Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. The higher the value the worse the performance. All diagnostic CT exams of specified anatomic sites performed in inpatient, outpatient and ambulatory care settings are eligible .

The level of aggregation for this eCQM is the clinician or clinician group. Parallel eCQMs report CT exams performed in inpatient and outpatient hospital settings and is aggregated on the facility level.  A single CT exam may be simultaneously measured in both the MIPS and one of the hospital reporting programs (inpatient or outpatient); however a single exam cannot be measured in both the inpatient and outpatient programs. 

As a radiology measure, the measure derives standardized data elements from structured fields within both the electronic health record (EHR) and the radiology electronic clinical data systems, including the Radiology Information System (RIS) and the Picture Archiving and Communication System (PACS). Primary imaging data required by the measure include the Radiation Dose Structured Reports and image pixel data, both stored in the PACS in Digital Imaging and Communications in Medicine (DICOM) format, a universally adopted standard for medical imaging information. 

Because of limitations in their specifications and format, eCQMs cannot currently access and consume these required data elements from these radiology sources in their original DICOM formats. Therefore this eCQM measure requires the use of additional software (translation software) to access the primary data elements that are required for measure computation and translate them into data elements that can be ingested by this eCQM. The purpose of this translation software is to access and link the primary data elements with minimal site burden, assess each CT exam for eligibility based on initial population criteria, and generate three data elements mapped to a clinical terminology for eCQM consumption. 

Please find more details on the translation software, LOINC codes, and measures calculation in the “Guidance” field below.

The translation software was written and will be updated and maintained by Alara Imaging and will be accessible by creating a secure account through Alara’s website.

Copyright (C) 2023 Alara Imaging Inc. All Rights Reserved. 

This Measure and related data specifications are owned by Alara Imaging Inc. Alara Imaging Inc. is not responsible for any use of the Measure. Alara Imaging Inc. makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and Alara Imaging Inc. has no liability to anyone who relies on such measures or specifications.

The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by Alara Imaging Inc. and are subject to a license at the discretion of Alara Imaging Inc.

The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

Alara Imaging Inc, the University of California San Francisco, and its members and users shall not be responsible for any use or accuracy of the Measure or any code contained within the Measure. THE MEASURE AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. 

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. Alara Imaging disclaims all liability for use or accuracy of any third-party code contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. SNOMED Clinical Terms(R) (SNOMED CT[R]) is copyright 2004-2022 International Health Terminology Standards Development Organization. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved. Due to technical limitations, registered trademarks are indicated by (R) or [R].

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Diagnostic imaging using CT occurs in more than a third of acute care hospitalizations in the U.S. (Vance, 2013) and greater than 90 million scans are performed annually in the U.S. (IMV, 2020). There is marked observed variation in the radiation doses used to perform these exams (Smith-Bindman, 2009, 2019). The inconsistency in how CT exams are performed represents a significant, unnecessary, and modifiable iatrogenic health risk, as there is extensive epidemiological and biological evidence that suggests exposure to radiation in the same range as that routinely delivered by CT increases a person's risk of developing cancer (Board of Radiation Effects, 2006; Pearce, 2012; Pierce, 2000; Preston, 2007; Brenner, 2003; Hong, 2019). It is estimated that 2% (37,000) of the 1.8 million cancers diagnosed annually in the U.S. are caused by CT exams (Berrington de Gonzalez, 2009; NCI Cancer Statistics, 2020). 

The measure focuses on reducing radiation dose in CT, an intermediate outcome directly and proportionally related to cancer prevention. As radiation dose is known to be directly related and proportional to future cancer risk (Board of Radiation Effects, 2006; Pearce, 2012; Pierce, 2000; Preston, 2007; Brenner, 2003; Hong, 2019; Berrington de Gonzalez, 2009), any reduction in radiation exposure would be expected to lead to a proportional reduction in cancers. Research suggests that when healthcare organizations and clinicians are provided with a summary of their CT radiation doses, their subsequent doses can be reduced without changing the usefulness of these tests (Smith-Bindman, 2020). 

