figure 22
Variation in the mean annual per caput effective dose between 2002 and 2017, per type of imaging.
b) in relative values

2

100%

1.8
1.6
1.4

1.3

1.2

0.07
0.13

1
0.8
0.6
0.4
0.2
0

0.83
0.13
0.06

1.56
0.05
0.12

1.11
0.75

1.53
0.04
0.17

1.14

0.34

0.30

0.34

0.28

2002

2007

2012

Conventional radiology

Contribution to the annual efffective dose

Mean annual effective dose per individual (mSv)a) in absolute values (mSv/individual)

90%
80%

15.3%

2017

Dental radiology

In this case, the term imaging covers all types of imaging, whether ionisingor non-ionising, such as MRI and ultrasound, which explains the different
percentages versus this study.

3.1%
7.8%

2.4%
11.3%

6.7%

70%
60%

40.9%

58.0%

50%
40%

20%

0%

Computed tomography

71.3%

74.2%

0.22%

30%

0.23%
36.8%
26.1%

10%
0.18

5.5%
10.2%

2002

2007

Nuclear medicine

0.16%
17.7%
2012

0.28%
11.8%
2017

Diag. interv. radiology

15

ExPRI study 201739

which is equivalent to the increase recorded for thefrequency of this type of imaging procedure.
These results are attributable, in addition to variation in
the frequency of the different types of imaging procedures,to variation in mean doses per examination between 2012
and 2017. Significant decreases in the mean doses of
conventional radiological examinations (7% globally) andcomputed tomography examinations (-12% globally) wererecorded over this period as part of the study on DRL [19].
With nuclear medicine, the doses absorbed by patients are
relatively stable as they mainly depend on the activity of
the radiopharmaceutical administered.

6.3 Variation in the distribution ofprocedures per examination category
Table XVI contains the number of imaging procedures
performed in France in 2007 and 2012, as published inappendix 5 of the previous report [7] and those in thisstudy focusing on 2017. The distribution of procedures isindicated for each examination category used in theprevious ExPRI study, and not those defined in this study,
in order to compare the three years studied using thesame basis for classification (cf. 2.1.2). Refer to appendix
1 of the previous report for details of this classification [7].
For conventional radiology, in 2007, thorax
examinations were the most frequent procedure; their
number has dropped by over 10% in ten years, downgrading
this category from the top rank in 2007 to the second mostfrequent rank in 2017. On the other hand, limb x-rays haveincreased noticeably (+27% since 2007) and rank as themost frequent category of procedures in 2017, representing
over one third (33.7%) of conventional radiology
procedures. Spine x-rays have increased substantially(+39% since 2007), but only represent a small percentage
of procedures (1.5% in 2017). It is important to take note
that, according to this classification, this category only
includes radiograms of the entire spine. Radiograms which
only cover part of the vertebral column are recorded under
the corresponding anatomical regions (e.g. radiography ofthe dorsal vertebral column is recorded under the thorax
category). The percentages of other conventional radiology
procedure categories are relatively stable (pelvic bone,breast, bone density testing, whole skeleton, biliary duct),or have very noticeably dropped (abdomen, head and neck,urogenital system, digestive tract, bed-ridden x-rays). The
number of procedures in these latter categories have also
decreased since 2012, and even since 2007 for somecategories (particularly the abdomen).

40

ExPRI study 2017

The percentage of extraoral categories (dental
panoramic imaging, cone-beam CT, skull teleradiography)
climbed steeply, particularly between 2012 and 2017, from
14% to almost 32% of dental radiological procedures. For
the reasons explained in the introduction to this chapter,large-amplitude variation was recorded between 2007 and2017 for the number of intraoral dental radiologicalprocedures, which led to a mechanical, but artificial,decrease in the percentage of these procedures in dental
radiology as a whole in 2017 compared with previous
years. However, the extraoral group procedures, whichwere not affected by changes to CCAM codes and only
slightly impacted by the withdrawal from the NGAP codes(cf. start of this chapter), have expanded substantiallysince 2012 (+107%). Therefore, the notable increase in thepercentage of extraoral procedures in dental radiology isvery real and very significant.
The most hard-hitting change for computed
tomography examinations over the 2007-2017 decade
involved the pronounced increase in procedures imaging
the entire trunk or the head and trunk (chest-abdomenpelvis (CAP) or Head+CAP category): these procedures
represent 13.4% of all computed tomography proceduresin 2017, versus 1.4% in 2007 and 4.2% in 2012. Thisobservation must be paralleled with the augmented meanannual per caput effective dose attributable to computed
tomography over the period (cf. 6.2). The percentages of
the two most frequent examination categories (abdomen
and/or pelvis, head and neck) have markedly decreased
since 2007 and each represent one quarter of all computed
tomography procedures in 2017. The percentage of thorax
examinations has also dropped (17.5% in 2017) although
the absolute number of such procedures has climbed(+21% over 10 years) and thorax imaging ranks third
procedure category in terms of frequency. The percentagesof vertebral column and limb categories are relatively
stable.
In a context where nuclear medicine procedures are
becoming considerably more frequent (cf. 6.1), clear
variation appears in terms of their distribution. In particular,
the percentage of the whole body PET category out of all
nuclear medicine procedures has tripled over a decade,rising from less than 10% in 2007 to over 32% in 2017, andreached the top rank in terms of frequency of nuclear
medicine procedures in 2017. On the other hand, thepercentage of procedures imaging the skeleton (bonescintigraphy) fell significantly over the same period, fromapproximately 42% to around 25%. However, theseprocedures remain the most frequent (over 410,000 in2017) after the whole body PET. Procedures imaging thethyroid, lungs or the urogenital system have also dropped
noticeably since 2007, in terms of both percentage andabsolute numbers. The percentage of cardiac scintigraphy
examinations remains generally constant, between 24%
and 25% over the period in question. The relatively steep
increase recorded for the category including other nuclear
medicine procedures, rising from 2.5% to 6.3% over ten
years, is also notable. This increase is mainly attributableto pre- or peri-surgical radio-isotopic detection procedures,
which are closely imbricated in cancer treatment, just likewhole body PET.
Finally, the percentage of cardiac procedures indiagnostic interventional radiology climbed substantiallybetween 2007 and 2017, when it reached 70% of allprocedures. However, this observation must be carefully
qualified as many peripheral vascular procedures are
frequently performed for both diagnostic and therapeutic
reasons, and are not included in the study for this reason,
as previously mentioned in section 4.2.5. Neither must thisobservation be assumed to represent actual variation forthis type of imaging.

ExPRI study 201741

Table XVIDistribution of diagnostic procedures in France in 2007, 2012 and 2017 (rounded values) depending on the categories
defined for the study focusing on 2012 [7].

Conventional radiology

Procedures in 2012

Procedures in 2017absolute

absolute%%%

47,012,200

100%

44,175,500

100%

46,680,600

100%

Thorax13,999,080

29.8%

12,356,600

28.0%

12,476,300

26.7%

Limbs

12,363,870

26.3%

13,224,000

29.9%

15,719,200

33.7%

Pelvis (bone)

