Download (OPEIR) Performance Measure Set

American Board of Medical Specialties
American Medical Association (AMA)-convened Physician Consortium for
Performance Improvement®
American College of Radiology
Optimizing Patient Exposure to Ionizing Radiation
Performance Measurement Set
PCPI and ABMS approved
April 2013
Updated January 2016
© [2014] American Board of Medical Specialties, American College of Radiology and American
Medical Association. All Rights Reserved. CPT® Copyright 2004-2013 American Medical Association.
T a b l e of C o n t e n t s
Executive Summary
Optimizing Patient Exposure to Ionizing Radiation (OPEIR) Measurement Set
Purpose of Measurement Set
Importance of Topic
Opportunity for Improvement
Clinical Evidence Base
Optimizing Patient Exposure to Ionizing Radiation Outcomes
Intended Audience, Care Setting, and Patient Population
Optimizing Patient Exposure to Ionizing Radiation Work Group Recommendations
Other Potential Measures
Quality Improvement Measures/Additional Measures Included (Measures Not
Developed by ABMS/ABR/ACR/PCPI Under This Project)
Measure Harmonization
Technical Specifications: Overview
Measure Exclusions and Measure Exceptions
Testing and Implementation of the Measurement Set
Optimizing Patient Exposure to Ionizing Radiation Measures
Measure #1: Reporting to a Radiation Dose Index Registry
Measure #2: Utilization of a Standardized Nomenclature for CT Imaging Description
Measure #3: Appropriateness: Follow-up CT Imaging for Incidentally Detected
Pulmonary Nodules According to Recommended Guidelines
Measures #4-6: Measures deleted
Measure #7: Equipment Evaluation for Pediatric CT Imaging Protocols
Measure #8: Utilization of Pediatric CT Imaging Protocols
Measure #9: Count of Potential High Dose Radiation Imaging Studies: Computed
Tomography (CT) and Cardiac Nuclear Medicine Studies
Measure #10: Search for Prior CT Studies through a Secure, Authorized, Mediafree, Shared Archive
Measure #11: CT Images Available for Patient Follow-Up and Comparison Purposes
Quality Improvement Measures/Additional Measures Referenced (Measures
Not Developed by ABMS/ABR/ACR/PCPI Under This Project)
Measure #12 (PCPI/ACR/NCQA): Exposure Time Reported for Procedures Using
Fluoroscopy
Measure #13 (Partners HealthCare/Brigham & Women’s Hospital): Pulmonary CT
Imaging for Patients at Low-risk for Pulmonary Embolism
Measure #14 (Partners HealthCare/Brigham & Women’s Hospital): Appropriate Head
CT Imaging in Adults with Mild Traumatic Brain Injury
Evidence Classification/Rating Schemes
Summary of Non-Material Interest Disclosures
References
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© [2014] American Board of Medical Specialties, American College of Radiology and American
Medical Association. All Rights Reserved. CPT® Copyright 2004-2013 American Medical Association.
2
The Measures are not clinical guidelines, do not establish a standard of medical care, and have not
been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for
noncommercial purposes, e.g., use by health care providers in connection with their practices.
Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or
incorporation of the Measures into a product or service that is sold, licensed or distributed for
commercial gain.
Commercial uses of the Measures require a license agreement between the user and the American
Medical Association (AMA), [on behalf of the Physician Consortium for Performance Improvement®
(PCPI®)], American Board of Medical Specialties (ABMS) and the American College of Radiology (ACR).
Neither the AMA, ABMS, ACR, PCPI, nor its members shall be responsible for any use of the Measures.
The AMA’s, PCPI’s and ABMS’s significant past efforts and contributions to the development and
updating of the Measures is acknowledged. ACR is solely responsible for the review and enhancement
(“Maintenance”) of the Measures as of August 1, 2014.
ACR encourages use of the Measures by other health care professionals, where appropriate.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the
proprietary code sets should obtain all necessary licenses from the owners of these code sets. The
AMA, ABMS, ACR, the PCPI and its members disclaim all liability for use or accuracy of any Current
Procedural Terminology (CPT®) or other coding contained in the specifications.
CPT® contained in the Measures specifications is copyright 2004-2014 American Medical Association.
LOINC® copyright 2004-2013 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®)
copyright 2004-2013 College of American Pathologists. All Rights Reserved.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
3
Optimizing Patient Exposure to Ionizing Radiation
Work Group Members
W or k G r o u p M e m b e r s
Milton J. Guiberteau, MD (Co-Chair) (nuclear radiology/diagnostic radiology)
David Seidenwurm, MD (Co-Chair) (neuroradiology/pediatric and diagnostic radiology)
Dennis M. Balfe, MD (diagnostic radiology)
Dorothy Bulas, MD (pediatric radiology)
Philip N. Cascade, MD (cardiothoracic radiology)
C. Daniel Johnson, MD, MS, MMM (gi radiology)
Richard L. Morin, PhD (radiologic physics)
Robert D. Rosenberg, MD (diagnostic radiology)
Howard Sandler, MD, MS (Physics) (radiation oncology)
Rebecca Smith-Bindman, MD (diagnostic radiology)
Christopher Wyatt, MHM (payer representative)
Advisory Group Members
Paul R. Sierzenski, MD, RDMS (emergency
medicine)
Liana Watson, DM, RT(R)(M)(S)(BS), RDMS, RVT
(radiography/sonography)
Sjirk J. Westra, MD (pediatric radiology)
Scott Jerome, DO (cardiology/internal medicine)
Paul M. Knechtges, MD (diagnostic radiology)
John R. Maese, MD (internal medicine/geriatrics)
Jason Sheehan, MD, PhD (neurosurgery)
W or k G r o u p S t a f f
American Board of Medical Specialties
Richard Hawkins, MD
Sheila Lazier
Katie Small
Robin Wagner, RN, MHSA
Kevin Weiss, MD, MPH
American Board of Radiology
Gary Becker, MD
Jennifer Bosma, PhD
Paul Wallner, DO
American College of Radiology
Judy Burleson, MHSA
American Medical Association
Mark Antman, DDS, MBA
Elvia Chavarria, MPH
Anu Gupta, JD
Kendra Hanley, MS
Samantha Tierney, MPH
PCPI Consultant
Rebecca Kresowik
© [2014] American Board of Medical Specialties, American College of Radiology and American
Medical Association. All Rights Reserved. CPT® Copyright 2004-2013 American Medical Association.
4
Executive Summary
Toward Improving Quality of Care for Patients Undergoing Imaging Studies
Using Ionizing Radiation
The American Board of Medical Specialties (ABMS) and the American Medical Association (AMA)convened Physician Consortium for Performance Improvement® (PCPI®) in collaboration with the
American Board of Radiology (ABR) and the American College of Radiology (ACR) formed an
Optimizing Patient Exposure to Ionizing Radiation (OPEIR) Work Group to develop a measurement set
for implementation into Maintenance of Certification® (MOC) programs and toward improving the
quality of care for patients undergoing high dose radiation studies, specifically computed tomography
(CT) and myocardial perfusion imaging.
Reasons for Prioritizing Optimal Patient Exposure to Ionizing Radiation
High Impact Topic Area
This topic was chosen for measure development because imaging studies are a significant source of
radiation exposure and because of the high costs associated with these procedures.
•
•
•
•
•
The average per capita exposure to ionizing radiation from imaging exams increased by about
600% from 1980 to 2006 in the United States. 1,2
The largest contributor to this dramatic increase in population radiation exposure is the
computed tomography (CT). In 1980 fewer than 3 million CT scans were performed; In 2006,
there were about 380 million radiologic procedures (including 67 million CT scans) and 18
million nuclear medicine procedures performed in the United States.1,2
The imaging study with the single highest radiation burden, accounting for 22% of cumulative
effective dose, is myocardial perfusion imaging. 3
Despite a comparatively small decrease in 2010, the cumulative growth in the volume of
imaging from 2000 to 2009 totaled 85 percent. 4
From 2000 through 2006, total Medicare expenditures for physician imaging services
increased from $6.7 billion to about $14 billion, an increase of approximately 13 percent per
year on average. 5
Clinical Evidence Base
Evidence-based clinical practice guidelines are available to optimize the radiation exposure for
patient’s undergoing imaging. This measurement set is based on guidelines from:
1. American College of Radiology
2. National Cancer Institute
3. National Council on Radiation Protection and Measurements
Optimal Patient Exposure to Ionizing Radiation Outcomes
Ideally, a set of performance measures would include measures of outcomes as well as key process
and structural measures known to positively influence desirable improvements and outcomes. The
development of outcome measures for optimizing patient exposure to ionizing radiation proved
particularly challenging because of the cumulative and potentially latent effects of radiation. In light of
these difficulties, the Work Group set out to develop performance measures based on structures and
processes that will reflect high quality care and a step toward achieving desired outcomes.
Desired outcomes for optimizing patient exposure to ionizing radiation include to:
1. Reduce the potential for patient harm
2. Reduce excessive radiation risks and exposures
3. Reduce procedural complications
4. Reduce morbidity in patients who undergo medical imaging
5. Reduce inappropriate and/or unnecessary repeat imaging
6. Encourage recording of medical imaging exam radiation dose indices and reporting of patientlevel tracking of imaging exams conducted
7. Enhance awareness of risks associated with medical imaging
8. Encourage appropriate utilization of ionizing and nonionizing radiation
© 2013 American Medical Association and American Board of Medical Specialties. All Rights Reserved
5
Optimizing Patient Exposure to Ionizing Radiation Work Group Recommendations
Process measures: Key processes of care designed to improve the quality of care for patients
undergoing ionizing radiation imaging are recommended:
Measures addressing safety, efficiency and appropriateness
Measure #3: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary
Nodules According to Recommended Guidelines
Measure #9: Count of Potential High Radiation Dose Imaging Studies: Computed
Tomography (CT) and Cardiac Nuclear Medicine Studies
Structural measures: Several structural measures, designed to reduce unnecessary or repeat
imaging and radiation exposure through the use of protocols and health information technology are
recommended:
Measures addressing the recording and reporting of imaging procedures
Measure #1: Reporting to a Radiation Dose Index Registry
Measure #2: Utilization of a Standardized Nomenclature for CT Imaging Description
Measure #10: Search for Prior CT Studies through a Secure, Authorized, Media-free, Shared
Archive
Measure #11: CT Images Available for Patient Follow-up and Comparison Purposes
Measures addressing pediatric patient safety
Measure #7: Equipment Evaluation for Pediatric CT Imaging Protocols
Measure #8: Utilization of Pediatric CT Imaging Protocols
Please note: Measures 4-6 of this project have been deleted.
These clinical performance measures are designed for practitioner-level quality improvement and as a
step in the journey towards achieving better outcomes for patients by optimizing patient exposure to
ionizing radiation. Unless otherwise indicated, the measures are also appropriate for accountability if
the appropriate methodological, statistical, and implementation rules are achieved.