On the basis of the current estimated number of CT scans performed annually in the U.S. (IMV, 2020), distribution in scan types and observed doses (Demb, 2017; Smith-Bindman 2019), modelling of the cancer risk associated with CT at different ages of exposure (Berrington de Gonzalez, 2009), and costs of cancer care (Dieguez, 2017; Mariotto, 2011), an estimated 13,982 cancers could be prevented among Medicare beneficiaries annually, resulting in $1.86 billion to $5.21 billion annual cost savings.

The measure aligns with numerous evidence- and consensus-based clinical guidelines asking radiologists to track, optimize, and lower CT radiation doses, guidelines that have been written by the American College of Radiology (American College of Radiology, 2015; Kanal, 2019), the Radiology Society of North America (Hricak, 2010), The Society of Interventional Radiology (Stecker, 2009), The Society of Cardiovascular CT (Halliburton, 2011), Cardiovascular imaging societies (Hirshfeld 2018), Image Wisely 2020 (a joint initiative of the American College of Radiology, Radiological Society of North America, American Society of Radiological Technologists, and American Association of Physicists in Medicine), and the US Food and Drug Administration (FDA, 2019).

This measure has been strongly supported by a Technical Expert Panel (TEP) comprising a diverse group of clinicians, patient advocates, and leaders of medical specialty societies, payers, and healthcare safety and accrediting organizations, all of whom were engaged through every stage of measure conceptualization, development, and testing. In assessing the face validity of the measure, 100% of TEP members agreed radiation dose and global noise are relevant metrics of CT quality, that size is an appropriate method of risk adjustment, and that performance on this measure of radiation dose and image quality as specified is a representation of quality.

Decreased score indicates improvement

Reference Type: CITATION

Reference Text: 'Berrington de González, A., Mahesh, M., Kim, K. P., Bhargavan, M., Lewis, R., Mettler, F., & Land, C. (2009). Projected cancer risks from computed tomographic scans performed in the United States in 2007. Archives of internal medicine, 169(22), 2071–2077. https://doi.org/10.1001/archinternmed.2009.440'

Reference Type: CITATION

Reference Text: 'Board of Radiation Effects Research Division on Earth and Life Sciences National Research Council of the National Academies. (2006). Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2, Washington, D.C.: The National Academies Press.'

Reference Type: CITATION

Reference Text: 'Brenner, D. J., Doll, R., Goodhead, D. T., Hall, E. J., Land, C. E., Little, J. B., … Zaider, M. (2003). Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proceedings of the National Academy of Sciences of the United States of America, 100(24), 13761–13766. https://doi.org/10.1073/pnas.2235592100'

Reference Type: CITATION

Reference Text: 'Demb, J., Chu, P., Nelson, T., Hall, D., Seibert, A., Lamba, R., … Smith-Bindman, R. (2017). Optimizing Radiation Doses for Computed Tomography Across Institutions: Dose Auditing and Best Practices. JAMA internal medicine, 177(6), 810–817. https://doi.org/10.1001/jamainternmed.2017.0445'

Reference Type: CITATION

Reference Text: 'Dieguez, G., Ferro, C., Pyenson, B. (2017, April 10). Milliman Research Report: A Multi-Year Look at the Cost Burden of Cancer Care. Milliman. https://www.milliman.com/en/insight/2017/a-multi-year-look-at-the-cost-burden-of-cancer-care'

Reference Type: CITATION

Reference Text: 'Halliburton, S. S., Abbara, S., Chen, M. Y., Gentry, R., Mahesh, M., Raff, G. L., … Society of Cardiovascular Computed Tomography (2011). SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. Journal of cardiovascular computed tomography, 5(4), 198–224. https://doi.org/10.1016/j.jcct.2011.06.001'