5,801,540

12.3%

5,289,300

12.0%

5,613,700

12.0%

Abdomen

5,184,450

11%

4,023,300

9.1%

3,623,200

7.8%

Breast

5,085,190

10.8%

5,102,500

11.6%

5,289,300

11.3%

Head and neck

1,399,870

5.7%

1,980,600

4.5%

1,710,900

3.7%

Bone density testing

717,950

1.5%

644,900

1.5%

673,200

1.4%

Spine

514,4801.1%

595,000

1.3%

715,500

1.5%

Urogenital system

309,7500.7%

182,600

0.4%

165,200

0.4%

Digestive tract

288,8700.6%

219,600

0.5%

171,100

0.4%

Entire skeleton

74,2900.2%

75,2000.2%

112,800

0.2%

Biliary duct

20,7200.04%

24,7000.1%

28,800

0.1%

3,090

0.01%

457,200

1.0%

381,400

0.8%

not counted separately

455,400

1.0%

380,300

0.8%

100%

25,022,900

100%

Other
of which bed-ridden x-rays
Dental radiology

18,430,150

100%

27,616,000

Intra-oral

15,739,050

85%

23,756,000

86%

17,033,400

68.1%

Extra-oral

2,691,100

15%

3,860,000

14%

7,989,400

31.9%

Computed tomography

7,563,920

100%

8,483,900

100%

10,865,800

100%

Abdomen and/or pelvis

2,256,820

29.9%

2,548,500

30.0%

2,720,800

25.0%

Head and neck2,088,010

27.6%

2,278,600

26.9%

2,719,200

25.0%

Thorax1,569,080

20.8%

1,654,400

19.5%

1,898,900

17.5%

Vertebral column

926,350

12.3%

1,028,000

12.1%

1,212,300

11.2%

Limbs

602,9508%

615,300

7.3%

854,300

7.9%

Chest-abdomen-pelvis (CAP) or Head+CAP

115,280

1.4%

355,300

4.2%

1,457,400

13.4%

5,430

0.1%

500

<0.01%

2,800

0.03%

1,177,120

100%

1,103,200

100%

1,662,200

100%

Skeleton

493,59041.9%

352,800

32.0%

413,900

24.9%

Heart

285,81024.3%

277,300

24.8%

398,900

24.0%

whole body PET

113,730

9.8%

229,300

20.8%

534,700

32.2%

Thyroid

96,9808.2%

62,3005.6%

62,100

3.7%

Lungs

71,3606.1%

51,7004.7%

53,200

3.2%

Urogenital system

31,8702.7%

15,1001.4%

18,600

1.1%

Head and neck (excluding the thyroid)

28,3502.3%

29,2002.6%

49,6003.0%

Whole body (excluding skeleton and PET)

20,5201.7%

16,6001.5%

20,800

1.3%

Other
Nuclear medicine

Abdomen and/or digestive tract

4,910

0.4%

3,000

0.3%

5,200

0.3%

Other

30,0002.5%

65,9006.0%

105,300

6.3%

439,610100%

376,900

100%

434,900

100%

Cardiovascular

277,900

63%

254,000

67%

304,300

70%

Perivascular

161,71037%

122,900

33%

130,600

30%

Diagnostic interventional radiology

TOTAL

42

Procedures in 2007
absolute

ExPRI study 201774,623,000

81,755,500

84,666,400

7Conclusions and prospects
This study is the 4th edition of the ExPRI system
launched in 2003 [5]. This approach updated informationon the exposure of the French population in 2017
compared with the most recent view focusing on 2012
data [7]. The method used for the study, which has notchanged substantially since the previous edition, is basedon the SNIIRAM generalist sample panel of beneficiaries(EGB) when determining the frequency of imaging
procedures, and mainly on the analysis of the datacollected by IRSN as part of diagnostic reference levels
when estimating the effective doses for these procedures.
The representativeness of EGB data available in 2017
has improved significantly since the report on 2012, withrespect to several points:• Medical data for public hospitals is far morecomprehensive, as per procedure invoicing system is
now near exclusively applied for financing purposes. The
EGB can therefore be considered as practically exhaustivefor hospital activities in 2017.
• As beneficiaries for ten local health insurance firms
have been integrated in the sample panel, it is more
representative of the wide range of healthcare habits of
the French population, particularly students, even if therepresentativeness of data for students still remains well
below that of the rest of the population.
• The reliability of dental radiology data has been greatly
enhanced thanks to the general use of CCAM codes forindependent doctors, ensuring a detailed description ofthis sector.
The main characteristics of the exposure of the
population to ionising radiation from diagnostic medical
imaging procedures in France in 2017 are as follows:• The mean number of annual procedures recorded
decreased from 1,247 to 1,187 for 1,000 beneficiaries
between 2012 and 2017, which is a 4.8 % decrease.
CCAM codes used to record dental radiological imaging
were substantially changed over the 2012-2017 period
and these modifications generally led to this variation.
Indeed, when dental radiology is excluded, the mean
number of annual procedures is equal to 836 for
1,000 beneficiaries, which is 1.3% higher than in2012 (826 for 1,000 beneficiaries).

• The mean annual per caput effective dose decreased by
1.9% from 1.56 to 1.53 mSv between 2012 and 2017.
This decrease is mainly attributable to conventional
radiology, for which the contribution (0.18 mSv) droppedby over 34%. The contribution of computed tomography
to the annual effective dose (1.14 mSv) increases
moderately (+2.4%) when compared with the increase ofover 17% recorded for the frequency of this type ofimaging procedure. The contribution of nuclear medicine
increased by around 44% from 0.12 mSv to 0.17 mSv,
which is equivalent to the increase recorded for thefrequency of this type of imaging procedure.
• Computed tomography ranks third in terms of frequency
of procedures, representing slightly under 13% of
diagnostic procedures, but it contributes approximately
75 % of the collective effective dose attributable to thediagnostic medical imaging sector. Procedures imaging
the entire trunk or the head and trunk are expanding
rapidly and represent 13.4% of all computed tomography
procedures, versus 1.4% in 2007.
• Dental radiology represents just under 30% of diagnostic
procedures and does not significantly contribute to thecollective effective dose. The percentage of extraoral
procedures (including dental panoramic imaging andcone-beam CT) has climbed steeply since 2012, from
14% to almost 32% of all dental radiological procedures.
• Nuclear medicine only represents 2% of procedures,but ranks 3rd in terms of contributions to the collective
effective dose at over 11 %, just behind conventional
radiology. Positron emission tomography (whole bodyPET) is the most frequent type of procedure and its
contribution to nuclear medicine examinations tripledover a decade, rising from less than 10% in 2007 toover 32%.
• Diagnostic interventional radiology, which represents
very few procedures in terms of number for this study(0.5%), contributes 2.4 % of the collective dose. It is
important to remember that diagnostic interventional
radiological procedures are very frequently associatedwith a therapeutic procedure and, in this case, are notconsidered in this study. On this basis, these figures
are probably well underestimated and must not be
considered as representative of clinical practice.

ExPRI study 201743• 45.4% of the population has benefitted from one orseveral diagnostic procedures, representing a slightincrease since 2012 (43.8%). A much higher percentageof women is exposed than men: 50.2 % versus 40.4 %. If
we exclude dental radiological procedures, which only
make a very minor contribution to the collective effective
dose, the exposed percentage of the population falls to
32.7%; it can therefore be considered that approximately
one third of the French population has benefitted fromat least one diagnostic procedure other than dental
radiology. The percentage of individuals exposed in the
population varies widely with age, from approximately
15% for very young children to slightly less than 70% forwomen aged 65-75 and approx. 55% for men aged 65-85.
• Patients (i.e. the population having benefitted from atleast once diagnostic procedure and therefore actually
exposed) participated in 2.6 procedures during the year,
on average. This number varies depending on the age ofthese patients: children aged under 10 participate in lessthan 2 procedures annually, on average, while adults
aged over 75 participate in approx. 3.5 procedures. No
significant difference was detected between men andwomen for the mean number of annual procedures.
•T he cumulative individual effective dose for patientsin 2017 represented a mean value of 3.4 mSv. The
distribution of this dose is extremely heterogeneous: halfof patients absorbed a dose of less than or equal to
0.1 mSv, most patients (approx. 82%) absorbed a dose ofless than the mean dose of 3.4 mSv, while the top 5% interms of exposure absorbed a dose of more than
18.1 mSv. A very noticeable difference is apparent
between men and women: men absorbed approx. 1 mSv
more than women in 2017 on average. The cumulative
individual effective dose varies widely with the age ofpatients: less than 1 mSv for children and very young
adults (aged 20 or less), climbing with age to reachapproximately 2 mSv before the age of 40. Above thisage, on average, annual exposure will be substantiallyhigher for men than for women (approx. 9 mSv vs 5 mSv
between the ages of 70 and 74).
A more specific study of the population of patients
having benefitted from at last one annual diagnostic
computed tomography procedure in 2017, andretrospectively over a cumulative period of up to 6 years,
was also completed. It would appear that a population
estimated at over 30,000 patients nationwide was exposed
to a cumulative effective dose of over 100 mSv in 2017
due to multiple computed tomography examinations. This
figure rises to 500,000 patients over a cumulative period of