Distinction between Measures for Accountability and Quality Improvement or Measures for
Quality Improvement Only
Measures developed for accountability, including those for use in public reporting, accreditation and
possibly pay-for-performance, must meet certain criteria to warrant the designation. In particular,
measures must be developed through a rigorous process that includes a public comment and peer
review period, be based on guideline recommendations that were prioritized because of the clinical
importance of the intervention and link to desired outcomes, the strength of evidence and strength of
recommendation, gaps in care, validity, and feasibility.
Other Potential Measures
The Work Group considered several other important constructs related to the optimization of patient
exposure to ionizing radiation, though ultimately determined that they were not suitable in the context
of this performance measurement project. In particular, there was universal agreement among Work
Group members that CT imaging was not the only ionizing radiology imaging modality of concern;
rather, the use of interventional radiology procedures and various types of nuclear medicine studies
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
6
also may contribute to high radiation dose exposure. Despite the importance and the frequent use of
these procedures, the Work Group opted to narrow its efforts and focus primarily on CT for this
measure development project. The Work Group also focused one measure on myocardial perfusion
studies given that these are the imaging studies with the single highest radiation burden.3
Measure Harmonization
When existing hospital- or plan-level measures are available for the same measurement topics, the
PCPI attempts to harmonize the measures to the extent feasible.
To address potential opportunities for harmonization, the following measures were reviewed:
NQF measure #0739: Radiation Dose of Computed Tomography (CT).
NQF measure #0740: Participation in a Systematic National Dose Index Registry.
NQF measure #0510: Exposure time reported for procedures using fluoroscopy.
Technical Specifications Overview
There are several data sources available for collecting performance measures; generally different data
sources require different sets of measure specifications, due to the structure of the systems storing
the data. The PCPI is focusing significant resources and expertise toward specifying and testing
measures within EHRs and other Health Information Technology systems, as they hold the promise of
providing the relevant clinical data for measures and for providing feedback to physicians and other
health care providers that is timely and actionable.
This performance measurement set has been put forward for PCPI vote without specifications. The
measures are not intended for implementation until the development of specifications is completed as
set forth in the following plan:
•
Six of the measures included in this set have been included in the 2013 Medicare Physician Fee
schedule and were finalized for inclusion in the 2014 Physician Quality Reporting System
(PQRS) as a Measures Group, effective January 1, 2014. AMA professional staff to the PCPI will
coordinate with the CMS contractor for the PQRS program to develop specifications for these
measures to be used in the PQRS program. These five measures are listed below:
- Measure #1: Reporting to a Radiation Dose Index Registry
- Measure #2: Utilization of a Standardized Nomenclature for CT Imaging Description
- Measure #3: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary
Nodules According to Recommended Guidelines
- Measure #9: Count of Potential High Dose Radiation Imaging Studies: Computed
Tomography (CT) and Cardiac Nuclear Medicine Studies
- Measure #10: Search for Prior CT Studies through a Secure, Authorized, Media-free,
Shared Archive
- Measure #11: CT Images Available for Patient Follow-up and Comparison Purposes
•
AMA professional staff to the PCPI will coordinate with ABMS, ACR, and the American Board of
Radiology to identify other implementations of these measures, such as in a Practice Quality
Improvement (PQI) project as part of Maintenance of Certification.
Testing and Implementation of the Measurement Set
The measures in this set are being made available without any prior formal testing. However, many of
the measures in this set (Utilization of a Standardized Nomenclature for CT Imaging Description,
Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac
Nuclear Medicine Studies, CT Images Available for Patient Follow-Up and Comparison Purposes,
Search for Prior CT Studies through a Secure, Authorized, Media-free, Shared Archive,
Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to
Recommended Guidelines and Reporting to a Radiation Dose Index Registry) have been in use in the
CMS Physician Quality Reporting System program since 2013 indicating the feasibility of collecting the
data elements required for measure calculation.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
7
The American College of Radiology recognizes the importance of thorough testing all of its measures
and encourages ongoing robust testing of the Optimizing Patient Exposure to Ionizing Radiation
measurement set for feasibility and reliability by organizations or individuals positioned to do so. The
ACR will welcome the opportunity to promote such testing of these measures and to ensure that any
results available from testing are used to refine the measures on an ongoing basis.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
8
© 2013 American Medical Association and American Board of Medical Specialties. All Rights Reserved
9
Optimizing Patient Exposure to Ionizing Radiation
Performance Measurement Set
P u r p o s e of M e a s u r e m e n t S e t
The American Board of Medical Specialties (ABMS) and the American Medical Association (AMA)convened Physician Consortium for Performance Improvement® (PCPI®) in collaboration with the
American Board of Radiology (ABR) and the American College of Radiology (ACR) formed an
Optimizing Patient Exposure to Ionizing Radiation (OPEIR) Work Group. The intent of the Work Group
was to identify and define quality measures toward improving the quality of care for patients
undergoing high dose radiation imaging studies and for use in Physician Quality Improvement (PQI)
projects for implementation into Maintenance of Certification® (MOC) Part IV programs.
The measures in this project address radiation exposure across a continuum – before, during and after
an imaging procedure. Measures intended for use before address the appropriateness of the exam,
measures intended for use during address the technical aspects of the exam and those intended for
use after radiological imaging address coordination and utilization of available images. The Work
Group aimed to develop a set of measures that support the efficient delivery of high quality health
care in each of the Institute of Medicine’s (IOM) six aims for quality improvement (safe, effective,
patient centered, timely, efficient, and equitable). 6
While the Work Group focused on developing measures that reflect the most rigorous clinical evidence
available and address areas most in need of performance improvement, several measures have been
developed to advance clinical practice through the use of health information technology (HIT).
Therefore, emerging standards, enhanced data storage and transmission abilities and the Health
Information Technology for Economic and Clinical Health (HITECH) Act form the basis for the HITrelevant measures. These measures aim to use HIT to improve the quality of health care, reduce
medical errors, increase appropriateness of ionizing radiation procedures, and improve the continuity
of care within and between healthcare settings. The Work Group considered opportunities for
outcome, process and structure measures as well as composite, bundled and group- or system-level
measures.
Importance of Topic
The use of medical imaging has resulted in revolutionary advances in the practice of medicine. The
increased sophistication and clinical efficacy of imaging have resulted in its considerable growth.
Consequently, the evolution of imaging has resulted in a significant increase in the population’s
cumulative exposure to ionizing radiation and a potential increase in adverse effects including
cancer. 7,8 Although experts may not agree on the extent of the risks of cancer from medical imaging,
there is uniform agreement that care should be taken to weigh the medical necessity of a given level
of radiation exposure against the risks, and that steps should be taken to eliminate avoidable
exposure to radiation.8,9
High Impact Topic Area
This topic was chosen for measure development because of the high costs associated with imaging
studies and because these medical procedures are a significant source of radiation exposure. The
following objective data support the degree of increase in the use of imaging studies and emphasize
the importance in taking steps to help eliminate avoidable exposure.
Prevalence and Incidence
•
•
The average per capita exposure to ionizing radiation from imaging exams increased by about
600% from 1980 to 2006 in the United States.1,2
The largest contributor to this dramatic increase in population radiation exposure is the
computed tomography (CT). In 1980 fewer than 3 million CT scans were performed; In 2006,
there were about 380 million radiologic procedures (including 67 million CT scans) and 18
million nuclear medicine procedures performed in the United States.1
© 2013 American Medical Association and American Board of Medical Specialties. All Rights Reserved
10
•
•
•
•
•
The imaging study with the single highest radiation burden, accounting for 22% of cumulative
effective dose is myocardial perfusion imaging.3
In 2006, an estimated 19 million head, 10.6 million chest and 21.2 million abdominal and
pelvic CT scans were performed accounting for 28, 15.9, and 31.7 percent, respectively, of the
total number of CT scans in the US.1
Currently, approximately 11% of CT examinations are performed on children, which could
account for more than 7 million pediatric CT examinations per year in the United States. 10,11,12
The prevalence of CT or MRI use during emergency department visits for injury-related
conditions increased from 6% in 1998 to 15% in 2007. 13
While CT utilization has decreased steadily since 2003 in pediatric facilities across North
America, 14 the use of CT in children who visit the ED increased from 0.33 to 1.65 from 1995 to
2008 and occurred primarily at non-pediatric focused facilities. 15
Costs
•
•
•
From 2000 through 2006, total Medicare expenditures for physician imaging services
increased from $6.7 billion to about $14 billion, an increase of 13 percent per year on
average.5
In 2005 imaging services represented an estimated 14 percent of 2005 spending included in
the sustainable growth rate (SGR) calculation, but represented 27 percent of the total increase
in such spending between 2004 and 2005. The majority of the growth occurred for advanced
imaging.5
In 2006, advanced imaging, including CT and MRI, accounted for 54 percent of total Medicare
imaging expenditures, up from 43 percent in 2000. This translates to an increase in Medicare
spending on advanced imaging from about $3 billion in 2000 to about $7.6 billion in 2006.5
Disparities
There is variation according to age, sex, and health care market in the proportion and mean dose of
patients undergoing medical imaging procedures. One study concluded that the proportion of subjects
undergoing at least one imaging procedure was higher in older patients, rising from 49.5% of those
who were 18 to 34 years old to 85.9% of those who were 60 to 64 years old. The study also found
that women underwent procedures significantly more often than men, with a total of 78.7% of women
undergoing at least one procedure during the study period, as compared with 57.9% of men.3
O p p o r t u n i t y f or I m p r o v e m e n t
One retrospective cross-sectional study describing radiation dose associated with some of the most
common types of diagnostic CT found variable radiation doses. The study found variability in the
following exams: 1) Routine chest exam without contrast, the CT Effective Doses ranged from 2mSv
to 24mSv; 2) Routine abdomen-pelvis, no contrast - CT Effective Dose ranged from 3mSv to 43mSv;
3) Routine head exam - CT Effective Dose ranged from 0.3mSv to 6mSv. 16
Clinical Evidence Base
Clinical practice guidelines serve as the foundation for the development of performance measures. A
number of clinical practice guidelines have been developed for the optimization of radiology imaging
based on exam modality and body part, offering an evidence base to guide clinical decision-making
and performance measure development. Guidelines from these organizations were reviewed during
the measure development process:
1. American College of Radiology
2. National Cancer Institute
3. National Council on Radiation Protection and Measurements
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
11
Additional recommendations from the Fleischner Society, the Alliance for Radiation Safety in Pediatric
Imaging Guidelines and other groups that focused on specific dimensions related to radiology imaging
were also incorporated. Relevant guidelines met all of the required elements and many, if not all, of
the preferred elements outlined in a PCPI position statement establishing a framework for consistent
and objective selection of clinical practice guidelines from which PCPI Work Groups may derive clinical
performance measures. 17
Performance measures, however, are not clinical practice guidelines and cannot capture the full
spectrum of care for all patients undergoing ionizing radiation imaging. The OPEIR Work Group
attempted to use guideline principles with the strongest recommendations and often the highest level
of evidence as the basis for measures in this set; however, due to the paucity of research related to
radiation exposure, the Work Group relied on those practice parameters and guidelines that are most
widely used in clinical practice.