Reference Type: CITATION

Reference Text: 'Hong, J. Y., Han, K., Jung, J. H., & Kim, J. S. (2019). Association of Exposure to Diagnostic Low-Dose Ionizing Radiation With Risk of Cancer Among Youths in South Korea. JAMA network open, 2(9), e1910584. https://doi.org/10.1001/jamanetworkopen.2019.10584'

Reference Type: CITATION

Reference Text: 'Hricak, H., Brenner, D. J., Adelstein, S. J., Frush, D. P., Hall, E. J., Howell, R. W., … Wagner, L. K. (2011). Managing radiation use in medical imaging: a multifaceted challenge. Radiology, 258(3), 889–905. https://doi.org/10.1148/radiol.10101157'

Reference Type: CITATION

Reference Text: 'Image Wisely 2020. The American College of Radiology and the Radiological Society of North America formed the Joint Task Force on Adult Radiation Protection to address concerns about the surge of public exposure to ionizing radiation from medical imaging. The Joint Task Force collaborated with the American Association of Physicists in Medicine and the American Society of Radiologic Technologists to create the Image Wisely campaign with the objective of lowering the amount of radiation used in medically necessary imaging studies and eliminating unnecessary procedures. https://www.imagewisely.org/'

Reference Type: CITATION

Reference Text: 'IMV 2019 CT Market Outlook Report. (2019). https://imvinfo.com/product/2019-ct-market-outlook-report/'

Reference Type: CITATION

Reference Text: 'Kanal, K. M., Butler, P. F., Sengupta, D., Bhargavan-Chatfield, M., Coombs, L. P., & Morin, R. L. (2017). U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations. Radiology, 284(1), 120–133. https://doi.org/10.1148/radiol.2017161911'

Reference Type: CITATION

Reference Text: 'Mariotto, A. B., Yabroff, K. R., Shao, Y., Feuer, E. J., & Brown, M. L. (2011). Projections of the cost of cancer care in the United States: 2010-2020. Journal of the National Cancer Institute, 103(2), 117–128. https://doi.org/10.1093/jnci/djq495'

Reference Type: CITATION

Reference Text: 'National Cancer Institute. (2020, September 25). Cancer Statistics. https://www.cancer.gov/about-cancer/understanding/statistics'

Reference Type: CITATION

Reference Text: 'Pearce, M. S., Salotti, J. A., Little, M. P., McHugh, K., Lee, C., Kim, K. P., … Berrington de González, A. (2012). Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet (London, England), 380(9840), 499–505. https://doi.org/10.1016/S0140-6736(12)60815-0'

Reference Type: CITATION

Reference Text: 'Pierce, D. A., & Preston, D. L. (2000). Radiation-related cancer risks at low doses among atomic bomb survivors. Radiation research, 154(2), 178–186. https://doi.org/10.1667/0033-7587(2000)154[0178:rrcral]2.0.co;2'

Reference Type: CITATION

Reference Text: 'Preston, D. L., Ron, E., Tokuoka, S., Funamoto, S., Nishi, N., Soda, M., … Kodama, K. (2007). Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiation research, 168(1), 1–64. https://doi.org/10.1667/RR0763.1'

Reference Type: CITATION

Reference Text: 'Shuryak, I., Sachs, R. K., & Brenner, D. J. (2010). Cancer risks after radiation exposure in middle age. Journal of the National Cancer Institute, 102(21), 1628–1636. https://doi.org/10.1093/jnci/djq346'

Reference Type: CITATION

Reference Text: 'Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., Gould, R., … Miglioretti, D. L. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of internal medicine, 169(22), 2078–2086. https://doi.org/10.1001/archinternmed.2009.427'

Reference Type: CITATION

Reference Text: 'Smith-Bindman, R., Moghadassi, M., Wilson, N., Nelson, T. R., Boone, J. M., Cagnon, C. H., … Miglioretti, D. L. (2015). Radiation Doses in Consecutive CT Examinations from Five University of California Medical Centers. Radiology, 277(1), 134–141. https://doi.org/10.1148/radiol.2015142728'