44

ExPRI study 2017

6 years (2012-2017). This strongly exposed population
appears to be steadily increasing since 2012. Most
members of this population are elderly, however one
quarter is aged under 55.
In general, exposure of the French population toionising radiation from diagnostic medical imaging
procedures, excluding dental radiology, was relatively
constant in 2017 compared with 2012. Variation detected
in terms of the mean frequency of imaging procedures
and the average per caput annual effective dose isgenerally minor. In particular, the almost 90% increase
recorded between 2002 and 2012 for the average percaput annual effective dose was no longer evident
between 2012 and 2017. Nuclear medicine recorded thegreatest increase over this 5-year period (+44%), in termsof both frequency and contribution to the collective
effective dose. Computed tomography remains the mostsignificant contribution to the exposure faced by the
population by far. However, the increase in collective
effective dose attributable to this type of imaging (+2.4%)
remains well below that of computed tomography
procedures, which became far more frequent over theperiod in question (+17%). These observations reflect
the decrease in doses per computed tomography
procedure recorded in the most recent review ofdiagnostic reference levels for the 2016-2018 period[19]. Only a small percentage of patients − but
representing several hundreds of thousands of patients
throughout France − combined high effective doses, andapproximately 25% of these patients were aged under
55. Although these patients are very certainly treated forserious pathologies, potential long-term radio-induced
effects must be considered.
Finally, with respect to the analysis of data in thisstudy, it would appear that improvements are required in
the interventional radiological sector, for which diagnostic
procedures are differentiated from therapeutic procedures.
The study is currently limited to diagnostic procedures,
which prevents any reliable representation of the exposureof patients benefitting from this type of medical treatment,
which has been extensively expanding throughout France
in recent years, as well as internationally. On this basis, itwould appear that the scope of the analysis of the ExPRI
system and the study methods used must be modified.
However, two difficulties must be faced when expanding
the scope of the study to therapeutic interventional
radiology procedures: firstly, it will probably be complicatedto identify procedures using CCAM codes due to the factthat some codes are rather generalist, secondly, the doses
associated with some interventional procedures vary

widely, which will make it complicate to assign a specificdose to a given procedure. However, changing the ExPRI
system in this way would ensure compliance with therecommended guidelines of international bodies such as
UNSCEAR.
This periodic report will be completed by complementarystudies focusing on specific topics in the coming years. To
begin with, the data in this report will be compared with all
available European and international data. Other topics
could be covered at a later time, such as changes to somespecific imaging procedures in recent years, e.g. conebeam CT for dental radiology or radiography imaging theentire vertebral column. Available data on the exposure ofchildren to computed tomography scans could be detailed
pending the future publication of the final results of theinternational epidemiological EPI-CT study [36].

ExPRI study 201745

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ExPRI study 2017

Appendix
List of CCAM codes per type of imaging and examination category.
Effective dose per procedure, frequency of procedures and contribution
to the mean per caput annual dose
Details of all of the 343 CCAM codes actually used for this study (i.e. codes for which at least one procedure wasrecorded) can be found below, in Table XVII to Table XXI for each of the types of imaging. They represent a total of
816,052 diagnostic procedures, i.e. 97.8% of all procedures counted for in the EGB sample panel in 2017. CCAM codes areclassified by examination category for each type of imaging, as defined in section 2.1.2 of this report. The “E / proc”
column indicates the mean effective dose for the CCAM code, in mSv. The “Freq of proc” column indicates how often theprocedure is performed yearly, as a number of procedures for 1,000 beneficiaries. The “Emean / indiv.” indicates thecontribution of the procedure to the mean per caput annual effective dose in µSv, calculated for the entire population of
the EGB sample panel in 2017. N.S. (not significant) is indicated if the code was recorded less than 20 times.
Dental radiology procedures without CCAM codes (cf. section 2.1.1) only represent 2.2% of all of the procedures
recorded and are not included in the appended tables. In order to calculate their contribution to the total effective dose,these procedures were considered as equivalent to one (two and four respectively) dental retroalveolar and/or retrocoronary
radiography of a sector of 1 to 3 contiguous teeth (CCAM code: HBQK389) for the reference service code 1331 (9422 and9423 respectively).

Table XVII
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for
CCAM codes for conventional radiology.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Head and neck
BBQH001

Unilateral or bilateral lacrimal dacryocystography

0.5

0.04

0.02

HCQH001

Sialography

0.5

N.S.

N.S.

HQQH002

Dynamic radiological study of deglutition, with recording [dynamic
pharyngography]

0.06

0.10

<0.01

LAQK003

Radiography of the skull and/or face bones according to 1 or 2 incidences

0.039

5.61

0.22

LAQK005

Radiography of the skull and/or face bones according to 3 or more incidences

0.79

2.60

2.05

LBQK001

Unilateral or bilateral tomography of the temporomandibular joint

0.5

0.16

0.08

LBQK005

Unilateral or bilateral radiography of the temporomandibular joint

0.012

0.38

<0.01

LCQK002

Radiography of soft neck tissue

0.06

0.53

0.03

Dorsal and/or lumbar myelography

9

0.08

0.70

Vertebral column
AEQH001
AEQH002

Cervical myelography

0.6

N.S.

N.S.

AFQH002

Saccoradiculography

9

0.05

0.44

LDQK001

Radiography of the cervical segment of the spine according to 1 or 2
incidences

0.063

1.72

0.11

LDQK002

Radiography of the cervical segment of the spine according to 3 or more
incidences

0.17

12.82

2.18

LDQK004

Radiography of the cervical segment and the thoracic segment of the
spine

0.33

2.28

0.75

ExPRI study 201749

Table XVII cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes forconventional radiology.
E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Radiography of the cervical segment and the lumbar segment of the
spine

0.95

0.84

0.80

LEQK001

Radiography of the thoracic segment of the spine

0.27

2.74

0.74

LEQK002

Radiography of the thoracic segment and the lumbar segment of the
spine

1.1

11.66

12.82

LFQK001

Radiography of the lumbar segment of the spine according to 4 or more
incidences

1.1

12.87

14.16

LFQK002

Radiography of the lumbar segment of the spine according to 1 to 3
incidences

0.85

11.12

9.45

CCAM code
LDQK005

Description of the procedure

LGQK001

Radiography of the sacrum and/or coccyx

0.5

1.38

0.69

LHQH001

Arthrography of the posterior spinal facet joints

0.7

0.82

0.57

LHQH003

Single intervertebral discography, by transcutaneous access

0.7

0.06

0.04

LHQH004

Multiple intervertebral discography, by transcutaneous access

1.5

N.S.

N.S.

LHQK002

Teleradiography of the entire spine according to 2 incidences

0.85

3.07

2.61

LHQK003

Teleradiography of the entire spine according to 2 incidences with supplementary segment incidence

1.1

1.13

1.24

LHQK004

Teleradiography of the entire spine according to 1 incidence

0.4

1.04

0.41

LHQK007

Radiography of the entire spine

0.85

4.79

4.07

MBQK001

Radiography of the arm

0.001

2.08

<0.01

Limbs

50

MCQK001

Radiography of the forearm

0.001

3.21

<0.01

MDQK001

Radiography of the hand or finger

0.00018

28.99

<0.01

MDQK002

Bilateral radiography of the hand and/or wrist, according to 1 incidence inone single frontal image

0.00018

2.26

<0.01

MFQH001

Arthrography of the elbow

0.004

0.06

<0.01

MFQK001

Radiography of the elbow according to 3 or more incidences

0.00153.9<0.01

MFQK002

Radiography of the elbow according to 1 or 2 incidences

0.00076

6.09

<0.01

MGQH001

Arthrography of the wrist

0.00048

0.33

<0.01

MGQK001

Radiography of the wrist according to 3 or more incidences

0.00037

10.46

<0.01

MGQK002

Dynamic radiographic imaging of the wrist for non-dissociative sprain
according 7 specific incidences

