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  • Measure Summary
  • NQMC:010207
  • Feb 2015

Diagnostic imaging: percentage of imaging studies for patients aged 18 years and older with shoulder pain undergoing shoulder MRI, MRA, or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source.

American College of Radiology (ACR), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), National Committee for Quality Assurance (NCQA). Diagnostic imaging performance measurement set. Reston (VA): American College of Radiology (ACR); 2015 Feb. 58 p. [89 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

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Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of imaging studies for patients aged 18 years and older with shoulder pain undergoing shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound who are known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source.

Rationale

Shoulder pain is common, affecting approximately 6.7% of the U.S. population (Cunningham & Kelsey, 1984). Radiographs are indicated as part of the initial work-up for shoulder pain. Advanced imaging studies should only be utilized when the diagnosis remains unclear. In recent years, there has been growing concern regarding the overuse of imaging services (American College of Radiology [ACR], 2012). One report estimates that 20% to 50% of diagnostic imaging studies fail to provide information that improves the diagnosis or treatment of the patient (America's Health Insurance Plans [AHIP], 2008).

The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references:

Acute (less than 2 weeks) shoulder pain can be attributable to structures related to the glenohumeral articulation and joint capsule, the rotator cuff, acromioclavicular joint, and scapula. Radiography is a safe, fast, low-cost imaging modality that effectively demonstrates many forms of shoulder pathology. However, a multimodal approach may be required to accurately assess shoulder pathology. Radiography is a useful initial screening modality for acute shoulder pain of all causes. Radiography is useful in the evaluation of fractures of the shoulder girdle (Wise et al., 2010).

Radiographs are indicated as part of the initial work-up for all chronic shoulder pain (Burbank et al., 2008).

Further testing of chronic shoulder pain should be utilized when the diagnosis remains unclear or the outcome would change management. Imaging options include MRI, arthrography, computed tomography (CT), and ultrasonography (Burbank et al., 2008).

Evidence for Rationale

American College of Radiology (ACR), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), National Committee for Quality Assurance (NCQA). Diagnostic imaging performance measurement set. Reston (VA): American College of Radiology (ACR); 2015 Feb. 58 p. [89 references]

American College of Radiology (ACR). Five things physicians and patients should question. Philadelphia (PA): ABIM Foundation; 2012 Apr 4. 2 p.

America's Health Insurance Plans (AHIP). Ensuring quality through appropriate use of diagnostic imaging. Washington (DC): America's Health Insurance Plans (AHIP); 2008 Jul. 12 p.

Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15;77(4):453-60. PubMed External Web Site Policy

Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984 Jun;74(6):574-9. PubMed External Web Site Policy

Wise JN, Daffner RH, Weissman BN, Bancroft L, Bennett DL, Blebea JS, Bruno MA, Fries IB, Jacobson JA, Luchs JS, Morrison WB, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Stoller DW, Taljanovic MS, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® acute shoulder pain. Reston (VA): American College of Radiology (ACR); 2010. 7 p. [31 references]

Primary Health Components

Imaging studies; shoulder pain; magnetic resonance imaging (MRI); magnetic resonance arthrography (MRA); shoulder ultrasound; shoulder radiographs; radiology information system (RIS)

Denominator Description

All imaging studies for patients aged 18 and older with shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), or a shoulder ultrasound

Numerator Description

Imaging studies for patients known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Importance of Topic
As imaging technology continues to advance, the United States healthcare system has seen an increase in both the type and frequency of imaging studies being performed. The increase in utilization of imaging studies is accompanied by a corresponding increase in cost and exposure to radiation for both patients and healthcare professionals.