Reference Type: CITATION

Reference Text: 'Smith-Bindman, R., Wang, Y., Chu, P., Chung, R., Einstein, A. J., Balcombe, J., … Miglioretti, D. L. (2019). International variation in radiation dose for computed tomography examinations: prospective cohort study. BMJ (Clinical research ed.), 364, k4931. https://doi.org/10.1136/bmj.k4931'

Reference Type: CITATION

Reference Text: 'Smith-Bindman, R., Chu, P., Wang, Y., Chung, R., Lopez-Solano, N., Einstein, A. J., … Miglioretti, D. L. (2020). Comparison of the Effectiveness of Single-Component and Multicomponent Interventions for Reducing Radiation Doses in Patients Undergoing Computed Tomography: A Randomized Clinical Trial. JAMA internal medicine, 180(5), 666–675. https://doi.org/10.1001/jamainternmed.2020.0064'

Reference Type: CITATION

Reference Text: 'Stecker, M. S., Balter, S., Towbin, R. B., Miller, D. L., Vañó, E., Bartal, G., … & CIRSE Standards of Practice Committee (2009). Guidelines for patient radiation dose management. Journal of vascular and interventional radiology : JVIR, 20(7 Suppl), S263–S273. https://doi.org/10.1016/j.jvir.2009.04.037'

Reference Type: CITATION

Reference Text: 'U.S. Food and Drug Administration. (2019, June 14) White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. https://www.fda.gov/radiation-emitting-products/initiative-reduce-unnecessary-radiation-exposure-medical-imaging/white-paper-initiative-reduce-unnecessary-radiation-exposure-medical-imaging'

Reference Type: CITATION

Reference Text: 'Vance, E. A., Xie, X., Henry, A., Wernz, C., & Slonim, A. D. (2013). Computed tomography scan use variation: patient, hospital, and geographic factors. The American journal of managed care, 19(3), e93–e99.'

Reference Type: CITATION

Reference Text: 'Hirshfeld, J. W., Jr, Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., … Wiggins, B. S. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 92(2), 222–246. https://doi.org/10.1002/ccd.27661'

Reference Type: CITATION

Reference Text: 'Hirshfeld, J. W., Jr, Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., … Wann, L. S. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 71(24), e283–e351. https://doi.org/10.1016/j.jacc.2018.02.016'

Reference Type: CITATION

Reference Text: 'Hirshfeld, J. W., Jr, Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., … Wann, L. S. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 71(24), 2811–2828. https://doi.org/10.1016/j.jacc.2018.02.017'

CT Dose and Image Quality Category: reflects the type of exam performed based on body region and clinical indication. Each CT Dose and Image Quality Category has a specific set of dose and image quality (global noise) thresholds. 

Calculated CT Size-Adjusted Dose: reflects the total radiation dose received during CT, risk-adjusted by patient size. The Calculated CT Size-Adjusted Dose thresholds vary by the CT Dose and Image Quality Category. 

Calculated CT Global Noise: reflects the image quality of the CT. The Calculated CT Global Noise thresholds vary by the CT Dose and Image Quality Category.

Translation software
As a radiology measure, the measure derives standardized data elements from structured fields within both the electronic health record (EHR) and the radiology electronic clinical data systems, including the Radiology Information System (RIS) and the Picture Archiving and Communication System (PACS). Primary imaging data including Radiation Dose Structured Reports and image pixel data are stored in the PACS in Digital Imaging and Communications in Medicine (DICOM) format, a universally adopted standard for medical imaging information. eCQMs cannot currently access and consume elements from these radiology sources in their original DICOM formats. Thus, translation software was developed to transform primary data into a format that the eCQM can consume. The purpose of this translation software is to access and link these primary data elements with minimal site burden, assess each CT exam for eligibility based on initial population criteria, and generate the three data elements mapped to a clinical terminology for eCQM consumption: CT Dose and Image Quality Category, Calculated CT Size-Adjusted Dose, and Calculated CT Global Noise.