0.0008

0.05

<0.01

MGQK003

Radiography of the wrist according to 1 or 2 incidences

0.0002

12.44

<0.01

MHQH001

Metacarpo-phalangeal or interphalangeal arthrography of a finger

0.00050.1<0.01

MZQK001

Unilateral or bilateral frontal teleradiography of the entire upper limb

0.002

0.04

<0.01

MZQK003

Radiography of 2 segments of the upper limb

0.002

5.38

0.01

MZQK004

Radiography of 3 or more segments of the upper limb

0.003

0.64

<0.01

NBQK001

Radiography of the thigh

0.001

2.59

<0.01

NCQK001

Radiography of the leg

0.002

4.69

<0.01

NDQK001

Unilateral radiography of the foot according to 1 to 3 incidences

0.00018

24.96

<0.01

NDQK002

Bilateral radiography of the foot according to 1 to 3 incidences on each side

0.00037

5.13

<0.01

NDQK003

Radiography of the foot according to 4 or more incidences

0.00037

2.97

<0.01

NDQK004

Radiography of the foot according to 4 or more incidences, for podometricstudy

0.00046

3.52

<0.01

NFQH001

Arthrography of the knee

0.005

1.12

<0.01

NFQK001

Unilateral radiography of the knee according to 1 or 2 incidences

0.0016

13.27

0.02

NFQK002

Bilateral radiography of the knee according to 1 or 2 incidences on each side

0.0032

2.26

<0.01

NFQK003

Radiography of the knee according to 3 or 4 incidences

0.0024

23.78

0.06

NFQK004

Radiography of the knee according to 5 or more incidences

0.0048

23.79

0.11

NGQH001

Arthrography of the ankle

0,00048

0,3

<0,01

ExPRI study 2017

Table XVII cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes forconventional radiology.
CCAM code
NGQK001

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Radiography of the ankle according to 1 to 3 incidences

0.00018

15.3

<0.01

NGQK002

Radiography of the ankle according to 4 or more incidences

0.00037

9.04

<0.01

NHQH001

Arthrography of the foot and/or toes

0.00050.1<0.01

NZQK001

Unilateral or bilateral frontal teleradiography of the entire lower limb
with bipedal support

0.005

3.79

0.02

NZQK003

Successive bilateral frontal teleradiography of the entire lower limb
with monopedal support

0.01

0.43

<0.01

NZQK005

Radiography of 2 segments of the lower limb

0.003

6.02

0.02

NZQK006

Radiography of 3 or more segments of the lower limb

0.005

1.15

<0.01

PAQK001

Comparative radiography of epiphyseal cartilages of long limb bones

0.01

0.04

<0.01

ThoraxGEQH001

Lung scans

LJQK001

Radiography of the thorax skeleton

0.2

N.S.

N.S.

0.079

2.05

0.16

LJQK002

Radiography of the thorax with radiography of the thorax skeleton

0.14

7.1

0.99

LJQK015

Radiography of the sternum and/or sternoclavicular joint

0.079

0.84

0.07

MAQK001

Radiography of the scapular belt and/or shoulder according to 3 or 4
incidences

0.017

16.83

0.29

MAQK002

Radiography of the scapular belt and/or shoulder according to 5 or more
incidences

0.026

10.8

0.28

MAQK003

Radiography of the scapular belt and/or shoulder according to 1 or 2
incidences

0.0086

12.91

0.11

MEQH001

Arthrography of the shoulder

0.026

2.34

0.06

ZBQK002

Radiography of the thorax

0.058

116.74

6.77

ZBQK003

Dynamic radiological examination of the thorax, in order to study respiratory
and/or cardiac functions

0.11

0.2

0.02

Installation of breast reference points, by transcutaneous accesswith mammographic guidance

0.16

0.17

0.03

QEQH001

Galactography

0.31

N.S.

N.S.

QEQK001

Bilateral mammography

0.31

32.35

10.03

Mammography
QELH001

QEQK004

Screening mammography

0.31

36.29

11.25

QEQK005

Unilateral mammography

0.16

5.31

0.85

HEQH001

Radiography of the oesophagus with contrast medium [oesophagealtransit]

1.2

0.16

0.19

HEQH002

Oesophageal-gastro-duodenal radiography with opacification by contrast
medium [oesophageal-gastro-duodenal transit]

10

1.69

16.89

HFMP002

Secondary radiological examination of the position and/or functioning ofadjustable gastric banding, with opacification by contrast medium

2.4

0.1

0.24

HGQH001

Radiography of the small intestine with contrast medium administeredusing a naso-duodenal probe [enteroclysis]

6

0.02

0.15

HGQH002

Radiography of the small intestine with contrast medium ingested[intestinal transit]

3.3

0.06

0.21

HHQH001

Radiography of the colon with opacification by contrast medium

9

0.25

2.21

HPMP002

Secondary radiological examination of the position and/or functioningof a peritoneal drain, a peritoneal dialysis catheter or a peritoneovenous
jugular shut, with opacification by contrast medium

2.4

N.S.

N.S.

HTQH002

Defecography [dynamic rectography]

9

0.04

0.38

HZMP002

Secondary radiological examination of the position and/or functioning ofa gastric probe, a biliary tube or a biliary endoprosthesis, with opacificationby contrast medium

2.4

0.06

0.13

JLQH002

Dynamic colpocystorectography

9

N.S.

N.S.

ZCQK002

Radiography of the abdomen without preparation

1.1

13.28

14.61

Digestive tract

ExPRI study 201751

Table XVII cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes forconventional radiology.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Urogenital system
JBQH001

Descending urography, by transcutaneous access with ultrasound and/or
radiological guidance

2.4

N.S.

N.S.

JBQH002

Ascending urography

2.4

0.53

1.28

JBQH003

Descending urography, with an existing nephrostomy

2.4

0.04

0.09

JDQH001

Ascending urethrocystography

2.4

0.41

0.98

JDQH002

Urethrocystography, with an existing cystostomy

2.4

N.S.

N.S.

JDQH003

Urethrocystography, by transcutaneous puncture of the bladder

2.4

N.S.

N.S.

JKQH001

Hysterosalpingography

1.7

1.14

1.94

JNQK001

Radiography of the contents of the gravid uterus [uterine content]

0.2

N.S.

N.S.

JZQH001

Radiological exploration of anomalies of the urogenital sinus[external genitography]

2.5

N.S.

N.S.

JZQH002

Intravenous urography without permictional urethrocystography

1.5

0.11

0.16

JZQH003

Intravenous urography with permictional urethrocystography

2.5

0.04

0.11

Pelvic bone
NAQK007

Radiography of the pelvic girdle [hip] according to 2 incidences

0.99

2.98

2.95

NAQK015

Radiography of the pelvic girdle [hip] according to 1 incidence

0.5

37.11

18.55

NAQK023

Radiography of the pelvic girdle [hip] according to 3 or more incidences

1.5

8.04

12.06

NAQK049

Radiography of the pelvic girdle [hip] according to 1 incidence and bilateralradiography of the coxofemoral joint according to 1 or 2 incidences per side

1.1

2.91

3.20

NAQK071

Radiography of the pelvic girdle [hip] according to 1 incidence and unilateralradiography of the coxofemoral joint according to 1 or 2 incidences

0.8

8.49

6.79

NEQH001

Functional assessment of a non-traumatic hip instability with arthrography
and production of a rigid cast under general anaesthetic

0.25

N.S.

N.S.

NEQH002

Arthrography of the hip

0.25

0.40

0.10

NEQK010

Radiography of the coxofemoral joint according to 1 or 2 incidences

0.3

8.69

2.61

NEQK012

Radiography of the coxofemoral joint according to 4 or more incidences

0.74

3.02

2.23

NEQK035

Radiography of the coxofemoral joint according to 3 incidences

0.45

5.63

2.54

ZCQK001

Radiographic pelvimetry

0.55

N.S.

N.S.

PAQK007

Bone density testing at 2 sites, by biphotonic method

0.001

9.23

<0.01

PAQK008

Bone density testing of the entire body by biphotonic method,for constitutional bone disorders in children

0.001

N.S.

N.S.

