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  • Measure Summary
  • NQMC:010218
  • Jan 2016

Optimizing patient exposure to ionizing radiation: percentage of pediatric CT imaging studies for patients aged 17 years and younger performed with individualized equipment evaluation protocols that comply with a widely used guideline.

American Board of Medical Specialties (ABMS), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), American College of Radiology (ACR). Optimizing patient exposure to ionizing radiation performance measurement set. Reston (VA): American College of Radiology; 2016 Jan. 51 p. [53 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Structure

Secondary Measure Domain

Clinical Quality Measure: Process

Description

This measure is used to assess the percentage of pediatric computed tomography (CT) imaging studies for patients aged 17 years and younger performed with individualized equipment evaluation protocols that comply with a widely used guideline.

Rationale

Radiation exposure is a concern in both adults and children. However, there are three unique considerations in children.

  1. Children are considerably more sensitive to radiation than adults, as demonstrated in epidemiologic studies of exposed populations.
  2. Children have a longer life expectancy than adults, resulting in a larger window of opportunity for expressing radiation damage.
  3. Children may receive a higher radiation dose than necessary if computed tomography (CT) settings are not adjusted for their smaller body size (National Cancer Institute [NCI], 2012).

Advances in technology continually change the design and capabilities of CT scanners, even from the same manufacturer and certainly from different manufacturers. Each CT scanner requires a unique protocol development to optimize dose savings (Strauss et al., 2010).

Substantial dose reduction and high compliance can be obtained with pediatric CT protocols tailored to clinical indications, patient weight, and number of prior studies (Singh et al., 2009).

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

Because children are more sensitive than adults to the effects of ionizing radiation, it is particularly important to tailor CT examinations to minimize exposure while providing diagnostic quality examinations (The Alliance for Radiation Safety in Pediatric Imaging, 2007).

Image GentlySM – How to Develop CT Protocols for Children (The Alliance for Radiation Safety in Pediatric Imaging, 2007)
The Image Gently instructions to develop pediatric CT protocols are available at the Image Gently Web site External Web Site Policy. These instructions provide guidance in either developing CT protocols for children or verifying that your current protocols are appropriate. You may be able to reduce doses to a greater degree for high contrast studies.

Calculation of the effective dose – Pediatrics (newborn to age 15) (Shrimpton & Wall, 2000)
The effective dose in CT is derived from the dose-length product (DLP)

  • Effective dose calculation: E = k DLP

    k = age and body region-specific conversion coefficient (mSv mGy-1 cm-1)

Pediatric Abdominal CT (American College of Radiology [ACR], 2008)

  • Scanning parameters should be optimized to obtain diagnostic image quality while adhering to the as low as reasonably achievable (ALARA) principle.
  • Scan area should be minimized according to the clinical indication.
  • Scanning parameters, including kVp, tube current, and exposure time (mAs), should be changed according to body size, area of interest, and clinical indication. May be achieved by using weight based tables or by using automatic exposure control (see Image Gently™ protocols).
  • Testicles should not be included the scanned area unless absolutely necessary for the clinical indication. Consideration should be given to shielding superficial structures in the scan region such as the testes.
  • If precontrast images are needed solely to determine whether calcification is present, these can be done with additional decrease in mAs.
  • Intravenous (IV) contrast is usually used in the CT evaluation of the pediatric abdomen, since vascular structures and internal organs are better visualized due to the paucity of body fat in many pediatric patients. Renal stone evaluation is an exception. A routine dose of 2mL/kg is generally used. Volume of contrast, rate of injection, scan delayed time, and hand/power injection should be determined according to the location, size, and type of IV access, the child's body size, the underlying disease (e.g., congestive heart failure), and the clinical indication.
  • Enteric contrast may be sued in the CT evaluation of the pediatric abdomen. Exceptions would include renal stone protocol, CT angiography and acute trauma.
  • In evaluating suspected appendicitis, IV contrast is typically used, generally to avoid repeat examinations. Precontrast and delayed scans are not necessary, unless a renal anomaly requiring evaluation of the collecting system is identified. Some centers use oral or rectal contrast. If oral contrast is given, sufficient time should be allowed to elapse for the contrast to reach the right lower quadrant prior to scanning.
  • Postprocessing 2D reformations and 3D reconstructions or 3D volume rendering may be useful adjuncts in displaying the anatomy.

To achieve acceptable clinical CT scans of body, the CT scanner should meet or exceed the following specifications:

  1. Gantry rotation times: less than or equal to 2 seconds.
  2. Slice thickness: less than or equal to 5 mm (less than or equal to 2 mm is preferred).
  3. Limiting spatial resolution: 8 lp/cm for greater than or equal to 32 cm DFOV and greater than or equal to 10 lp/cm for less than 24 cm DFOV.
  4. Table pitch: no greater than 2:1 for single-row-detector helical scanners.

