The American College of Emergency Physicians has raised red flags over proposed measures aimed at CT scan usage in the emergency department and patient radiation dose exposure.

One measure is proposed by the Centers for Medicare and Medicaid Services (CMS), OP-15 – Use of Brain Computed Tomography in the ED for Atraumatic Headache. Additionally, the Patient Radiation Dose Optimization Performance Measurement Set is intended for use in physician maintenance of certification programs. Both measures have generated “deep concerns” from ACEP.

ACEP has applauded the serious consideration given to the use and overuse of CT scanning, as well as efforts to reduce radiation exposure and health costs. But the College cautions that there is the potential for missed diagnoses resulting from fewer scans. ACEP strongly urges modifications or removal of these measures as written from the proposed sets.

“We used to miss brain bleeds, but now with CT scans we find them before they kill or paralyze,” said ACEP President Dr. Sandra Schneider. “My high school best friend nearly died from a subarachnoid hemorrhage and was left with paralysis and difficulty speaking for the past 25 years. I don’t want to miss patients we might save from similar disability.”

“This measure, if it moves forward, will turn back the clock to those terrible old days,” she said. “If we get this measure rescinded, lives will be saved – I really mean that.”

CMS has included of the CT scan measure OP-15 in its Hospital Outpatient Quality Data Reporting Program (HOP QDRP).

ACEP objects to this measure because it is not evidence based, is simply a raw “utilization” measure that will not improve patient outcomes, and could increase missed diagnoses in the emergency department as physicians are pressured against administering the CT scans.

The measure, which also could hold physicians liable for any bad outcomes, is scheduled for hospital reporting, with payment implications beginning October 2012.

ACEP supports the use of a broad consensus-based process to vet measures that hold physicians and hospitals accountable for improving patient care. ACEP objected to the CT scan measure as it was being considered at the National Quality Forum (NQF), a multistakeholder, consensus-based endorser of quality measures in the field.

During the NQF process, ACEP objected to the measure because it does not follow published guidelines for care and will not produce reliable and valid results about the quality of care when implemented. ACEP wrote that “without high quality evidence to guide appropriateness decisions, a measure comparing use of CTs between institutions is a utilization measure rather than an efficiency measure.”

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.”

Dr. Schneider had specific concerns regarding draft Measure #5 (CT Perfusion for Headache) and draft Measure #6 (CT for Atraumatic Headache), which are proposed “for quality improvement only.”

“There is no clear evidence basis demonstrated that either measure would improve quality,” Dr. Schneider wrote. “Including these measures in any maintenance of certification process will only perpetuate the myth that non-evidence based measures of imaging utilization can improve quality.”

As ACEP continues to pursue a strategy to address these problematic measures, Dr. Schneider urges emergency physicians to familiarize themselves with the issue and send ACEP any feedback that they may have.