PAQK900

Bone density testing of the entire body by biphotonic method,
for non-constitutional bone disorders

0.001

0.19

<0.01

Bone density testing

Other

52

FCQH002

Lymphography of the lower limbs

PAQK002

Radiography of the skeleton to calculate bone age, after the age of 2 years

8

N.S.

N.S.

0.0086

0.83

<0.01

PAQK003

Radiography of the entire skeleton, segment by segment, for children

PAQK005

Radiography of the hemiskeleton to calculate bone age, before the ageof 2 years

1.8

0.13

0.24

0.0086

0.03

<0.01

YYYY163

Radiography of the hemiskeleton or entire skeleton for an adult

1.8

0.58

1.05

ZZQH002

Radiography of a fistula [Fistulography]

1.7

N.S.

N.S.

ZZQK001

Radiography of bed-ridden patient, according to 3 or more incidences

1.4

0.03

0.04

ZZQK002

Radiography of bed-ridden patient, according to 1 or 2 incidences

0.57

5.30

3.02

ExPRI study 2017

Table XVIII
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for
CCAM codes for dental radiology.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Intraoral
HBQK001

Pelvibuccal radiography [occlusal]

0.025

0.69

0.02

HBQK040Pre-interventional or peri-interventional retroalveolar intraoral radiographies over a sector of 1 to 3 contiguous teeth with final radiography forendodontics therapeutic procedure

0.0072

32.21

0.23

HBQK041

Retroalveolar and/or retrocoronary intraoral radiographies covering
14 separate sectors of 1 to 3 contiguous teeth

0.05

0.81

0.04

HBQK046

Retroalveolar and/or retrocoronary intraoral radiographies covering
9 separate sectors of 1 to 3 contiguous teeth

0.032

0.13

<0.01

HBQK061

Final retroalveolar and/or retrocoronary intraoral radiography over a sectorof 1 to 3 contiguous teeth for an endodontics therapeutic procedure or
peri-interventional and/or final procedure, excluding endodontics
therapeutic procedures

0.00367.1

0.03

HBQK065

Retroalveolar and/or retrocoronary intraoral radiographies covering
10 separate sectors of 1 to 3 contiguous teeth

0.036

0.33

0.01

HBQK093

Retroalveolar and/or retrocoronary intraoral radiographies covering
13 separate sectors of 1 to 3 contiguous teeth

0.047

0.05

<0.01

HBQK142

Retroalveolar and/or retrocoronary intraoral radiographies covering
8 separate sectors of 1 to 3 contiguous teeth

0.029

0.43

0.01

HBQK191

Retroalveolar and/or retrocoronary intraoral radiographies covering
2 separate sectors of 1 to 3 contiguous teeth

0.0072

18.62

0.13

HBQK303

Pre-interventional, peri-interventional and final retroalveolar intraoral
radiographies over a sector of 1 to 3 contiguous teeth for endodontics
therapeutic procedure

0.011

23.8

0.26

HBQK331Retroalveolar and/or retrocoronary intraoral radiographies covering
3 separate sectors of 1 to 3 contiguous teeth

0.011

4.31

0.05

HBQK389

Retroalveolar and/or retrocoronary intraoral radiographies covering asector of 1 to 3 contiguous teeth

0.0036112.94

0.41

HBQK424

Retroalveolar and/or retrocoronary intraoral radiographies covering
11 separate sectors of 1 to 3 contiguous teeth

0.04

0.09

<0.01

HBQK428

Retroalveolar and/or retrocoronary intraoral radiographies covering
5 separate sectors of 1 to 3 contiguous teeth

0.018

1.37

0.02

HBQK430

Retroalveolar and/or retrocoronary intraoral radiographies covering
7 separate sectors of 1 to 3 contiguous teeth

0.025

0.25

<0.01

HBQK443

Retroalveolar and/or retrocoronary intraoral radiographies covering
4 separate sectors of 1 to 3 contiguous teeth

0.014

8.55

0.12

HBQK476

Retroalveolar and/or retrocoronary intraoral radiographies covering
12 separate sectors of 1 to 3 contiguous teeth

0.043

0.16

<0.01

HBQK480

Retroalveolar and/or retrocoronary intraoral radiographies covering
6 separate sectors of 1 to 3 contiguous teeth

0.022

0.73

0.02

Dentomaxillary panoramic radiography

0.019

98.37

1.87

Extraoral
HBQK002
LAQK001

Teleradiography of the skull and/or face bones according to 2 incidences

0.026

0.97

0.03

LAQK008

Teleradiography of the skull and/or face bones according to 3 incidences

0.039

0.05

<0.01

LAQK012Teleradiography of the skull and/or face bones according to 1 incidence

0.013

4.81

0.06

LAQK027

Cone Beam Computerized Tomography (CBCT) of the maxillary,
the mandible and/or dental arch

0.1

7.77

0.78

ExPRI study 201753

Table XIX
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for
CCAM codes for computed tomography.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Head and neck
ACQH001

Computed tomography of the skull and its contents, with intrathecal
injection of contrast medium

1.9

0.11

0.2

ACQH003

Computed tomography of the skull and its contents, with intravenous
injection of contrast medium

2.6

5.42

14.1

ACQK001

Computed tomography of the skull and its contents, without injection ofcontrast medium

1.3

20.26

26.33

EAQH002

Computed tomography of brain blood vessels

2.3

0.68

1.56

EBQH004

Computed tomography of cervicocephalic blood vessels

3.6

1.32

4.76

EBQH006

Computed tomography of cervical blood vessels

3.1

0.49

1.52

LAQK002

Unilateral or bilateral computed tomography of the petrous temporal bone
and the middle ear

1.3

1.17

1.53

LAQK009

Computed tomography of the face with computed tomography of softneck tissue

1.8

0.86

1.55

LAQK011

Unilateral or bilateral computed tomography of the cerebellopontile angle
and/or internal auditory canal

1.1

0.06

0.07

LAQK013

Computed tomography of the mandible/maxilla

0.61

5.99

3.66

LBQH002

Unilateral or bilateral computed tomography arthrogram of
the temporomandibular joint

0.5

N.S.

N.S.

LCQH001

Computed tomography of the soft neck tissue, with intravenous injectionof contrast medium

4.2

1.48

6.22

LCQK001

Computed tomography of the soft neck tissue, without intravenous injectionof contrast medium

3.3

0.25

0.82

AFQH001

Saccoradiculography with computed tomography of the spine

11

0.06

0.61

AFQH003

Myelography with computed tomography of the spine

11

N.S.

N.S.

LHQH002

Computed tomography of several segments of the vertebral column, withintravenous injection of contrast medium

13

0.07

0.96

LHQH005

Single intervertebral discography by transcutaneous access with computed
tomography of the spine

11

N.S.

N.S.

LHQH006

Computed tomography of one segment of the vertebral column, withintravenous injection of contrast medium

11

0.73

8.01

LHQK001

Computed tomography of one segment of the vertebral column, without
intravenous injection of contrast medium

9.3

14.81

137.74

LHQK005

Computed tomography of several segments of the vertebral column,
without intravenous injection of contrast medium

11

1.29

14.2

EKQH001

Computed tomography of blood vessels in the upper limbs

16

0.04

0.68

Vertebral column

Limbs

54

EMQH001

Computed tomography of blood vessels in the lower limbs

20

1.18

23.58

MZQH001

Computed tomography arthrogram of the upper limb

5.8

0.96

5.58

MZQH002

Unilateral or bilateral computed tomography of one segment of the upper
limb, with injection of contrast medium

4.8

0.17

0.82

MZQK002

Unilateral or bilateral computed tomography of one segment of the upper
limb, without injection of contrast medium

3.8

3.81

14.46

NZQH001

Unilateral or bilateral computed tomography of one segment of the lower
limb, with injection of contrast medium

0.2

0.18

0.04

NZQH002

Computed tomography arthrogram of the lower limb

3.8

0.55

2.07

NZQH005

Computed tomography of the hip and lower limb for the integrated computer design of a customised prosthetic bone joint

10

0.11

1.05

NZQK002

Unilateral or bilateral computed tomography of one segment of the lower
limb, without injection of contrast medium