Optimizing Patient Exposure to Ionizing Radiation O u t c om e s
Ideally, a set of performance measures would include measures of outcomes as well as key process
and structural measures known to positively influence desirable outcomes. The development of
outcome measures for optimizing patient exposure to ionizing radiation proved particularly challenging
because of the cumulative and potentially latent effects of radiation. In light of these difficulties, the
Work Group set out to develop performance measures based on structures and processes that will
achieve desired outcomes and reflect high quality care.
Desirable outcomes for optimizing patient exposure to ionizing radiation include:
1. Reducing patient harm
2. Reducing excessive radiation risks and exposures
3. Reducing procedural complications
4. Reducing morbidity in patients who undergo radiology imaging and/or radiation dosing
5. Reducing inappropriate and/or unnecessary repeat imaging
6. Encouraging recording of medical imaging exam radiation dose indices and reporting of
patient-level tracking of imaging exams conducted
7. Enhancing awareness of risks associated with medical imaging
8. Encouraging appropriate utilization of ionizing and nonionizing radiation
I n t e n d e d A u d i e n c e , C a r e S e t t i n g , a n d P a t i e n t P o p u l a t i on
ABMS and the PCPI encourage the use of these measures by physicians, other healthcare
professionals, and healthcare systems, or health plans, to manage the care for patients undergoing
radiation imaging studies in the Emergency Department, or within Inpatient or Ambulatory care.
These clinical performance measures are designed for implementation into MOC programs to satisfy
Part IV requirements and practitioner- and/or system-level quality improvement to achieve better
outcomes for patients undergoing radiologic imaging. Unless otherwise indicated, the measures are
also appropriate for accountability if the appropriate methodological, statistical, and implementation
rules are achieved and their original relationship to the MOC process is recognized.
Performance measurement serves as an important component in a quality improvement strategy but
performance measurement alone will not achieve the desired goal of improving patient care. Measures
can have the greatest effect when used judiciously and linked directly to operational steps that
clinicians, patients, and health plans can apply in practice to improve care. To that end, the PCPI will
work with quality improvement collaboratives and other initiatives to ensure that these measures are
implemented with the goal of improved patient care.
Optimizing Patient Exposure to Ionizing Radiation W or k G r ou p R e c o m m e n d a t i o n s
The Optimizing Patient Exposure to Ionizing Radiation (OPEIR) Work Group considered a wide range of
measurement opportunities focusing on a variety of imaging modalities – CT, fluoroscopy, perfusion
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
12
scan, nuclear medicine and interventional radiology – and varying anatomical areas of the body, head,
abdomen, pelvis and lungs. The Work Group concluded that this measure development project would
primarily focus on the use of CT and on myocardial perfusion studies which are considered some of the
largest contributors to population radiation exposure.1,3 The key priorities of this measurement set are
to improve the effectiveness of care and optimize patient exposure as the use of ionizing radiology
procedures grow.
The OPEIR Work Group identified several desired outcomes for patients undergoing high radiation
dose imaging procedures (see “Link to Outcomes” diagram in preceding section). Current quality gaps
among imaging equipment, institutional processes and overuse of imaging for low-risk populations
need to be critically evaluated to improve ionizing radiation outcomes (ie, the evaluation and
monitoring of low-risk patient populations, safety interventions, and the standardization and sharing of
images). As a result, many of the measures in the Optimizing Patient Exposure to Ionizing Radiation
set focus on the provision of safe, effective and efficient patient-centered care.
These clinical performance measures are designed for practitioner-level quality improvement to
achieve better outcomes for patients undergoing high radiation dose imaging. Unless otherwise
indicated, the measures are also appropriate for accountability if the appropriate methodological,
statistical, and implementation rules are achieved. The measures listed below may be used for quality
improvement and accountability.
Process measures: Several key processes of care designed to improve outcomes for patients
undergoing ionizing radiation imaging are recommended:
Measures addressing safety, efficiency and appropriateness
Measure #3: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary
Nodules According to Recommended Guidelines
Measure #9: Count of Potential High Dose Radiation Imaging Studies: Computed
Tomography (CT) and Cardiac Nuclear Medicine Studies
Structural measures: Several structural measures, designed to reduce unnecessary or repeat
imaging and radiation exposure through the use of protocols and health information technology are
recommended:
Measures addressing the recording and reporting of imaging procedures
Measure #1: Reporting to a Radiation Dose Index Registry
Measure #2: Utilization of a Standardized Nomenclature for CT Imaging Description
Measure #10: Search for Prior CT Studies through a Secure, Authorized, Media-free, Shared
Archive
Measure #11: CT Images Available for Patient Follow-up and Comparison Purposes
Measures addressing pediatric patient safety
Measure #7: Equipment Evaluation for Pediatric CT Imaging Protocols
Measure #8: Utilization of Pediatric CT Imaging Protocols
Please note: Measures 4-6 of this project have been deleted.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
13
These measures support the efficient delivery of high quality health care in many of the IOM’s six aims
for quality improvement as described in the following table:
IOM Domains of Health
Care Quality
Draft Measures
1
Reporting to a
Radiation Dose
Index Registry
2
Utilization of a
Standardized
Nomenclature for
CT Imaging
Description
Safe
IOM Domains of Health
Care Quality
Safe
3
Appropriateness:
Follow-up CT
Imaging for
Incidentally
Detected
Pulmonary Nodules
According to
Recommended
Guidelines
Effective
Underuse
Overuse

Patientcentered
Timely


Effective

Overuse
Equitable


Underuse
Efficient

Patientcentered
Timely

Efficient
Equitable

Measures 4-6 deleted
7
8
9
10
11
Equipment
Evaluation for
Pediatric CT
Imaging Protocols
Utilization of
Pediatric CT
Imaging Protocols
Count of Potential
High Dose
Radiation Imaging
Studies: CT and
Cardiac Nuclear
Medicine Studies
Search for Prior CT
Studies through a
Secure, Authorized,
Media-free, Shared
Archive
CT Images
Available for
Patient Follow-Up
and Comparison
Purposes
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© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
14
Other Potential Measures
The OPEIR Work Group considered several other important constructs related to optimizing patient
exposure to ionizing radiation, though ultimately determined that they were not suitable in the context
of this performance measurement project. In particular, there was universal agreement among Work
Group members that CT imaging was not the only high radiation dose imaging modality of concern;
rather, the use of interventional radiology procedures and nuclear medicine studies also contribute
greatly to high radiation dose exposure. Despite the importance and the frequent use of these
procedures, the Work Group made the decision to narrow its efforts and focus primarily on CT studies.
The Work Group also focused one measure on myocardial perfusion studies given that these are the
imaging studies with the single highest radiation burden.3
The Work Group also discussed broadening the scope of this project to include imaging related to
anatomical areas other than the head, abdomen and/or pelvis and lungs. These discussions focused on
the overuse of CT imaging for renal colic, hepatic hemangiomas, and trauma and to rule out disease of
the abdomen. Again, to maintain a more focused measurement set, development outside of the
proposed set was limited.
Q u a l i t y I m p r ov e m e n t M e a s u r e s / A d d i t i o n a l M e a s u r e s R e f e r e n c e d ( M e a s u r e s
N ot D e v e l o p e d b y A B M S / A B R / A C R / P C P I U n d e r T h i s P r o j e c t )
The Work Group discussed existing overuse quality improvement measures that may be implemented
at the site- or system-level if appropriate for accountability purposes. Implementation at this level
would more accurately reflect the actionability of practice ordering patterns, rather than maintain a
focus on point of imaging service. Two measures of this type, not developed under this project, are
referenced in this measure set, Measure #13 (Partners HealthCare/Brigham & Women’s Hospital):
Pulmonary CT Imaging for Patients at Low-risk for Pulmonary Embolism and Measure #14 (Partners
HealthCare/Brigham & Women’s Hospital): Appropriate Head CT Imaging in Adults with Mild Traumatic
Brain Injury. These measures are referenced in this set as quality improvement measures that may be
implemented by a radiologist in an MOC Part IV project as an opportunity to optimize radiation dose
through appropriate imaging. Both measures were endorsed by the National Quality Forum (NQF) in
April 2011. Full descriptions and specifications for these Partners HealthCare/Brigham & Women’s
Hospital measures are available at:
http://www.brighamandwomens.org/Research/labs/cebi/bestcare/HowDoWeAvoid.aspx#quality
A third measure, Exposure Time Reported for Procedures Using Fluoroscopy, previously developed by
PCPI/ACR/NCQA for its Radiology Measure set, and NQF-endorsed® has also been referenced in this
measure set as a potential MOC Part IV project. The Radiology measure set is available at:
http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI.
Other related measures not discussed by the work group may be available for implementation.
Measure Harmonization
When existing hospital- or plan-level measures are available for the same measurement topics, the
PCPI attempts to harmonize the measures to the extent feasible.
To address potential opportunities for harmonization, the following measures were reviewed:
NQF measure #0739: Radiation Dose of Computed Tomography (CT) is intended for the quantification
and reporting of radiation dose associated with CT examinations of the head, neck, chest,
abdomen/pelvis and lumbar spine, obtained in children and adults.
NQF measure #0740: Participation in a Systematic National Dose Index Registry, is an attestation
measure specifically requiring the use of a national, registry with systematic and automated data
collection.
NQF measure #0510: Exposure time reported for procedures using fluoroscopy, focuses on radiation
exposure related to fluoroscopic and not CT imaging.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
15
Technical Specifications: Overview
Technical Specifications Overview
There are several data sources available for collecting performance measures; generally different data
sources require different sets of measure specifications, due to the structure of the systems storing
the data. The PCPI is focusing significant resources and expertise toward specifying and testing
measures within EHRs and other Health Information Technology systems, as they hold the promise of
providing the relevant clinical data for measures and for providing feedback to physicians and other
health care providers that is timely and actionable.
This performance measurement set has been put forward for PCPI vote without specifications. The
measures are not intended for implementation until the development of specifications is completed as
set forth in the following plan:
•
Six of the measures included in this set have been included in the 2013 Medicare Physician Fee
schedule and were finalized for inclusion in the 2014 Physician Quality Reporting Program as a
Measures Group, effective January 1, 2014. AMA professional staff to the PCPI will coordinate
with the CMS contractor for the PQRS program to develop specifications for these measures to
be used in the PQRS program. These five measures are listed below:
- Measure #1: Reporting to a Radiation Dose Index Registry
- Measure #2: Utilization of a Standardized Nomenclature for CT Imaging Description
- Measure #3: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary
Nodules According to Recommended Guidelines
- Measure #9: Count of Potential High Dose Radiation Imaging Studies: Computed
Tomography (CT) and Cardiac Nuclear Medicine Studies
- Measure #10: Search for Prior CT Studies through a Secure, Authorized, Media-free,
Shared Archive
- Measure #11: CT Images Available for Patient Follow-up and Comparison Purposes
AMA professional staff to the PCPI will coordinate with ABMS, ACR, and the American Board of
Radiology to identify other implementations of these measures, such as in a Practice Quality
Improvement (PQI) project as part of Maintenance of Certification.