LOINC codes
The translation software will create three variables required for measure computation including the CT Dose and Image Quality Category (LOINC Code 96914-7), the Calculated CT Global Noise (LOINC Code 96912-1) and the Calculated CT Size-Adjusted Dose (LOINC Code 96913-9). These variables are defined in the “Definition” field above. These transformed data elements can be stored in the EHR. The included population for this eCQM will include all CT scans with non-missing values of these three new variables where the defining of these variables, occurs in the translation software.

Measure calculation
The measure will evaluate each included CT examination based on allowable thresholds that are specified by the CT dose and image quality category. An examination is considered out of range if either the Calculated CT Global Noise, or the Calculated CT Size-Adjusted Dose is out of range for the CT Dose and Image Quality Category. Exams with be evaluated against their corresponding threshold, shown below with the following format: [Category shorthand (CT Dose and Image Quality Category), threshold for the Calculated CT Global Noise in Hounsfield units, threshold for the Calculated CT Size-Adjusted Dose in dose length product].

[ABDOPEL LD (=Abdomen and Pelvis, Low Dose), 64, 598];
[ABDOPEL RT (=Abdomen and Pelvis, Routine Dose), 29, 644];
[ABDOPEL HD (=Abdomen and Pelvis, High Dose), 29, 1260];
[CARDIAC LD (=Cardiac Low Dose), 55, 93];
[CARDIAC RT (= Cardiac Routine Dose), 32, 576];
[CHEST LD (=Chest Low Dose), 55, 377];
[CHEST RT (=Chest Routine Dose), 49, 377];
[CHEST-CARDIAC HD (=Chest High Dose or Cardiac High Dose), 49, 1282];
[HEAD LD (=Head Low Dose), 115, 582];
[HEAD RT (=Head Routine Dose), 115, 1025];
[HEAD HD (=Head High Dose), 115, 1832];
[EXTREMITIES (=Upper or Lower Extremity), 73, 320];
[NECK-CSPINE (= Neck or Cervical Spine), 25, 1260];
[TSPINE-LSPINE (=Thoracic or Lumbar Spine), 25, 1260];
[CAP (=Combined Chest, Abdomen and Pelvis), 29, 1637];
[TLSPINE (= Combined Thoracic and Lumbar Spine), 25, 2520];
[HEADNECK RT (=Combined Head and Neck, Routine Dose), 25, 2285];
[HEADNECK HD (=Combined Head and Neck, High Dose), 25, 3092]

This eCQM is an episode-based measure and should be reported for each eligible CT scan performed during the measurement period.

Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes. 

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All diagnostic CT exams performed on adults aged 18 years and older during the measurement period that have a non-missing CT Dose and Image Quality Category, a Calculated CT Size-Adjusted Dose value, and a Calculated CT Global Noise value. CT exams with missing patient age, Calculated CT Size-Adjusted Dose, or Calculated CT Global Noise are technical exclusions from the initial population. Technical exclusions will be flagged, corrected whenever possible, and tracked at the accountable entity level by the translation software.

Initial Population

CT exams that cannot be categorized by anatomical area or by clinical indication either because they are simultaneous exams of multiple body regions outside of four commonly encountered multiple region groupings, or because there is insufficient data for their classification based on diagnosis and procedure codes, are assigned a CT Dose and Image Quality Category (LOINC 96914-7) value using the LOINC Answer list (LL5824-9) of Full body LA31771-1. This value identifies exams that are excluded from the calculation. These exams are included in the initial population because they have a non-missing CT Dose and Image Quality Category but are then excluded in the eCQM because the value is full body.

Calculated CT Size-Adjusted Dose greater than or equal to a threshold specific to the CT Dose and Image Quality Category, or Calculated CT Global Noise value greater than or equal to a threshold specific to the CT Dose and Image Quality Category.

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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