0.2

4.94

0.99

NZQK004

Telemetry of the lower limbs by computed tomography

5.5

0.05

0.27

ExPRI study 2017

Table XIX cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes forcomputed tomography.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Thorax and heart
ECQH010

Computed tomography of the thorax and/or heart

11

4.68

51.49

ZBQH001

Computed tomography of the thorax, with intravenous injection of contrast medium

4.5

9.9

44.57

ZBQK001

Computed tomography of the thorax, without intravenous injection ofcontrast medium

4.6

12.03

55.32

0.1

2.25

Abdomen and/or pelvis
ELQH001

Computed tomography of the hepatic blood vessels to study vascularisation during at least 3 different phases

22

ELQH002

Computed tomography of the blood vessels in the abdomen and/or pelvis

19

0.98

18.7

ZCQH001

Computed tomography of the abdomen and pelvis, with intravenous
injection of contrast medium

10

24.28

242.78ZCQH002

Computed tomography of the abdomen or pelvis, with intravenous injection of contrast medium

11

2.06

22.65

ZCQK003

Computed tomographic pelvimetry

0.37

0.45

0.17

ZCQK004

Computed tomography of the abdomen and pelvis, without intravenous
injection of contrast medium

7.3

8.86

64.69

ZCQK005

Computed tomography of the abdomen or pelvis, without intravenous
injection of contrast medium

7.3

1.4

10.2

ACQH002

Computed tomography of the skull, its contents and the thorax, withintravenous injection of contrast medium

5.8

0.52

3.03

ACQH004

Computed tomography of the skull, its contents and the trunk, with intravenous injection of contrast medium

19

0.49

9.35

ECQH011

Computed tomography of the blood vessels in the thorax and/or heartwith computed tomography of the abdomen and/or pelvis

18

1.22

21.96

ZZQH033

Computed tomography of 3 or more anatomical regions, with intravenous
injection of contrast medium

18

16.63

299.28ZZQK024

Computed tomography of 3 or more anatomical regions, without injectionof contrast medium

11

1.56

17.21

PDQK001

Quantification of the different components of soft tissues, by computed
tomography

1

N.S.

N.S.

QEQH002

Computed tomography of the breast, with intravenous injection of contrast medium

4.5

N.S.

N.S.

QEQK006

Computed tomography of the breast, without intravenous injection ofcontrast medium

4.6

N.S.

N.S.

ZZQH001

Computed tomography of a fistula

7,3

N.S.

N.S.

Multiple regions

Other

ExPRI study 201755

Table XX
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for
CCAM codes for nuclear medicine.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Cardiovascular system
DAQL001

Myocardial perfusion emission computed tomography after physical effort
or pharmacological effort, without synchronisation using an electrocardiogram

4.3

N.S.

N.S.

DAQL002

Scintigraphy of the heart chambers at rest according to 1 incidence

5.2

0.57

2.96

DAQL003

Myocardial perfusion emission computed tomography at rest, without
synchronisation using an electrocardiogram

2.8

N.S.

N.S.

DAQL006

Myocardial positron emission computed tomography, with dedicated PET
camera

4.8

N.S.

N.S.

DAQL007

Myocardial emission computed tomography with no perfusion marker

5

N.S.

N.S.

DAQL008

Scintigraphy of the heart chambers at rest according to several incidence

5.2

0.05

0.27

DAQL009

Myocardial perfusion emission computed tomography at rest, withmyocardial perfusion emission computed tomography after physical effort
or pharmacological effort, with synchronisation using an electrocardiogram

11

3.18

34.99

DAQL010

Myocardial perfusion emission computed tomography after physical effort
or pharmacological effort, with synchronisation using an electrocardiogram

4.3

1.29

5.55

DAQL011

Myocardial perfusion emission computed tomography at rest, withmyocardial perfusion emission computed tomography after physical effort
or pharmacological effort, without synchronisation using an electrocardiogram

11

N.S.

N.S.

DAQL012

Scintigraphy of the heart chambers for a cardiac rhythm study

5.2

N.S.

N.S.

DAQL014

Myocardial perfusion emission computed tomography at rest,with synchronisation using an electrocardiogram

8.1

0.42

3.42

DAQL015

Emission computed tomography of the heart chambers at rest,with synchronisation using an electrocardiogram

6.7

0.03

0.21

Musculoskeletal system
PAQL001

Bone scintigraphy of the entire body, segment by segment, over one
phase [delayed], with complementary acquisition by a pinhole collimator

3.2

N.S.

N.S.

PAQL002

Bone scintigraphy of the entire body over several phases

3.2

2.95

9.45

PAQL003

Bone scintigraphy of the entire body over one phase [delayed]

3.2

2.39

7.66

PAQL005

Bone scintigraphy of the entire body, segment by segment, over several
phases, without complementary acquisition by a pinhole collimator

3.2

0.16

0.51

PAQL006

Bone scintigraphy segment by segment, over one phase [delayed],
without complementary acquisition by a pinhole collimator

3.2

N.S.

N.S.

PAQL007

Bone scintigraphy segment by segment, over several phases,
with complementary acquisition by a pinhole collimator

3.2

N.S.

N.S.

PAQL008

Bone scintigraphy segment by segment, over several phases, withoutcomplementary acquisition by a pinhole collimator

3.2

0.24

0.76

PAQL009

Bone scintigraphy of the entire body, segment by segment, over one
phase [delayed], without complementary acquisition by a pinhole collimator

3.2

0.03

0.09

PAQL010

Bone scintigraphy of the entire body, segment by segment, over several
phases, with complementary acquisition by a pinhole collimator

3.2

N.S.

N.S.

Emission computed tomography of pulmonary ventilation

0.2

N.S.

N.S.

Respiratory system
GFQL001
GFQL002

Emission computed tomography of pulmonary perfusion and ventilation

2.6

0.47

1.22

GFQL004

Scintigraphy of pulmonary ventilation

0.2

N.S.

N.S.

GFQL005

Emission computed tomography of pulmonary perfusion

2.4

0.06

0.14

GFQL006

Scintigraphy of pulmonary perfusion and ventilation

2.6

0.18

0.47

GFQL007

Scintigraphy of pulmonary perfusion

2.4

0.03

0.07

Glomerular or tubular renal scintigraphy [Isotopic nephrography]
without pharmacological effort

1.3

0.03

0.04

JAQL002

Renal cortical scintigraphy

0.98

0.10

0.10

JAQL003

Glomerular or tubular renal scintigraphy [Isotopic nephrography]
with pharmacological effort

1.3

0.11

0.14

JAQL005

Glomerular or tubular renal scintigraphy [Isotopic nephrography] without
pharmacological effort, with retrograde scintigraphy of the bladder

1.3

N.S.

N.S.

Urogenital system
JAQL001

56

ExPRI study 2017

Table XX cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes fornuclear medicine.
CCAM code
JAQL007

Description of the procedure
Glomerular or tubular renal scintigraphy [Isotopic nephrography]
with pharmacological effort and reinjection of radio-isotopic productE / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)

(µSv)

1.9

N.S.

N.S.

JBQL001

Scintigraphy of pyelo-ureteral stent

0.9

N.S.

N.S.

JDQL001

Scintigraphy of the bladder, by retrograde access

0.2

N.S.

N.S.

JHQL001

Unilateral or bilateral scintigraphy of the testicle and/or scintigraphy ofthe penis

5

N.S.

N.S.

KGQL001

Radio-isotopic measurement of plasma and urinary clearance

0.036

0.05

<0.01

KGQL004

Radio-isotopic measurement of plasma clearance

0.02

N.S.

N.S.

KCQL001

Scintigraphy of the thyroid gland with radio-isotopic measurement of
the fixation of iodine by the thyroid

1.8

0.20

0.36

KCQL002

Radio-isotopic measurement of the fixation of iodine by the thyroid

2

N.S.

N.S.

Endocrine system

KCQL003

Scintigraphy of the thyroid gland

1.3

0.66

0.85

KDQL001

Scintigraphy of the parathyroid glands

6.1

0.18

1.10

KEQL001

Scintigraphy of the medulla of the adrenal gland

3.2

N.S.

N.S.