  • From 1980 to 2006, the number of radiologic procedures performed in the United States showed a ten-fold increase while the annual per-capita effective dose from radiologic and nuclear medicine procedures increased by 600% (Mettler et al., 2009).
  • From 1996 to 2010, the number of computerized tomographic (CT) examinations tripled, while the number of ultrasounds nearly doubled (Smith-Bindman et al., 2012).
  • From 1996 to 2010, advanced diagnostic imaging (i.e., CT, magnetic resonance imaging [MRI], nuclear medicine, and ultrasound) accounted for approximately 35% of all imaging studies (Smith-Bindman et al., 2012).
  • From 1980 to 2006, the proportion of radiation exposure that is attributable to medical sources increased from 17% to 53% (Mettler et al., 2009).
  • In 2006, while CT scans only accounted for approximately 17% of all radiologic procedures performed in the United States, they accounted for over 65% of the total effective radiation dose from radiologic procedures (Mettler et al., 2009).
  • In 2006, the estimated per-capita effective radiation dose for radiologic procedures in the United States was nearly 20% higher than the average for other well-developed countries (Mettler et al., 2009).

Diagnostic imaging was prioritized as a topic area for measure development due to a high level of utilization, rising costs, and the need for measures to help promote appropriate use of imaging and improve outcomes.

Opportunity for Improvement
From 1996 to 2005, the use of musculoskeletal MRIs increased by 353.5% among Medicare recipients, while the use of musculoskeletal CT scans increased by 326.5%. In comparison, the use of musculoskeletal x-rays only increased 19.1% (Parker et al., 2008). A recent study by George et al. (2014) found that approximately 35% of all shoulder MRIs were performed without recent prior radiographs.

Evidence for Additional Information Supporting Need for the Measure

American College of Radiology (ACR), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), National Committee for Quality Assurance (NCQA). Diagnostic imaging performance measurement set. Reston (VA): American College of Radiology (ACR); 2015 Feb. 58 p. [89 references]

George E, Tsipas S, Wozniak G, Rubin DA, Seidenwurm DJ, Raghavan K, Golden W, Tallant C, Bhargavan-Chatfield M, Burleson J, Rybicki FJ. MRI of the knee and shoulder performed before radiography. J Am Coll Radiol. 2014 Nov;11(11):1053-8. PubMed External Web Site Policy

Mettler FA, Bhargavan M, Faulkner K, Gilley DB, Gray JE, Ibbott GS, Lipoti JA, Mahesh M, McCrohan JL, Stabin MG, Thomadsen BR, Yoshizumi TT. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. Radiology. 2009 Nov;253(2):520-31. PubMed External Web Site Policy

Parker L, Nazarian LN, Carrino JA, Morrison WB, Grimaldi G, Frangos AJ, Levin DC, Rao VM. Musculoskeletal imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008 Mar;5(3):182-8. PubMed External Web Site Policy

Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, Greenlee RT, Kruger RL, Hornbrook MC, Roblin D, Solberg LI, Vanneman N, Weinmann S, Williams AE. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012 Jun 13;307(22):2400-9. PubMed External Web Site Policy

Extent of Measure Testing

Some of the measures in this set are being made available without any prior testing. The Physician Consortium for Performance Improvement (PCPI) recognizes the importance of testing all of its measures and encourages testing of the diagnostic imaging measurement set for feasibility and reliability by organizations or individuals positioned to do so. The Measure Testing Protocol for PCPI Measures was approved by the PCPI in 2010 and is available on the PCPI Web site (see Position Papers at www.physicianconsortium.org External Web Site Policy); interested parties are encouraged to review this document and to contact PCPI staff. The PCPI will welcome any opportunity to promote the initial testing of these measures and to ensure that any results available from testing are used to refine the measures before implementation.

Evidence for Extent of Measure Testing

American College of Radiology (ACR), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), National Committee for Quality Assurance (NCQA). Diagnostic imaging performance measurement set. Reston (VA): American College of Radiology (ACR); 2015 Feb. 58 p. [89 references]

State of Use

Current routine use

Current Use

Internal quality improvement

Professional certification

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Hospital Inpatient

Hospital Outpatient

Long-term Care Facilities - Other

Skilled Nursing Facilities/Nursing Homes

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Making Quality Care More Affordable
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Efficiency

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Diagnostic Evaluation

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All imaging studies for patients 18 years and older with shoulder pain who undergo shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) or a shoulder ultrasound

Exclusions
Unspecified

Exceptions
None

Exclusions/Exceptions

None

Numerator Inclusions/Exclusions

Inclusions
Imaging studies for patients known to have had shoulder radiographs performed within the preceding 3 months based on information from the radiology information system (RIS), patient-provided radiological history, or other health-care source

Note: Images and/or results of prior shoulder radiographs should be available to radiologist at the time of the shoulder magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) or ultrasound. If the report, but not images, from prior radiographs are available, this should be noted in the final report.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Imaging data

Paper medical record

Registry data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Measure #7: appropriate use of imaging for shoulder pain.

