ACEP also observed that a utilization measure for head CT use in the emergency department will be influenced by case mix, patient severity, and clinician behavior, and therefore does not accurately represent appropriateness nor efficiency.

ACEP voiced concern that the measure deviates from the published scientific evidence and consensus guidelines for care of patients with acute headache by measuring the use of head CT in the Medicare population (primarily those 65 years of age and older) using ICD-9 discharge diagnoses. Published studies on headache have identified increasing age as a risk factor for significant intracranial pathology, and headache guidelines have either excluded older adults or recommended a lower threshold for the use of CT scans.

The NQF has rejected the measure to date. And when CMS included the measure in its 2011 HOP QDRP, ACEP Past President Dr. Angela Gardner sent a letter to CMS Administrator Dr. Donald M. Berwick noting that the measure “failed to meet the consensus requirement as it was not recommended for endorsement by the NQF.”

Despite these objections, CMS is proceeding with the measure for calendar years 2012-2014, and has statutory leeway to proceed. However, ACEP believes this tactic sets a bad precedent for including measures that fall outside of the widely accepted consensus process.

ACEP also has expressed some of the same concerns with the draft Patient Radiation Dose Optimization Performance Measurement Set, prepared by the American Board of Medical Specialties and the American Medical Association’s Physician Consortium for Performance Improvement (AMA/PCPI), in collaboration with the American Board of Radiology and the American College of Radiology. This measure was recently released for public comment.

According to the drafters, the purpose of their work was to identify and define 14 quality measures to include in Maintenance of Certification programs intended to improve outcomes for patients undergoing high-dose radiation imaging studies.

In an April 29, 2011, letter, Dr. Schneider expressed strong objections regarding the drafting process and the lack of evidence for several statements and draft measures included in the set, including a head CT measure that is similar to the measure proposed by CMS.

Dr. Schneider wrote that although ACEP is “highly interested in provision of the highest quality patient care and supports measuring radiation doses in imaging with the goal of reducing patient radiation exposure,” the College has “strong objections regarding the drafting process and the lack of an evidence base for several statements and draft measures included in the set.”