KEQL002

Adrenocortical scintigraphy

100

N.S.

N.S.

5

0.03

0.14

9.3

0.04

0.34

8

N.S.

N.S.

8.7

0.03

0.24

KGQL003

Radio-isotopic measurement of biological reservoirs

KZQL002

Scintigraphy of somatostatin analogues with complementary emission
computed tomography, scintigraphy of the entire body to complement animage of a segment and scintigraphy of the entire body after 72 hours

KZQL003

Scintigraphy of somatostatin analogues over 2 phases

KZQL004

Scintigraphy of somatostatin analogues over 2 phases with scintigraphyof the entire body to complement an image of a segment

Immune and hematopoietic systems
FCQL001

Lymphoscintigraphy

0.4

0.11

0.04

FDQL001

Scintigraphy of bone marrow

2.9

N.S.

N.S.

FEQL002

Radio-isotopic measurement of the life of platelets

5.5

N.S.

N.S.

FEQL007

Radio-isotopic measurement of blood volume

0.2

0.06

0.01

FFQL001

Scintigraphy of the spleen, by injecting a specific radio-isotopic marker

1

N.S.

N.S.

ZZQL006

Search for an infectious or inflammatory focus by injecting marked
polynuclear leukocytes, with no separation of lymphocytes

3.6

N.S.

N.S.

ZZQL011

Search for an infectious or inflammatory focus by injecting marked
polynuclear leukocytes, with separation of lymphocytes

7

0.03

0.19

ZZQL015

Search for an infectious or inflammatory focus by injecting antibodies
or a marked peptide, or a non-specific radio-isotopic marker

12

0.02

0.29

ACQL001

Brain emission computed tomography using a neurotransmission
and/or metabolism marker

7.8

0.25

1.93

ACQL002

Brain positron emission computed tomography, with dedicated PET
camera

3.8

0.20

0.77

ACQL003

Brain emission computed tomography for diagnostic purposes and brain
tumour assessment

28

N.S.

N.S.

ACQL005

Emission computed tomography of cerebral perfusion with complex
quantification and activation test

8

N.S.

N.S.

ACQL007

Emission computed tomography of cerebral perfusion without activation
test

5.9

0.06

0.36

ZZQL002

Scintigraphic search for tumours with a specific monophotonic transmitterfor tumours, with complementary emission computed tomography,
scintigraphy of the entire body to complement an image of a segment
and scintigraphy of the entire body after 72 hours

25

N.S.

N.S.

ZZQL005

Scintigraphic search for a tumour by monophotonic transmitter not
specific to tumours

18

N.S.

N.S.

ZZQL012

Scintigraphic search for a tumour by monophotonic transmitter specificto tumours

5

N.S.

N.S.

Nervous system

PET and oncology

ExPRI study 201757

Table XX cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes fornuclear medicine.
E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

ZZQL013Pre-surgical radio-isotopic detection of a lesion by intratumoral or peritumoraltranscutaneous injection, with pre-surgical radio-isotopic detection

0.3

0.65

0.19

ZZQL016

Positron emission computed tomography of the entire body, with dedicatedPET camera

13

7.49

97.42

CCAM code

Description of the procedure

Other
HEQL001

Radio-isotopic search for gastroesophageal reflux

0.6

N.S.

N.S.

HEQL002

Scintigraphy of oesophageal transit by solid or liquid substance

0.9

N.S.

N.S.

HEQL003

Scintigraphy of oesophageal transit by solid and liquid substances

0.6

N.S.

N.S.

HFQL002

Scintigraphy of gastric or duodenal transit by solid or liquid substancewith no pharmacological effort

0.3

N.S.

N.S.

HFQL004

Scintigraphy of gastric or duodenal transit by solid and liquid substanceswith no pharmacological effort

0.6

N.S.

N.S.

HGQL001

Radio-isotopic search for Meckel’s diverticulum

2.9

N.S.

N.S.

HFQL002

Scintigraphy of the liver and spleen by a reticuloendothelial system marker

1.4

N.S.

N.S.

HFQL004

Scintigraphy of the bile ducts

2.9

N.S.

N.S.

HGQL001Pre-surgical detection of a lesion after injecting a radio-isotopic product

0.3

0.67

0.20

Table XXI
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for
CCAM codes for diagnostic interventional radiology.
CCAM code

Description of the procedure

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

Cardiac
DDQH006

Arteriography of a coronary bypass, by transcutaneous artery access

5.6

N.S.

N.S.

DDQH009

Coronary arteriography without left ventriculography, by transcutaneousartery access

5.6

3.12

17.45

DDQH010

Coronary arteriography with left ventriculography and bilateral or unilateralinternal thoracic arteriography [mammary], by transcutaneous arterial access

5.6

N.S.

N.S.

DDQH011

Coronary arteriography with angiography of a coronary bypass and left
ventriculography, by transcutaneous arterial access

5.6

N.S.

N.S.

DDQH012

Coronary arteriography with left ventriculography, by transcutaneousarterial access

5.6

0.94

5.27

DDQH013

Coronary arteriography with angiography of several coronary bypasses
without left ventriculography, by transcutaneous arterial access

5.6

0.11

0.63

DDQH014

Coronary arteriography with angiography of a coronary bypass without
left ventriculography, by transcutaneous arterial access

5.6

0.04

0.22

DDQH015

Coronary arteriography with angiography of several coronary bypasses
and left ventriculography, by transcutaneous arterial access

5.6

0.03

0.18

DFQH001

Selective arteriography of the pulmonary trunk and/or branches,by transcutaneous venous access

5

N.S.

N.S.

DFQH002

Hyperselective arteriography of pulmonary arteries, by transcutaneousarterial access

5

N.S.

N.S.

EBQH001

General cervicocephalic phlebography, by transcutaneous venous access

5

N.S.

N.S.

EBQH002

Selective arteriography of 3 or more cervicocephalic sections,by transcutaneous arterial access

5

0.18

0.92

EBQH005

Hyperselective cervicocephalic arteriography, by transcutaneous arterial
access

5

0.06

0.29

EBQH007

Supraselective cervicocephalic arteriography, by transcutaneous arterial
access

5

N.S.

N.S.

EBQH008

Arteriography of several cervicocephalic sections, by multiple
transcutaneous intra-arterial injections

5

N.S.

N.S.

EBQH010

Cervicocephalic arteriography, by a single transcutaneous intra-arterial
injection

5

N.S.

N.S.

EBQH011

Selective arteriography of one or 2 cervicocephalic sections,by transcutaneous arterial access

5

0.06

0.28

Neurological

58

ExPRI study 2017

Table XXI cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes fordiagnostic interventional radiology.
E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

ECQH012

Selective or hyperselective arteriography of the entire spinal cord,by transcutaneous arterial access

60

N.S.

N.S.

ECQH013

Selective or hyperselective arteriography of one segment of the spinal
cord, by transcutaneous arterial access

60

N.S.

N.S.

ECQH014Supraselective arteriography of the spinal cord, by transcutaneous arterial
access

60

N.S.

N.S.

HMQH003

Retrograde cholangiography with infundibulectomy [punctal diathermy of
the gall bladder infundibulum] or pre-cutting of the major duodenal papilla,by oesophago-gastro-duodenoscopy

1.6

0.03

0.04

HMQH004

Cholangiography, by transcutaneous injection of a contrast medium inbile ducts, with ultrasound and/or radiological guidance

1.6

0.04

0.07

HMQH005

Retrograde cholangiopancreatography without sphincter of Oddi manometry,by oesophago-gastro-duodenoscopy

1.6

N.S.

N.S.

HMQH006

Cholangiography, by injecting a contrast medium in an external biliary
tube

1.6

0.12

0.20

HMQH007

Retrograde cholangiography, by oesophago-gastro-duodenoscopy

1.6

0.19

0.31

HNQH001

Retrograde pancreatography with use of a minor duodenal papilla [accessory
papilla] catheter technique, by oesophago-gastro-duodenoscopy

1.6

N.S.

N.S.

HNQH003

Retrograde pancreatography with use of a major duodenal papilla catheter
technique, by oesophago-gastro-duodenoscopy

1.6

N.S.