•
Measure Exclusions and Measure Exceptions
Measure Exclusions
Exclusions arise when patients who are included in the initial patient or eligible population for the
measure set do not meet the denominator criteria specific to the intervention required by the
numerator. Exclusions are absolute and apply to all patients and therefore are not part of clinical
judgment within a measure. Specific exclusions should be derived from evidence-based guidelines.
Measure Exceptions
In the context of physician performance measurement, exceptions are the mechanism used to remove
patients from the denominator of a performance measure when a patient does not receive a therapy
or service AND that therapy or service would not be appropriate due to specific reasons for which the
patient would otherwise meet the denominator criteria. Exceptions are not absolute, and are based on
clinical judgment and individual patient characteristics.
For process measures, the PCPI provides three categories of reasons for which a patient may be
excluded from the denominator of an individual measure:
•
Medical reasons
Includes:
- not indicated (absence of organ/limb, already received/performed, other)
- contraindicated (patient allergic history, potential adverse drug interaction, other)
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
16
•
Patient reasons
Includes:
- patient declined
- social or religious reasons
- other patient reasons
•
System reasons
Includes:
- resources to perform the services not available
- insurance coverage/payor-related limitations
- other reasons attributable to health care delivery system
These measure exception categories are not available uniformly across all measures; for each
measure, there must be a clear rationale to permit an exception for a medical, patient, or system
reason. For some measures, examples have been provided in the measure exception language of
instances that would constitute an exception. Examples are intended to guide clinicians and are not
all-inclusive lists of all possible reasons why a patient could be excluded from a measure. One
mechanism to report an exception of a patient is by appending the appropriate modifier to the CPT
Category II code designated for the measure:
•
•
•
Medical reasons: modifier 1P
Patient reasons: modifier 2P
System reasons: modifier 3P
Although this methodology does not require the external reporting of more detailed exception data,
the PCPI recommends that physicians document the specific reasons for exception in patients’ medical
records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the
systematic review and analysis of each physician’s exceptions data to identify practice patterns and
opportunities for quality improvement. For example, it is possible for implementers to calculate the
percentage of patients that physicians have identified as meeting the criteria for exception.
Please refer to documentation for each individual measure for information on the acceptable exception
categories and the codes and modifiers to be used for reporting. The full position statement 18 that
discusses exclusions/exceptions and their use may be accessed through the PCPI website
(www.physicianconsortium.org).
T e s t i n g a n d I m p l e m e n t a t i o n of t h e M e a s u r e m e n t S e t
The measures in this set are being made available without any prior formal testing. However, many of
the measures in this set (Utilization of a Standardized Nomenclature for CT Imaging Description,
Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac
Nuclear Medicine Studies, CT Images Available for Patient Follow-Up and Comparison Purposes,
Search for Prior CT Studies through a Secure, Authorized, Media-free, Shared Archive,
Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to
Recommended Guidelines and Reporting to a Radiation Dose Index Registry) have been in use in the
CMS Physician Quality Reporting System program since 2013 indicating the feasibility of collecting the
data elements required for measure calculation.
The American College of Radiology recognizes the importance of thorough testing all of its measures
and encourages ongoing robust testing of the Optimizing Patient Exposure to Ionizing Radiation
measurement set for feasibility and reliability by organizations or individuals positioned to do so. The
ACR will welcome the opportunity to promote such testing of these measures and to ensure that any
results available from testing are used to refine the measures on an ongoing basis.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
17
Measure #1: Reporting to a Radiation Dose Index Registry
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age,
that are reported to a radiation dose index registry AND that include at a minimum selected data
elements
M e a s u r e C om p o n e n t s
Numerator
Statement
CT studies performed that are reported to a radiation dose index registry AND that
include at a minimum all of the following data elements*:
Manufacturer
Study description
Manufacturer’s model name
Patient’s weight
Patient’s size
Patient’s sex
Patient’s age
Exposure time
X-Ray tube current
Kilovoltage (kV)
Mean Volume Computed tomography dose index (CTDIvol)
Dose-length product (DLP)
*Detailed information regarding the patient demographic and scanner data elements
included in the Digital Imaging and Communication in Medicine (DICOM) header and
CT irradiation event data elements included in the DICOM Supplement 127: CT
Radiation Dose Reporting (Dose Structured Report) can be found in the Dose Index
Registry Data Dictionary available on the American College of Radiology (ACR) Web
site: Dose Index Registry Data Dictionary
Denominator
Statement
All CT studies performed for all patients, regardless of age
Denominator
Exceptions
None.
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
The goal in medical imaging is to obtain image quality consistent with the medical
imaging task. Diagnostic reference levels are used to manage the radiation dose to
the patient. The medical radiation exposure must be controlled, avoiding
unnecessary radiation that does not contribute to the clinical objective of the
procedure. By the same token, a dose significantly lower than the reference level
may also be cause for concern, since it may indicate that adequate image quality is
not being achieved. The specific purpose of the reference level is to provide a
benchmark for comparison, not to define a maximum or minimum exposure limit. 19
For CT, the diagnostic reference levels are based on the volume CT dose index
(CTDI )19
vol
Measure Importance
Relationship
Clinical registries have become an important tool in efforts to improve quality of
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
18
to desired
outcome
care. Registries provide a structured mechanism to monitor clinical practice
patterns, evaluate healthcare effectiveness and safety, and evaluate patient
outcomes. 20,21,22 Clinical registries like the ADHERE, Get with the Guidelines and
the Advanced Cardiovascular Imaging Consortium registries, have been
associated with performance improvement by registry participants.21,23,24,25
Establishing diagnostic reference levels is vital to helping clinicians determine
optimal radiation dosage to produce acceptable image quality. A data registry
such as the ACR Dose Index Registry (DIR) allows facilities to compare their CT
dose indices to regional and national values enabling imaging providers and the
imaging community to measure the effectiveness of dose lowering efforts over
time.
Reference levels are based on actual patient doses for specific procedures
measured at a number of representative clinical facilities. The levels are set at
approximately the 75th percentile of these measured data, meaning that the
procedures are performed at most institutions with doses at or below the
reference level. Consequently, reference levels are suggested action levels at
which a facility should review its methods and determine if acceptable image
quality can be achieved at lower doses.19
A prospective, controlled, nonrandomized study using a cardiac computed
tomography angiography registry found that consistent application of dosereduction techniques was associated with a reduction in estimated radiation
doses without impairment of image quality.25
During the follow-up period, patients' estimated median radiation dose was
reduced by 53% and effective dose from 21 mSv to 10 mSv as compared with
the control period.25
Opportunity
for
Improvement
A central database established for collecting dose indices as a function of patient
qualities (ie, gender, age, size, etc.) and exam type (ie, lateral lumbar spine,
pelvis CT, etc.), would allow the relative range of radiation dose indices to be
analyzed and compared against established benchmarks.
One retrospective cross-sectional study describing radiation dose associated with
some of the most common types of diagnostic CT found variable radiation doses,
highlighting the need for greater standardization.16
The study suggests variability in the following exams:
Routine chest exam without contrast
CT Effective Doses ranging from 2mSv to 24mSv
Routine abdomen-pelvis, no contrast
CT Effective Dose ranging from 3mSv to 43mSv
Routine head exam
CT Effective Dose ranging from 0.3mSv to 6mSv
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
•
•
Safe
Patient-centered
•
Efficient
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
19
Harmonization
with Existing
Measures
NQF measure #0739: Radiation Dose of Computed Tomography (CT) is intended
for the quantification and reporting of radiation dose associated with CT
examinations of the head, neck, chest, abdomen/pelvis and lumbar spine,
obtained in children and adults.
NQF measure #0740: Participation in a Systematic National Dose Index Registry,
is an attestation measure specifically requiring the use of a national, registry with
systematic and automated data collection.
NQF measure #510: Exposure time reported for procedures using fluoroscopy,
focuses on radiation exposure related to fluoroscopic and not CT imaging.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Public reporting
Structure
Physician
Physicist
Provider Group*
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Documentation of original self-assessment
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry data
Practice Quality Improvement Module
*The American Board of Radiology’s Practice Quality Improvement Definition of "Group":
Two or more physicians/physicists of the same or different specialties/subspecialties, sharing a
common central organizational structure, who work together to provide patient care, regardless of
individual contractual affiliations or relationships. These physicians/physicists may provide services at
single or multiple facilities or locations in a variety of clinical settings, including hospitals, offices or
patient imaging centers.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
20
Measure #2: Utilization of a Standardized Nomenclature for Computed
Tomography (CT) Imaging Description
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the
imaging study named according to a standardized nomenclature* and the standardized nomenclature
is used in institution’s computer systems
M e a s u r e C om p o n e n t s
Numerator
Statement
CT imaging reports with the imaging study named according to a standardized
nomenclature* and the standardized nomenclature is used in institution’s computer
systems, including but not limited to:
•
•
•
•
computerized physician ordering system
charge master
radiology information system
electronic health record
*Use of a standardized nomenclature is meant to enable reporting to a Dose
Index Registry. There is no standard lexicon implemented across the board
for naming CT exam procedures. To make like comparisons of sites
reporting dose index data to a registry, it is necessary to use a specific CT
exam name and standardize that across registry participants.
Denominator
Statement
All CT imaging reports for all patients, regardless of age
Denominator
Exceptions
None.
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines and/or other references:
The Lexicon-Enabled Radiology Practice 26
As images, imaging reports and medical records move online, radiologists need a
unified language to organize and retrieve them. Radiologists currently use a variety
of terminologies and standards, but no single lexicon serves all of their needs.
The existence of a standardized lexicon for radiology enables numerous
improvements in the clinical practice of radiology, starting with the ordering of
imaging exams, through the use of information in the resulting radiology report. It
also makes possible more effective reuse of information for research and educational
purposes. Some specific uses of RadLex® terminology include:
•
Automatic order entry decision support. Because the names of imaging
exams are described in consistent language, the applicability of appropriateness
criteria developed by the ACR and others can be determined automatically.
•
Vendor independent "protocoling" of complex imaging exams.
Imaging exam protocols for CT and MR exams can be specified using vendor
independent language. Consistent names for imaging exams and procedure steps
(eg, radiographic view, CT sequence, MR series) are used throughout the radiology
practice.
•
Improved speech recognition accuracy. Because the exam descriptions
are explicitly linked to the body site imaged and the modality used, speech
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
21
recognition systems use this linkage information to improve recognition accuracy.
•
Real-time decision support for the radiologist. Because standardized
terms are associated with radiology reports, these terms can trigger decision
support tools for the radiologist. Decision support systems automatically retrieve
case-relevant information in real time, such as checklists for image features to
seek, additional differential diagnoses, or information from PubMed, the Internet,
and proprietary decision support databases.
