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

Compare Versions of: "Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR)"

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Measure Information 2025 Reporting Period
Title Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility IQR)
CMS eCQM ID CMS1074v1
Short Name IP-ExRad
NQF Number 3663e
Description

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. All diagnostic CT exams of specified anatomic sites performed in hospital inpatient care settings are eligible. This eCQM requires the use of additional software to access primary data elements stored within radiology electronic health records and translate them into data elements that can be ingested by this eCQM. Additional details are included in the Guidance field.

Initial Population

All CT scans in adults aged 18 years and older at the start of the measurement period that have a CT Dose and Image Quality Category and were performed during an inpatient hospitalization during the measurement period

Denominator

Initial population with a CT Dose and Image Quality Category, a Calculated Global Noise value, and a Calculated CT Size-Adjusted Dose value

Denominator Exclusions Denominator, where a CT scan with a CT Dose and Image Quality Category = full body
Numerator

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward Alara Imaging, Inc.
Measure Scoring Proportion measure
Measure Type Intermediate Clinical Outcome measure
Improvement Notation

Lower score indicates higher quality, and a decreased score over time indicates improvement

Guidance

This is an inverse measure; as such the higher the value the worse the performance.

The level of aggregation for this eCQM is the facility. A parallel eCQM measures CT exams aggregated at the level of the clinician or clinician group. 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 hospital quality reporting programs.

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. Because of limitations in their specifications and format, 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. This eCQM 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 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. The translation software necessary to use this eCQM is written and maintained by Alara Imaging, Inc.

CODING

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.

MEASURE CALCULATION

The measure will evaluate each included CT exam based on allowable thresholds that are specified by the CT Dose and Image Quality Category. An exam 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 will 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]

EXCLUSIONS

CT scans with missing patient age or missing CT Dose and Image Quality Category (LOINC 96914-7) are excluded from the initial population.

CT scans with a missing Calculated Global Noise value or a missing Calculated CT Size-Adjusted Dose value are not included in the denominator.

CT scans assigned a CT Dose and Image Quality Category (LOINC 96914-7) value using the LOINC answer list (LL5824-9) of full body (LA31771-1) are excluded from the denominator. These exams are included in the initial population because they have a non-missing CT Dose and Image Quality Category but are then removed as a Denominator Exclusion in the eCQM because the value is full body, which reflects 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 the given diagnosis and procedure codes.

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

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.

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Last Updated: Dec 28, 2023