Measure Collection Name

Diagnostic Imaging Performance Measurement Set

Submitter

American College of Radiology - Medical Specialty Society

Developer

American College of Radiology - Medical Specialty Society

National Committee for Quality Assurance - Health Care Accreditation Organization

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Diagnostic Imaging Measure Development Work Group Members

  • William Golden, MD (Co-chair) (internal medicine)
  • David Seidenwurm (Co-chair) (diagnostic radiology)
  • Michael Bettmann, MD
  • Dorothy Bulas, MD (pediatric radiology)
  • Rubin I. Cohen, MD, FACP, FCCP, FCCM
  • Richard T. Griffey, MD, MPH (emergency medicine)
  • Eric J. Hohenwalter, MD (vascular interventional radiology)
  • Deborah Levine, MD, FACR (radiology/ultrasound)
  • Mark Morasch, MD (vascular surgery)
  • Paul Nagy, MD, PhD (radiology)
  • Mark R. Needham, MD, MBA (family medicine)
  • Hoang D. Nguyen (diagnostic radiology/payer representative)
  • Charles J. Prestigiacomo, MD, FACS (neurosurgery)
  • William G. Preston, MD, FAAN (neurology)
  • Robert Pyatt, Jr., MD (diagnostic radiology)
  • Robert Rosenberg, MD (diagnostic radiology)
  • David A. Rubin, MD (diagnostic radiology)
  • B Winfred (B.W.) Ruffner, MD, FACP (medical oncology)
  • Frank Rybicki, MD, PhD, FAHA (diagnostic radiology)
  • Cheryl A. Sadow, MD (radiology)
  • John Schneider, MD, PhD (internal medicine)
  • Gary Schultz, DC, DACR (chiropractic)
  • Paul R. Sierzenski, MD, RDMS (emergency medicine)
  • Michael Wasylik, MD (orthopedic surgery)

Diagnostic Imaging Measure Development Work Group Staff

American College of Radiology: Judy Burleson, MHSA; Alicia Blakey, MS

American Medical Association-convened Physician Consortium for Performance Improvement: Mark Antman, DDS, MBA; Kathleen Blake, MD, MPH; Kendra Hanley, MS; Toni Kaye, MPH; Marjorie Rallins, DPM; Kimberly Smuk, RHIA; Samantha Tierney, MPH; Stavros Tsipas, MA

National Committee for Quality Assurance: Mary Barton, MD

Financial Disclosures/Other Potential Conflicts of Interest

None of the members of the Diagnostic Imaging Work Group had any disqualifying material interest under the Physician Consortium for Performance Improvement (PCPI) Conflict of Interest Policy.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Feb

Measure Maintenance

This measure is reviewed and updated every 3 years.

Date of Next Anticipated Revision

2018

Measure Status

This is the current release of the measure.

Source(s)

American College of Radiology (ACR), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), National Committee for Quality Assurance (NCQA). Diagnostic imaging performance measurement set. Reston (VA): American College of Radiology (ACR); 2015 Feb. 58 p. [89 references]

Measure Availability

Source available from the American College of Radiology (ACR) Web site External Web Site Policy.

For more information, contact ACR at 1891 Preston White Drive, Reston, VA 20191; Phone: 703-648-8900; E-mail: info@acr.org; Web site: www.acr.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on October 13, . The information was verified by the measure developer on November 19, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

©2014 American Medical Association (AMA) and American College of Radiology (ACR). All Rights Reserved. CPT® Copyright 2004 to 2013 American Medical Association.

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