Measure Importance
Relationship to
desired
outcome
Promoting Effective Communication and Coordination of Care is one of the
priorities in the National Strategy for Quality Improvement in Health care, with
great potential for rapidly improving health outcomes and increasing the
effectiveness of care for all populations. 27
A uniform structure for capturing, indexing, and retrieving a variety of radiology
information may facilitate the structured reporting of radiology reports. This will
also permit mining of data for participation in research projects, registries, and
quality improvement efforts. 28
Standardized nomenclature may include RadLex®. Other standardized
nomenclature may be available and would be acceptable for this measure.
RadLex® is a controlled terminology for radiology—a single unified source of
radiology terms that is designed to fill this need. The purpose of RadLex® is to
provide a uniform structure for capturing, indexing, and retrieving a variety of
radiology information sources, such as teaching files and research data. This
may facilitate a first step toward structured reporting of radiology reports. This
will also permit mining of data for participation in research projects, registries,
patient outcomes and quality assurance. 29
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Radiologists currently use a variety of terminologies and standards, but no single
lexicon serves all of their needs.28 Terminology is increasingly vital to the
practice of medicine. Many of the benefits of clinical information technology
cannot be realized unless information is stored using standard terms in a
structured format.28,30
•
•
•
Safe
Effective
Efficient
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
•
•
•
•
Type of measure
Level of
Measurement
• Structure
• Physician
• Physicist
Accountability
Quality improvement
Maintenance of Certification® programs
Public reporting
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
22
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
Provider Group
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Documentation of original self-assessment
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
23
Measure #3: Appropriateness: Follow-up Computed Tomography (CT)
Imaging for Incidentally Detected Pulmonary Nodules According to
Recommended Guidelines
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients
aged 18 years and older with documented follow-up recommendations for incidentally detected
pulmonary nodules (eg, follow-up CT imaging studies needed or that no follow-up is needed) based at
a minimum on nodule size AND patient risk factors
M e a s u r e C om p o n e n t s
Numerator
Statement
Final reports with documented follow-up recommendations* for incidentally detected
pulmonary nodules (eg, follow-up CT imaging studies needed or that no follow-up is
needed) based at a minimum on nodule size AND patient risk factors
*Definition
Follow-up Recommendations: No follow-up recommended in the final CT report
OR follow-up is recommended within a designated time frame in the final CT report.
Recommendations noted in the final CT report should be in accordance with
recommended guidelines.
Denominator
Statement
All final reports for CT imaging studies of the thorax for patients aged 18 years and
older with documented follow-up recommendations for incidentally detected
pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up
is needed) based at a minimum on nodule size AND patient risk factors
Denominator
Exceptions
None.
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines and/or other references:
Fleischner Society Recommendations for Follow-up and Management of
Nodules Smaller than 8mm Detected Incidentally at Nonscreening CT 31
Since the decision to perform follow-up studies relies on size, lesion characteristics
(eg, morphology), and growth rates (typically described as doubling time), an
understanding of these features and their relationship to malignancy should dictate
further evaluation. In addition, the patient's risk profile, including age and smoking
history, needs to be integrated into the diagnostic algorithm.
Nodule size* ≤ 4 mm
Low-Risk Patient: no follow-up needed†
High-Risk Patient: follow-up at 12 months; if unchanged, no further follow-up‡
Nodule size >4-6 mm
Low-Risk Patient: follow-up at CT at 12 months; if unchanged, no further followup‡
High-Risk Patient: initial follow-up CT at 6-12 months, then at 18-24 months if
no change‡
Nodule size >6-8 mm
Low-Risk Patient: initial follow-up CT at 6-12 months, then at 18-24 months if
no change
High risk Patient: initial follow-up CT at 3-6 months, then at 9-12 and 24
months if no change
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
24
Nodule size >8 mm
Same for Low- or High-Risk Patient: follow-up CT at around 3, 9, and 24
months, dynamic
contrast enhanced CT, PET, and/or biopsy
Note – Newly detected indeterminate nodule in persons 35 years of age or
older.
Low-Risk Patient - minimal or absent history of smoking and of other known
risk factors.
High-Risk Patient - history of smoking or of other known risk factors.
* Average of length and width.
† The risk of malignancy in this category (<1%) is substantially less than that in
a baseline CT scan of an asymptomatic smoker.
‡ Nonsolid (ground-glass) or partly solid nodules may require longer follow-up to
exclude indolent adenocarcinoma.
These recommendations apply only to adult patients with nodules that are
“incidental” in the sense that they are unrelated to known underlying disease. The
following examples describe patients for whom the above guidelines would not
apply:
•
•
•
Patients known to have or suspected of having malignant disease. Patients
with a cancer that may be a cause of lung metastases should be cared for
according to the relevant protocol or specific clinical situation.
Young patients. Primary lung cancer is rare in persons under 35 years of age
(<1% of all cases), and the risks from radiation exposure are greater than in
the older population. Therefore, unless there is a known primary cancer,
multiple follow-up CT studies for small incidentally detected nodules should
be avoided in young patients.
Patients with unexplained fever. In certain clinical settings, such a patient
presenting with neutropenic fever, the presence of a nodule may indicate
active infection, and short-term imaging follow-up or intervention may be
appropriate.
Previous CT scans, chest radiographs, and other pertinent imaging studies should be
obtained for comparison whenever possible, as they may serve to demonstrate
either stability or interval growth of the nodule in question.
A low-dose, thin-section, unenhanced technique should be used, with limited
longitudinal coverage, when follow-up of a lung nodule is the only indication for the
CT examination.
SOURCE: MacMahon H, Austin JHM, Gamsu G, et al. Guidelines for management of
small pulmonary nodules detected on CT scans: a statement from the Fleischner
Society. Radiology 2005; 237: 395-400.
Measure Importance
Relationship to
desired
outcome
Pulmonary nodules are commonly encountered in both primary care and
specialty settings.31,33 Pulmonary nodules require appropriate management
to avoid missing early malignancies or conversely subjecting
patients to unnecessary follow-up scans.33
At least 99% of all nodules 4mm or smaller are benign and because such small
opacities are common on thin-section CT scans, follow-up CT is not
recommended. 32 Additionally, there is no conclusive evidence that serial CT
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
25
studies with early intervention for detected cancers can reduce disease-specific
mortality, even in high-risk patients. Therefore, follow-up CT for every small
indeterminate nodule is not recommended.31
Opportunity
for
Improvement
Pulmonary nodules have been identified in 8 up to 51% of individuals at the time
of baseline low-dose CT screening. 33,34 Compared with larger nodules, nodules
that measure < 8 to 10 mm in diameter are much less likely to be malignant and
typically defy accurate characterization by imaging tests.33
One study found no cancer in patients in whom the largest noncalcified
nodule detected at initial CT was less than 5.0 mm in diameter. Thus there was
no advantage in performing short-interval follow-up for nodules smaller than 5
mm in their study, even in high-risk patients. 35
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Because of the high frequency with which small pulmonary nodules are detected
by CT, the number of resultant follow-up scans is a substantial source of patient
anxiety, radiation exposure, and medical cost.34
•
•
Safe
Effective
•
Efficient
The Optimizing Patient Exposure to Ionizing Radiation Work Group opted to
include a medical reason exception so that clinicians can justifiably exclude the
documentation of follow-up recommendations for incidental pulmonary nodule(s)
(eg, patients with known malignant disease, patients with unexplained fever).
Additionally, the focus and intent of this measure set is to optimize patient
exposure to ionizing radiation used in diagnostic studies.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Process
•
•
•
•
•
•
•
•
•
•
•
•
Physician
Provider Group
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
26
Measures 4-6 deleted
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
27
Measure #7: Equipment Evaluation for Pediatric CT Imaging Protocols
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of pediatric CT imaging studies for patients aged 17 years and younger performed with
equipment that has complied with a CT equipment evaluation protocol at least once within the 12month period prior to the exam
M e a s u r e C om p o n e n t s
Numerator
Statement
Pediatric CT imaging studies performed with equipment that has complied with a CT
equipment evaluation protocol* at least once within a 12-month period prior to the
exam
*CT equipment evaluation protocol should include at a minimum all of the following
documented components:
•
Evaluation date of CT imaging equipment
•
Measurements of CT dose index values of commonly used imaging protocols
or of other dosimetric metrics performed and compared to the vendor
displays values
•
Prepared tables of patient radiation absorbed dose for representative
protocol exams (eg, head, thorax, abdomen and pelvis) supplied to facility
•
Established radiation doses for pediatric patients by “child-sizing” CT
scanning parameters
•
Dose recording and reduction technologies installed in equipment if available
Denominator All pediatric CT imaging studies for patients aged 17 years and younger
Statement
Denominator Documentation of medical reason(s) for not performing studies with equipment that
Exceptions
has complied with a CT equipment evaluation protocol (eg, CT studies performed for
radiation treatment planning or image-guided radiation treatment delivery)
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines and/or other references:
Advances in technology continually change the design and capabilities of CT
scanners, even from the same manufacturer and certainly from different
manufacturers. Each CT scanner requires a unique protocol development to optimize
dose savings.
Image GentlySM Ten Steps to Lower CT Radiation Dose for Patients While
Maintaining Image Quality 36
1. Increase awareness and understanding of CT radiation dose issues among
radiologic technologists.
2. Enlist the services of a qualified medical physicist.
3. Obtain accreditation from the American College of Radiology for your CT program.
4. When appropriate, use an alternative imaging strategy that does not use ionizing
radiation.
5. Determine if the ordered CT is justified by the clinical indication.
6. Establish baseline radiation dose for adult-sized patients.
7. Establish radiation doses for pediatric patients by “child-sizing” CT scanning
parameters.
8. Optimize pediatric examination parameters:
a. Center the patient in the gantry,
b. Reduce doses during projection scout (topogram) views,
c. Axial versus helical mode,
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
28
d. Reduce detector size in z direction during acquisition,
e. Adjust the product of tube current and exposure time,
f. When to adjust the kilovoltage,
g. Increase pitch, and
h. Manual or automatic exposure control.
9. Scan only the indicated area: scan once.
10. Prepare a child-friendly and expeditious CT environment.
The Image GentlySM guidelines are available at:
http://www.pedrad.org/associations/5364/ig/index.cfm?page=614.
Performance Monitoring of CT Equipment - Patient Radiation Dose 37
1. Evaluate at least yearly.
2. Measurements of CT dose index values of commonly used imaging protocols or of
other dosimetric metrics should be performed and compared to the vendor displays
values.
3. Prepare tables of patient radiation absorbed dose for representative protocol
exams (eg, head, thorax, abdomen and pelvis) and supplied to facility.
4. Compare results with appropriate guidelines or recommendations when available.
Measure Importance
Relationship to
desired
outcome
Radiation exposure is a concern in both adults and children. However, there are
three unique considerations in children.
1. Children are considerably more sensitive to radiation than adults, as
demonstrated in epidemiologic studies of exposed populations.
2. Children have a longer life expectancy than adults, resulting in a larger
window of opportunity for expressing radiation damage.