N.S.

DGQH001

General arteriography of the abdominal aorta and lower limbs,
by transcutaneous arterial access

12

0.20

2.46

DGQH002

General arteriography of the abdominal aorta, by transcutaneous arterial
access

12

0.09

1.02

DGQH003

Arteriography of the abdominal aorta and lower limbs, by lumbartranscutaneous intro-aortic injection

12

N.S.

N.S.

DGQH004

Arteriography of the aorta and its branches, by transcutaneous intravenous
injection

5

N.S.

N.S.

DGQH005

General arteriography of the thoracic and abdominal aorta,by transcutaneous arterial access

12

N.S.

N.S.

DGQH006

General arteriography of the thoracic aorta, by transcutaneous arterial
access

5

0.10

0.50

DGQH007

General arteriography of the arterial aorta and its cervicocephalic branches[aortic arch, by transcutaneous arterial access

5

0.05

0.27

DHQH001

Selective phlebography of several branches of the common iliac vein
and/or the inferior vena cava, by transcutaneous venous access

12

N.S.

N.S.

DHQH002

Phlebography of the inferior vena cava [inferior caval venography],by transcutaneous venous access

12

N.S.

N.S.

DHQH003

Phlebography of the superior vena cava [superior caval venography],by transcutaneous intravenous injection

5

0.07

0.36

DHQH004

Selective phlebography of one branch of the common iliac vein or theinferior vena cava, by transcutaneous venous access

12

N.S.

N.S.

DHQH005

Phlebography of iliac veins and inferior vena cava [Iliac venography],by unilateral or bilateral femoral transcutaneous intravenous injection

12

N.S.

N.S.

DHQH006

General phlebography of the superior vena cava [superior caval venography],by transcutaneous venous access

5

0.03

0.15

DHQH007

Hyperselective phlebography of one branch of the common iliac veinor the inferior vena cava, by transcutaneous venous access

12

0.05

0.55

ECQH001

Bilateral arteriography of the upper limb by arterial access or transcutaneous
intra-arterial injection, with positional manoeuvres

8

N.S.

N.S.

ECQH002

Supraselective arteriography of the upper limb, by transcutaneous arterial
access

8

N.S.

N.S.

ECQH005

Hyperselective or selective arteriography of the upper limb,
by transcutaneous arterial access

8

N.S.

N.S.

ECQH006

Arteriography of the upper limb by transcutaneous intra-arterial injection,
without positional manoeuvres

8

N.S.

N.S.

ECQH007

Bilateral arteriography of the hand, by transcutaneous intra-arterial injection

8

N.S.

N.S.

ECQH015

Selective or hyperselective arteriography of the parietal and/or visceralinternal thoracic artery, by transcutaneous arterial access

5

N.S.

N.S.

ECQH016

Supraselective arteriography of the parietal and/or visceral internal
thoracic artery, by transcutaneous arterial access

5

N.S.

N.S.

CCAM code

Description of the procedure

Biliary duct

Vascular

ExPRI study 201759

Table XXI cont.
Effective dose per procedure, frequency of procedures and contribution to the mean per caput annual dose for CCAM codes fordiagnostic interventional radiology.

60

E / proc.

Freq of proc

Emean / indiv.

(mSv)(/1,000 indiv.)(µSv)

EDQH001

Supraselective arteriography of an extra-intestinal branch of the abdominal
aorta or internal iliac artery branch, by transcutaneous arterial access

12

N.S.

N.S.

EDQH003

Hyperselective or selective arteriography of an extra-intestinal branchof the abdominal aorta or internal iliac artery branch, by transcutaneousarterial access

12

N.S.

N.S.

EDQH005

Hyperselective and/or selective arteriography of several extra-intestinal
branches of the abdominal aorta or several internal iliac artery branches,by transcutaneous arterial access

12

0.04

0.44

EDQH006

Hyperselective and/or selective arteriography of several intestinal branchesof the abdominal aorta, by transcutaneous arterial access

12

0.03

0.31

EDQH007

Supraselective arteriography of the intestinal branch of the abdominal
aorta, by transcutaneous arterial access

12

N.S.

N.S.

EDQH008

Hyperselective and/or selective arteriography of an intestinal branch of
the abdominal aorta, by transcutaneous arterial access

12

N.S.

N.S.

EEQH001

Bilateral arteriography of the lower limb, by bilateral transcutaneous
femoral intra-arterial injection

8

N.S.

N.S.

EEQH002

Hyperselective or selective arteriography of the lower limb,
by transcutaneous arterial access

8

0.04

0.35

EEQH003

Arteriography of the food, by intra-arterial injection or transcutaneousarterial access

8

N.S.

N.S.

EEQH004

Supraselective arteriography of the lower limb, by transcutaneous arterial
access

8

N.S.

N.S.

EEQH005

General arteriography of the lower limb, by transcutaneous arterial access

8

0.04

0.33

EEQH006

Unilateral arteriography of the lower limb, by transcutaneous femoral
intra-arterial injection

8

0.08

0.61

EFQH001

Selective phlebography of the upper limb by transcutaneous venous
access, with no study of the proximal veins

8

N.S.

N.S.

EFQH002

Selective phlebography of one branch of the brachiocephalic veinor the superior vena cava, by transcutaneous venous access

5

N.S.

N.S.

EFQH003

Bilateral phlebography of the upper limb by transcutaneous intravenous
injection, with study of proximal veins and the superior vena cava

8

0.03

0.20

EFQH005

Unilateral phlebography of the upper limb by intravenous injection
or transcutaneous venous access, with study of proximal veins
and the superior vena cava

8

N.S.

N.S.

EFQH006

Unilateral phlebography of the upper limb by transcutaneous intravenous
injection, with no study of the proximal veins

8

N.S.

N.S.

EFQH007

Hyperselective phlebography of one branch of the brachiocephalic veinor the superior vena cava, by transcutaneous venous access

5

N.S.

N.S.

EHQH001

Selective phlebography of a hepatic vein, by transcutaneous venous
access

12

N.S.

N.S.

EJQH001

Varicography of the lower limb, by transcutaneous intravenous injection

8

N.S.

N.S.

EJQH003

Retrograde phlebography of the lower limb by ipsilateral femoraltranscutaneous intravenous injection or by contralateral femoral venous
access

8

N.S.

N.S.

EJQH004

Bilateral phlebography of the lower limb, by transcutaneous intravenous
injection in the foot

8

N.S.

N.S.

EJQH006

Unilateral phlebography of the lower limb, by transcutaneous intravenous
injection in the foot

8

N.S.

N.S.

EKQH002

Angiography of arteriovenous vascular access of an upper limb with
exploration of the proximal deep veins and the superior vena cava,by transcutaneous intravascular injection

5

0.13

0.67

EZMH001

Secondary radiological examination of the permeability and/or the positionof a vascular access device or a vascular endoprosthesis, by injecting acontrast medium

0.1

0.24

0.02

EZQH002

Angiography of arteriovenous vascular access in a limb, by transcutaneous
vascular access

8

N.S.

N.S.

EZQH003

Angiography of arteriovenous vascular access in a limb, by transcutaneous
intravascular injection

8

N.S.

N.S.

YYYY024

Full radiological assessment of the lower limbs for complex venous
pathologies requiring several types of access, use of tourniquets
if necessary and imaging in various positions

8

N.S.

N.S.

CCAM code

Description of the procedure

ExPRI study 2017

ExPRI study 2017
Pôle Santé et Environnement
Service d’études et d’expertise en radioprotection
Cover photo: Sophie Brändström/Signatures/Médiathèque
IRSN
Graphic design & production: Chromatiques, Paris.

For any additional information:
IRSN
Pôle santé et environnement (PSE-SANTE)
31, avenue de la Division Leclerc
92262 Fontenay-aux-Roses cedex
RCS Nanterre B 440 546 018
Telephone: +33 (0)1 58 35 88 88
Email: contact@irsn.fr
Report No.: IRSN /2020-00564
IRSN - All rights reserved
August 2020
Subject to third-party rights, this document may not be transmitted,
disclosed or reproduced to, for or by any third party without priorwritten consent.

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