3. Children may receive a higher radiation dose than necessary if CT
settings are not adjusted for their smaller body size. 38
Advances in technology continually change the design and capabilities of CT
scanners, even from the same manufacturer and certainly from different
manufacturers. Each CT scanner requires a unique protocol development to
optimize dose savings.36
Substantial dose reduction and high compliance can be obtained with pediatric
CT protocols tailored to clinical indications, patient weight, and number of prior
studies. 39
Opportunity
for
Improvement
Currently, approximately 11% of CT examinations are performed on children,
which could account for more than 7 million pediatric CT examinations per year
in the United States.10,11,12
While CT utilization has decreased steadily since 2003 in pediatric facilities
across North America,14 the use of CT in children who visit the ED increased from
0.33 to 1.65 from 1995 to 2008 and occurred primarily at non-pediatric focused
facilities.15
IOM Domains
of Health Care
Quality
Addressed
•
•
Safe
Effective
•
•
Patient-centered
Efficient
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
29
Exception
Justification
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
Harmonization
with Existing
Measures
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Structure
Physician
Provider Group
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
30
Measure #8: Utilization of Pediatric CT Imaging Protocols
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of pediatric CT imaging studies for patients aged 17 years and younger performed with
individualized equipment evaluation protocols that comply with a widely used guideline
M e a s u r e C om p o n e n t s
Numerator
Statement
Pediatric CT imaging studies performed with individualized equipment evaluation
protocols* that comply with a widely used guideline
*Equipment evaluation protocols should include at a minimum the following two
documented components:
•
Baseline techniques for an adult head and abdomen CT
•
Determine the appropriate mAs for a pediatric thorax, abdomen and
head CT
Denominator
Statement
All pediatric CT imaging studies for patients aged 17 years and younger
Denominator
Exceptions
Documentation of medical reason(s) for not performing CT studies with
individualized equipment evaluation protocols (eg, CT studies performed for
radiation treatment planning or image-guided radiation treatment delivery)
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced
clinical guidelines and/or other references:
Because children are more sensitive than adults to the effects of ionizing
radiation, it is particularly important to tailor CT examinations to minimize
exposure while providing diagnostic quality examinations. 40
Image Gently SM – How to Develop CT Protocols for Children40
The Image Gently instructions to develop pediatric CT protocols are available at
http://www.pedrad.org/associations/5364/ig/?page=598.
These instructions provide guidance in either developing CT protocols for children
or verifying that your current protocols are appropriate. You may be able to
reduce doses to a greater degree for high contrast studies.
Calculation of the effective dose – Pediatrics (newborn to age 15) 41
• The effective dose in CT is derived from the dose-length product
Effective dose calculation: E = k DLP
k = age and body region-specific conversion coefficient (mSv mGy-1 cm-1)
Pediatric Abdominal CT 42
• Scanning parameters should be optimized to obtain diagnostic image quality
while adhering to the ALARA principle.
• Scan area should be minimized according to the clinical indication.
• Scanning parameters, including kVp, tube current, and exposure time (mAs),
should be changed according to body size, area of interest, and clinical
indication. May be achieved by using weight based tables or by using automatic
exposure control (see Image Gently™ protocols.
• Testicles should not be included the scanned area unless absolutely necessary
for the clinical indication. Consideration should be given to shielding superficial
structures in the scan region such as the testes.
• If precontrast images are needed solely to determine whether calcification is
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
31
present, these can be done with additional decrease in mAs.
• Intravenous (IV) contrast is usually used in the CT evaluation of the pediatric
abdomen, since vascular structures and internal organs are better visualized
due to the paucity of body fat in many pediatric patients. Renal stone
evaluation is an exception. A routine dose of 2mL/kg is generally used. Volume
of contrast, rate of injection, scan delayed time, and hand/power injection
should be determined according to the location, size, and type of IV access, the
child’s body size, the underlying disease (eg, congestive heart failure), and the
clinical indication. .
• Enteric contrast may be sued in the CT evaluation of the pediatric abdomen.
Exceptions would include renal stone protocol, CT angiography and acute
trauma.
• In evaluating suspected appendicitis, IV contrast is typically used, generally to
avoid repeat examinations. Precontrast and delayed scans are not necessary,
unless a renal anomaly requiring evaluation of the collecting system is
identified. Some centers use oral or rectal contrast. If oral contrast is given,
sufficient time should be allowed to elapse for the contrast to reach the right
lower quadrant prior to scanning.
• Postprocessing 2D reformations and 3D reconstructions or 3D volume
rendering may be useful adjuncts in displaying the anatomy.
To achieve acceptable clinical CT scans of body, the CT scanner should meet or
exceed the following specifications:
1. Gantry rotation times: ≤ 2 seconds.
2. Slice thickness: ≤ 5 mm (≤ 2 mm is preferred).
3. Limiting spatial resolution: 8 lp/cm for ≥ 32 cm DFOV and ≥ 10 lp/cm for
< 24 cm DFOV. 4. Table pitch: no greater than 2:1 for single-rowdetector helical scanners.
Measure Importance
Relationship to
desired
outcome
Radiation exposure is a concern in both adults and children. However, there are
three unique considerations in children.
1. Children are considerably more sensitive to radiation than adults, as
demonstrated in epidemiologic studies of exposed populations.
2. Children have a longer life expectancy than adults, resulting in a larger
window of opportunity for expressing radiation damage.
3. Children may receive a higher radiation dose than necessary if CT
settings are not adjusted for their smaller body size. 43
Advances in technology continually change the design and capabilities of CT
scanners, even from the same manufacturer and certainly from different
manufacturers. Each CT scanner requires a unique protocol development to
optimize dose savings.36
Substantial dose reduction and high compliance can be obtained with pediatric
CT protocols tailored to clinical indications, patient weight, and number of prior
studies.39
Opportunity
for
Improvement
Currently, approximately 11% of CT examinations are performed on children,
which could account for more than 7 million pediatric CT examinations per year
in the United States.10,11,12
While CT utilization has decreased steadily since 2003 in pediatric facilities
across North America,14 the use of CT in children who visit the ED increased from
0.33 to 1.65 from 1995 to 2008 and occurred primarily at non-pediatric focused
facilities.15
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
32
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
•
•
Safe
Effective
•
•
Patient-centered
Efficient
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Structure
Physician
Provider Group
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
33
Measure #9: Count of Potential High Dose Radiation Imaging Studies:
Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies)
imaging reports for all patients, regardless of age, that document a count of known previous CT (any
type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received
in the 12-month period prior to the current study
M e a s u r e C om p o n e n t s
Numerator
Statement
CT and cardiac nuclear medicine (myocardial perfusion studies) imaging reports
that document a count of known previous CT (any type of CT) and cardiac
nuclear medicine (myocardial perfusion) studies that the patient has received in
the 12-month period prior to the current study
Instructions: Physicians will need to document in the final report all known
previous CT and cardiac nuclear medicine (myocardial perfusion) studies the
patient has received in the 12-month period prior to the current study as a count
that includes studies from the Radiology Information System, patient-provided
radiological history or other source.
Denominator
Statement
All CT and cardiac nuclear medicine (myocardial perfusion studies) imaging
reports for all patients, regardless of age
Denominator
Exceptions
None.
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced
clinical guidelines:
Radiologists, medical physicists, radiologic technologists, and all supervising
physicians have a responsibility to minimize radiation dose to individual patients,
to staff, and to society as a whole, while maintaining the necessary diagnostic
image quality.42,44,45
Importance
Relationship to
desired
outcome
Increased CT use has resulted in growing rates of repeat or multiple imaging. 46
Opportunity
for
Improvement
According to the National Council on Radiation Protection (NCRP), the average
per capita exposure to ionizing radiation from imaging exams increased by
nearly 600% from 1980 to 2006 in the United States.1,2
Physicians may lack important information that could inform their decisions in
ordering imaging exams that use ionizing radiation. Ordering physicians may not
have access to patients’ medical imaging or radiation dose history. Due to
insufficient information, physicians may unnecessarily order imaging procedures
that have already been conducted.9
One retrospective cohort study reported median, mean, and maximum values for
the study count were 10, 13, and 70 with cumulative CT doses of 91, 122, and
579 mSv within the 7.7 year study period.46
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
34
Another study of patients with at least 3 visits to a tertiary care center within
one year, determined a median of 15 procedures involving radiation exposure; of
which 4 were high-dose procedures. 47
The imaging study with the single highest radiation burden, accounting for 22%
of cumulative effective dose is myocardial perfusion imaging.3
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
•
•
Safe
Patient-centered
•
Efficient
The Optimizing Patient Exposure to Ionizing Radiation Work Group opted to
include a medical reason exception so that clinicians can exclude patients for
whom a count of previous CT and cardiac nuclear medicine (myocardial perfusion
studies) studies may not be indicated or applicable for this measure. The focus
and intent of this measure set is to optimize patient exposure to ionizing
radiation used in diagnostic studies.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Process
Physician
Provider Group
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
35
Measure #10: Search for Prior Computed Tomography (CT) Studies
through a Secure, Authorized, Media-free, Shared Archive
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of final reports of computed tomography (CT) studies performed for all patients,
regardless of age, which document that a search for Digital Imaging and Communications in Medicine
(DICOM) format images was conducted for prior patient CT imaging studies completed at nonaffiliated external entities within the past 12-months and are available through a secure, authorized,
media-free, shared archive prior to an imaging study being performed
M e a s u r e C om p o n e n t s
Numerator
Statement
Final reports of CT studies, which document that a search for DICOM format
images was conducted for prior patient CT imaging studies completed at nonaffiliated external entities within the past 12-months and are available through a
secure, authorized, media-free*, shared archive prior to an imaging study being
performed
*Definition
Media-free: Radiology images that are transmitted electronically ONLY, not
images recorded on film, CD, or other imaging transmittal form.
Instructions: This measure is intended for reporting by facilities that have
archival abilities through a shared archival system.
Denominator
Statement
All final reports for CT studies performed for all patients, regardless of age
Denominator
Exceptions
Due to system reasons search not conducted for DICOM format images for prior
patient CT imaging studies completed at non-affiliated external healthcare
facilities or entities within the past 12 months that are available through a
secure, authorized, media-free, shared archive (e.g., non-affiliated external
healthcare facilities or entities does not have archival abilities through a shared
archival system)
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced
clinical guidelines and/or other references:
Core functional requirements for an Internet-based system for sharing
medical records 48
(a) methods to ensure privacy and confidentiality of data;
(b) capability to move and store large data files (eg, images) with the same
efficiency and reliability as possible with small data files (eg, text);
(c) construction of registries, which contain “knowledge” of all fragments of
medical information (and their physical location) from all sources for a given
patient;
(d) an ability to match records and accurately reconcile patient identities without
a common patient identifier;
(e) a means to regulate access to data and audit the access;
(f) a method for moving blocks of data from one location to another; and
(g) a method to aggregate and consume the data at the point of care.
Optimal patient care requires that care providers and patients be able to create,
manage and access comprehensive electronic health records (EHRs) efficiently
and securely The sharing of radiologic images has become a fundamental part of
radiology services and is essential for delivering high-quality care.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
36
Integrating the Healthcare Enterprise (IHE)
IHE is an initiative by healthcare professionals and industry to improve the way
computer systems in healthcare share information The IHE Radiology Technical
Framework, defines specific implementations of established standards to achieve
integration goals that promote appropriate sharing of medical information to
support optimal patient care. The IHE Radiology Technical Framework includes
various Integration Profiles that provide a convenient way for both users and
vendors to reference a subset of the functionality detailed in the IHE Technical
Framework.
The Cross-enterprise Document Sharing for Imaging (XDS-I) Integration Profile
specifies actors and transactions that allow users to share imaging information
across enterprises. This profile depends on the IHE IT Infrastructure CrossEnterprise Document Sharing (XDS) profile. XDS for Imaging (XDS-I) defines the
information to be shared such as sets of DICOM instances (including images,
evidence documents, and presentation states), diagnostic imaging reports
provided in a ready-for-display.
Cross-Document Sharing Work Flow 49
The basic workflow is as follows: A document such as an x-ray report is created
and stored at the document source, perhaps an imaging center. In addition, a
(redundant) copy is sent into the document repository for the affinity domain in
which this imaging center is participating.
Upon receiving the x-ray report, the document repository registers it with the
document registry for that affinity domain. The document registry ensures that
the document is assigned to the correct patient by transacting with the patient
identity source, which may be using the PIX-PDQ profiles to reconcile the varying
demographic data and medical record numbers that different systems assign to
the same patient. Sometime (perhaps even years) later, the patient is seen by
another healthcare provider at a remote site. The healthcare provider wishes to
read the prior x-ray reports. This remote site participates in the same affinity
domain and is now regarded as a document consumer. As such, it may query the
document registry as to the existence of the prior reports and query the
document repository to obtain the reports. Again, patient identity is reconciled
and confirmed using the patient identity source and the relevant IHE actors and
profiles. This scenario can be expanded to describe the sharing of many kinds of
healthcare documents. There are also slight variations permitted in which some
of the actors can be placed either within the affinity domain centrally or at one of
the sites at which documents arise.
Federal Register, Electronic Health Record Incentive Program 50
While the Federal Register, Electronic Health Record Incentive Program is not an
evidence-based clinical guideline, the HITECH Act requires the use of health
information technology in improving the quality of health care, reducing medical
errors, reducing health disparities, increasing prevention and improving the
continuity of care among health care settings. The Incentive program includes
meaningful use objectives and associated measures that pertain to the use of
EHRs to facilitate the availability and use of health information.
Measure Importance
Relationship to
desired
outcome
The current radiology information systems in hospitals generally do not collect or
report radiation exposures and the medical imaging devices that communicate
with radiology information systems do not currently forward data on the
radiation dose received by a patient from each such test. As a result, physicians
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
37
are uncertain of their patients’ cumulative exposure and lifetime attributable risk
(LAR), which is problematic when assessing, prioritizing and discussing the risks
and benefits associated with their patients’ clinical needs. 51
NQF’s Safe Practices for Better Healthcare-2009 Update: A Consensus Report
was prepared incorporating the National Priorities Partnership six crosscutting
priorities. Safe Practice 12: Patient Care Information addresses the lack of care
continuum by not communicating critical patient information such as medical
history, diagnostic test results, medications, treatments, and procedures. The
Safe Practice Statement addressing this topic reads as follows, “Ensure that care
information is transmitted and appropriately documented in a timely manner and
in a clearly understandable form to patients and to all of the patient’s providers /
professionals, within and between care settings, who need that information to
provide continued care.” 52
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
It has been estimated that between $3 and $10 billion are wasted in the United
States annually on unnecessary or duplicative imaging studies. Duplicative
imaging procedures could be substantially reduced with improved access to
existing imaging data. Additionally, universal access to existing imaging studies
to retrieve relevant prior images could improve diagnostic specificity for
radiologists and potentially further minimize recommendations for follow-up
studies. 53
•
•
•
Safe
Effective
Patient-centered
•
•
•
Timely
Efficient
Equitable
Exception
Justification
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
Harmonization
with Existing
Measures
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Structure
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
38
Measure #11: Computed Tomography (CT) Images Available for Patient
Follow-Up and Comparison Purposes
Optimizing Patient Exposure to Ionizing Radiation
Measure Description
Percentage of final reports for computed tomography (CT) studies performed for all patients,
regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM)
format image data are available to non-affiliated external healthcare facilities or entities on a secure,
media free, reciprocally searchable basis with patient authorization for at least a 12-month period
after the study
M e a s u r e C om p o n e n t s
Numerator
Statement
Final reports for CT studies, which document that DICOM format image data are
available to non-affiliated external healthcare facilities or entities on a secure,
media free*, reciprocally searchable basis with patient authorization for at least a
12-month period after the study
*Definition
Media-free: Radiology images that are transmitted electronically ONLY, not
images recorded on film, CD, or other imaging transmittal form.
Denominator
Statement
All final reports for CT studies performed for all patients, regardless of age
Denominator
Exceptions
None.
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced
clinical guidelines and or other references.:
Core functional requirements for an Internet-based system for sharing
medical records48
(a) methods to ensure privacy and confidentiality of data;
(b) capability to move and store large data files (eg, images) with the same
efficiency and reliability as possible with small data files (eg, text);
(c) construction of registries, which contain “knowledge” of all fragments of
medical information (and their physical location) from all sources for a given
patient;
(d) an ability to match records and accurately reconcile patient identities without
a common patient identifier;
(e) a means to regulate access to data and audit the access;
(f) a method for moving blocks of data from one location to another; and
(g) a method to aggregate and consume the data at the point of care.
Optimal patient care requires that care providers and patients be able to create,
manage and access comprehensive electronic health records (EHRs) efficiently
and securely The sharing of radiologic images has become a fundamental part of
radiology services and is essential for delivering high-quality care.
Integrating the Healthcare Enterprise (IHE)
IHE is an initiative by healthcare professionals and industry to improve the way
computer systems in healthcare share information The IHE Radiology Technical
Framework, defines specific implementations of established standards to achieve
integration goals that promote appropriate sharing of medical information to
support optimal patient care. The IHE Radiology Technical Framework includes
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
39
various Integration Profiles that provide a convenient way for both users and
vendors to reference a subset of the functionality detailed in the IHE Technical
Framework.
The Cross-enterprise Document Sharing for Imaging (XDS-I) Integration Profile
specifies actors and transactions that allow users to share imaging information
across enterprises. This profile depends on the IHE IT Infrastructure CrossEnterprise Document Sharing (XDS) profile. XDS for Imaging (XDS-I) defines the
information to be shared such as sets of DICOM instances (including images,
evidence documents, and presentation states), diagnostic imaging reports
provided in a ready-for-display.
Cross-Document Sharing Work Flow49
The basic workflow is as follows: A document such as an x-ray report is created
and stored at the document source, perhaps an imaging center. In addition, a
(redundant) copy is sent into the document repository for the affinity domain in
which this imaging center is participating.
Upon receiving the x-ray report, the document repository registers it with the
document registry for that affinity domain. The document registry ensures that
the document is assigned to the correct patient by transacting with the patient
identity source, which may be using the PIX-PDQ profiles to reconcile the varying
demographic data and medical record numbers that different systems assign to
the same patient. Sometime (perhaps even years) later, the patient is seen by
another healthcare provider at a remote site. The healthcare provider wishes to
read the prior x-ray reports. This remote site participates in the same affinity
domain and is now regarded as a document consumer. As such, it may query the
document registry as to the existence of the prior reports and query the
document repository to obtain the reports. Again, patient identity is reconciled
and confirmed using the patient identity source and the relevant IHE actors and
profiles. This scenario can be expanded to describe the sharing of many kinds of
healthcare documents. There are also slight variations permitted in which some
of the actors can be placed either within the affinity domain centrally or at one of
the sites at which documents arise.
Federal Register, Electronic Health Record Incentive Program50
While the Federal Register, Electronic Health Record Incentive Program is not an
evidence-based clinical guideline, the HITECH Act requires the use of health
information technology in improving the quality of health care, reducing medical
errors, reducing health disparities, increasing prevention and improving the
continuity of care among health care settings. The Incentive program includes
meaningful use objectives and associated measures that pertain to the use of
EHRs to facilitate the availability and use of health information.
Measure Importance
Relationship to
desired
outcome
The current radiology information systems in hospitals generally do not collect or
report radiation exposures and the medical imaging devices that communicate
with radiology information systems do not currently forward data on the
radiation dose received by a patient from each such test. As a result, physicians
are uncertain of their patients’ cumulative exposure and lifetime attributable risk
(LAR), which is problematic when assessing, prioritizing and discussing the risks
and benefits associated with their patients’ clinical needs.51
NQF’s Safe Practices for Better Healthcare-2009 Update: A Consensus Report
was prepared incorporating the National Priorities Partnership six crosscutting
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
40
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
priorities. Safe Practice 12: Patient Care Information addresses the lack of care
continuum by not communicating critical patient information such as medical
history, diagnostic test results, medications, treatments, and procedures. The
Safe Practice Statement addressing this topic reads as follows, “Ensure that care
information is transmitted and appropriately documented in a timely manner and
in a clearly understandable form to patients and to all of the patient’s providers /
professionals, within and between care settings, who need that information to
provide continued care.”52
It has been estimated that between $3 and $10 billion are wasted in the United
States annually on unnecessary or duplicative imaging studies. Duplicative
imaging procedures could be substantially reduced with improved access to
existing imaging data. Additionally, universal access to existing imaging studies
to retrieve relevant prior images could improve diagnostic specificity for
radiologists and potentially further minimize recommendations for follow-up
studies.53
•
•
•
Safe
Effective
Patient-centered
•
•
•
Timely
Efficient
Equitable
Exception
Justification
The focus and intent of this measure set is to optimize patient exposure to
ionizing radiation used in diagnostic studies.
Harmonization
with Existing
Measures
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Accountability
Quality improvement
Maintenance of Certification® programs
Structure
Facility
Integrated delivery system
Multi-site/corporate chain
Inpatient care
Emergency department
Ambulatory care
Electronic Administrative Data/Claims
Electronic Clinical Data (eg, RIS) (Feasibility of data source TBD)
Electronic Health/Medical Record (Feasibility of data source TBD)
Registry Data
Practice Quality Improvement Module
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
41
Quality Improvement Measures/Additional Measures
Included (Measures Not Developed by
ABMS/ABR/ACR/PCPI Under This Project)
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
42
Measure #12
Exposure Time Reported for Procedures Using Fluoroscopy
(PCPI/ACR/NCQA)
Radiology
NQF-endorsed®
The Patient Radiation Dose Optimization Work Group recommended that this measure, developed by
the PCPI, the ACR, and the National Committee for Quality Assurance (NCQA), be referenced in this
document as a quality improvement measure that addresses an additional opportunity to optimize
patient radiation dosing through appropriate imaging and that may potentially be implemented by
radiologists in a Maintenance of Certification (MOC) Part IV project.
A full description and technical specifications for this measure can be found within the PCPI/ACR/NCQA
Radiology measure set available at:
http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
43
Measure #13
Pulmonary CT Imaging for Patients at Low Risk for Pulmonary Embolism
(Partners HealthCare/Brigham & Women’s Hospital)
NQF-endorsed®
Measure #14
Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury
(Partners HealthCare/Brigham & Women’s Hospital)
NQF-endorsed®
The Patient Radiation Dose Optimization Work Group recommended that these two measures,
developed by Partners HealthCare/Brigham & Women’s Hospital, be referenced in this document as
quality improvement measures that address additional opportunities to optimize patient radiation
dosing through appropriate imaging and that may potentially be implemented by radiologists in a
Maintenance of Certification (MOC) Part IV project.
The National Quality Forum (NQF) Board of Directors announced the endorsement of these two
measures in April 2011.
Full descriptions and specifications for these Partners HealthCare/Brigham & Women’s Hospital
measures are available at:
http://www.brighamandwomens.org/Research/labs/cebi/bestcare/HowDoWeAvoid.aspx#
quality
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
44
Guideline Evidence Classification and Rating Schemes
Optimizing Patient Exposure to Ionizing Radiation
American College of Radiology (ACR) APPROPRIATENESS CRITERIA®
Evidence Table Development
Evidence Table Development
A. Purpose: To determine the quality of each reference and present the evidence in a succinct
format. Typically, the quality is referred to as the strength of evidence (SOE) rating for the study. The
SOE rating is called Study Quality in the evidence tables (ET) of the more recent AC.
B. General Information: The research associate (RA) develops an ET for each AC topic. The ET
consists of the citation, study type, number of patients, study objective, study results and SOE (or
study quality) for all articles included in the narrative reference list.
C. Defining the Elements of the Evidence Table
1. Citation – Author(s), title, journal, volume and date should be included.
2. Study Type –Studies are classified based on the study types as shown in appendix A. The
first nine study types are used for studies on treatments while the remaining eight are used
for studies on diagnostic interventions.
3. Patients/Events – The number of patients included in the study and/or the number of
images evaluated is listed in this column. The number of observers or interpreters of images,
if mentioned in abstract, should also be included. If patients in the study are placed in
different groups, the number within each group should be listed separately. If the study is a
quantitative review, the number of studies included in that review should be listed. The
column should be filled with N/A to indicate “not available” if the number of patients is
unavailable or if the document is not concerned with individual patients (as in the case of
guidelines).
4. Study Objective – The central question(s) addressed by the study is listed in this column.
Some indication of how the study was structured may be included. For example, “A
retrospective review of patient records was undertaken to determine whether those who had
an MRI had a lower rate of surgery than patients who had ultrasound”.
5. Study Results – The principal findings of the research should document the overall
conclusions of the study authors (e.g., CT should not be performed for this patient group).
Additionally, specific numerical results should be included when practical.
6. Strength of Evidence (SOE) or Study Quality – A four category rating scale is used to
describe the evidence. “Category 1” denotes the strongest level of evidence and “Category 4”
the weakest. For each study, a rating from the scale below is assigned, with the exception of
“book chapters” which are assigned N/A.
CODE
1
CATEGORY NAME
Category 1
2
Category 2
3
Category 3
4
Category 4
CATEGORY DEFINITION
The conclusions of the study are valid and strongly
supported by study design, analysis and results.
The conclusions of the study are likely valid, but study
design does not permit certainty.
The conclusions of the study may be valid but the evidence
supporting the conclusions is inconclusive or equivocal.
The conclusions of the study may not be valid because the
evidence may not be reliable given the study design or
analysis.
ACR Appropriateness Criteria® - Procedure Contrast Information
Contrast agents are widely referred to in the ACR Appropriateness Criteria®. References to them
follow sound general principles. Currently, all MRI and MRA procedures that refer to contrast
specifically mean gadolinium-based compounds. Other agents are now available, but data on their
comparative effectiveness are still relatively sparse. Oral or rectal contrast is a barium preparation
unless otherwise specified. Intravenous contrast for all imaging procedures involving ionizing radiation
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
45
is iodine-based. There are many different specific iodine–and gadolinium–based agents that are
currently available. At this time, however, despite extensive debates in the published literature and
some conflicting results, there are no situations in which studies are sufficiently definitive to mandate
the use of one specific agent as compared to others.
There are four basic terms used throughout the Appropriateness Criteria describing the use of
intravenous contrast for a specific procedure in a given clinical scenario:
1. “without contrast” (A contrast agent is not recommended.)
2. “with contrast” (A contrast agent is recommended.)
3. “without and with contrast” (It is recommended that the procedure first be performed without a
contrast agent followed by a procedure with a contrast agent.)
4. “with or without contrast” (Available studies suggest that the procedure is equally definitive with or
without the use of a contrast agent.)
The issue of nephrogenic systemic fibrosis (NSF) in relation to gadolinium-based contrast agents is
addressed in the Appropriateness Criteria topics in which it is relevant. There are clear concerns about
specific agents and specific settings in regard to NSF. Other issues concerning contrast agents,
including prevention, diagnosis and treatment of reactions, contrast-induced nephropathy (CIN), and
NSF are addressed in detail in the ACR Manual on Contrast Media.
ACR -- Process to Developing Practice Guidelines and Technical Standards
As part of the overall reorganization of the ACR Commission and Committee structure, the Standards
and Accreditation Commission (renamed the Quality and Safety Commission) was formed. It is one of
eight operational commissions. The members of this commission are, to a large extent, composed of
people who also serve on a specialty commission. There are eleven specialty commissions and each of
these commissions has a series of operational committees, one of which is a Guidelines and Standards
Committee. The chairpersons of these committees make up the membership of the Quality and Safety
Commission. This guarantees a broad spectrum of specialty representation on the Commission as well
as members from private practice settings and academic medical centers with a wide geographic
distribution.
The method for developing a practice guideline or technical standard starts with the specialty
commissions or committees receiving suggestions for guidelines or standards from organizations,
individual practicing radiologists, ACR State Chapters, or any other appropriate entity related to the
specialty of radiology. A proposal form is submitted to the chair and vice-chair of the commission for
approval.
Once approved, a draft is developed and then circulated throughout the guidelines committee for
review and comment until deemed ready to submit for full member comment. If done collaboratively,
a committee is formed with members of each collaborating society. The guideline is developed and
then sent to the collaborative societies for review and comment.
The draft guideline or standard is available on the ACR Web site for on-line commenting during a
three-week field review cycle. The ACR Web site provides access to the draft documents for all
members to submit their comments online.
After each field review cycle, a Chair is appointed by the Council Steering Committee (CSC) and a
subcommittee is formed. A conference call may be scheduled for a guideline/standard if comments
were received during the field review. The subcommittee members include the principal drafters
(drafting committee), Chairs of sponsoring Commission and Committee, Speaker, Vice-Speaker, 2-3
field review commenters, 2-3 guidelines committee members, collaborative committee members, ACR
staff and legal counsel.
The revised draft from this conference call is then placed on the ACR Web site for an additional 3-week
review period prior to the ACR Annual Meeting and Chapters Leadership Conference (AMCLC). If
collaborative, the revised draft is sent to the collaborative society for approval. Comments are collated
and provided to an assigned ACR Reference Committee to be considered as testimony at the AMCLC.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
46
The approval process for collaborative guidelines during the AMCLC was revised in 2008. All
guidelines, whether ACR only or collaborative, are treated in the same manner, allowing for testimony
from the floor to be considered and draft language to be amended by the Reference Committee. The
ACR also established a process to allow representatives at the AMCLC in order to provide input from
the collaborating societies’ on amendments to the collaborative guidelines proposed by ACR
councilors.
The guidelines or standards that are approved at the AMCLC are published in a CD format and mailed
to all College Members for implementation in their practices. The effective date for guidelines or
standards is October first of that year.
This process provides opportunity for input from all sectors of radiology. The chairperson of the
Quality and Safety Commission is most interested in this broad participation and invites comments as
well as proposals for new practice guidelines or technical standards from all members of the American
College of Radiology.
The National Council on Radiation Protection and Measurements (NCRP)
NCRP is a nonprofit corporation chartered by Congress in 1964 to:
1. Collect, analyze, develop and disseminate in the public interest information and recommendations
about (a) protection against radiation and (b) radiation measurements, quantities and units,
particularly those concerned with radiation protection.
2. Provide a means by which organizations concerned with the scientific and related aspects of
radiation protection and of radiation quantities, units and measurements may cooperate for effective
utilization of their combined resources, and to stimulate the work of such organizations.
3. Develop basic concepts about radiation quantities, units and measurements, about the application
of these concepts, and about radiation protection.
4. Cooperate with the International Commission on Radiological Protection, the International
Commission on Radiation Units and Measurements, and other national and international organizations,
governmental and private, concerned with radiation quantities, units and measurements and with
radiation protection.
The Council is the successor to the unincorporated association of scientists known as the National
Committee on Radiation Protection and Measurements and was formed to carry on the work begun by
the Committee in 1929. The participants in the Council’s work are the Council members and members
of scientific and administrative committees. Council members are selected solely on the basis of their
scientific expertise and serve as individuals, not as representatives of any particular organization. The
scientific committees, composed of experts having detailed knowledge and competence in the
particular area of the committee's interest, draft proposed recommendations. These are then
submitted to the full membership of the Council for careful review and approval before being
published.
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
47
Summary of Non-Material Interest Disclosures
None of the members of the Patient Optimizing Patient Exposure to Ionizing Radiation Work Group had
any disqualifying material interests under the PCPI Conflict of Interest Policy. The following is a
summary of non-disqualifying interests disclosed on Work Group members' Material Interest
Disclosure Statements (not including information concerning family member interests). Completed
Material Interest Disclosure Statements are available upon request.
Work Group Member
Disclosures
David Seidenwurm, MD
(Co-Chair)
Sole Ownership: Medical Legal Expert Witness
Salary Support: Radiological Associates of Sacramento Medical
Group (RASMG)
Royalties/IP Rights: Textbook Chapter; Meals: Occasional; Books:
Textbook Chapter; Consulting Services: Medical Legal Expert
Witness
Fiduciary Relationship: Director, RASMG Inc.; Co-Director,
California Management Imaging (CMI)
Consulting Services: OSI Pharmaceutical, Brain Tumor Research,
Income to Practice
Robert D. Rosenberg, MD
Financial Relationship: Salary Support: University of New Mexico,
FDA; Research or other Grant Support: American Cancer Society
Fiduciary Relationship: Officer, Treasurer of New Mexico Society
of Radiologists
Previous Service on Quality Committee: ACR
Howard Sandler, MD, MS
Stock Ownership: Biogen, Amgen, Tomotherapy (now sold)
Research or Grant Support: American College of
Radiology/Radiation Therapy Oncology Group (RTOG); Speaking
Appointments: Sanofi-Aventis; Consulting Services: Varian,
Calypso, Myriad, Genentech, Ortho, ITA Partners Medical Advisory
Board
Peer Reviewed Journals: Journal of Clinical Oncology (JCO)
© [2014] American Board of Medical Specialties, American College of Radiology and American Medical
Association. All Rights Reserved.
48
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51