Evidence for Rationale

American Board of Medical Specialties (ABMS), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), American College of Radiology (ACR). Optimizing patient exposure to ionizing radiation performance measurement set. Reston (VA): American College of Radiology; 2016 Jan. 51 p. [53 references]

American College of Radiology (ACR). Practice guideline for the performance of pediatric computed tomography (CT). Reston (VA): American College of Radiology (ACR); 2008.

National Cancer Institute (NCI). Radiation risks and pediatric computed tomography: a guide for health care providers. [internet]. Bethesda (MD): National Institutes of Health (NIH); 2012 Jun 7. 

Shrimpton PC, Wall BF. Reference doses for paediatric computed tomography. Radiat Prot Dosimetry. 2000;290:249-52.

Singh S, Kalra MK, Moore MA, Shailam R, Liu B, Toth TL, Grant E, Westra SJ. Dose reduction and compliance with pediatric CT protocols adapted to patient size, clinical indication, and number of prior studies. Radiology. 2009 Jul;252(1):200-8. PubMed External Web Site Policy

Strauss KJ, Goske MJ, Kaste SC, Bulas D, Frush DP, Butler P, Morrison G, Callahan MJ, Applegate KE. Image gently: Ten steps you can take to optimize image quality and lower CT dose for pediatric patients. AJR Am J Roentgenol. 2010 Apr;194(4):868-73. PubMed External Web Site Policy

The Alliance for Radiation in Pediatric Imaging. How to develop CT protocols for children. Reston (VA): The Alliance for Radiation in Pediatric Imaging; 2007 Dec. 7 p.

Primary Health Components

Ionizing radiation; pediatric computer tomography (CT) imaging studies; individualized equipment evaluation protocols; Image GentlySM

Denominator Description

All pediatric computed tomography (CT) imaging studies for patients aged 17 years and younger (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Pediatric computed tomography (CT) imaging studies performed with individualized equipment evaluation protocols that comply with a widely used guideline (see the related "Denominator 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
The use of medical imaging has resulted in revolutionary advances in the practice of medicine. The increased sophistication and clinical efficacy of imaging have resulted in its considerable growth. Consequently, the evolution of imaging has resulted in a significant increase in the population's cumulative exposure to ionizing radiation and a potential increase in adverse effects including cancer (Amis, Butler, & American College of Radiology [ACR], 2010; Amis et al., 2007). Although experts may not agree on the extent of the risks of cancer from medical imaging, there is uniform agreement that care should be taken to weigh the medical necessity of a given level of radiation exposure against the risks, and that steps should be taken to eliminate avoidable exposure to radiation (Amis et al., 2007; Center for Devices and Radiological Health [CDRH], 2010).

High Impact Topic Area
This topic was chosen for measure development because of the high costs associated with imaging studies and because these medical procedures are a significant source of radiation exposure. The following objective data support the degree of increase in the use of imaging studies and emphasize the importance in taking steps to help eliminate avoidable exposure.

Prevalence and Incidence

  • The average per capita exposure to ionizing radiation from imaging exams increased by about 600% from 1980 to 2006 in the United States (U.S.) (Mettler et al., 2009; National Council on Radiation Protection and Measurements [NCRP], 2009).
  • The largest contributor to this dramatic increase in population radiation exposure is computed tomography (CT). In 1980 fewer than 3 million CT scans were performed; in 2006, there were about 380 million radiologic procedures (including 67 million CT scans) and 18 million nuclear medicine procedures performed in the U.S. (Mettler et al., 2009).
  • The imaging study with the single highest radiation burden, accounting for 22% of cumulative effective dose, is myocardial perfusion imaging (Fazel et al., 2009).
  • In 2006, an estimated 19 million head, 10.6 million chest and 21.2 million abdominal and pelvic CT scans were performed accounting for 28%, 15.9%, and 31.7%, respectively, of the total number of CT scans in the U.S. (Mettler et al., 2009).
  • Currently, approximately 11% of CT examinations are performed on children, which could account for more than 7 million pediatric CT examinations per year in the U.S. (Mettler et al., 2000; Frush & Applegate, 2004; Linton, Mettler, & NCRP, 2003).
  • The prevalence of CT or magnetic resonance imaging (MRI) use during emergency department (ED) visits for injury-related conditions increased from 6% in 1998 to 15% in 2007 (Korley, Pham, & Kirsch, 2010).
  • While CT utilization has decreased steadily since 2003 in pediatric facilities across North America (Townsend et al., 2010) the use of CT in children who visit the ED increased from 0.33 to 1.65 from 1995 to 2008 and occurred primarily at non-pediatric focused facilities (Larson et al., 2011).

Costs

  • From 2000 through 2006, total Medicare expenditures for physician imaging services increased from $6.7 billion to about $14 billion, an increase of 13% per year on average (U.S. Government Accountability Office [GAO], 2008).
  • In 2005 imaging services represented an estimated 14% of 2005 spending included in the sustainable growth rate (SGR) calculation, but represented 27% of the total increase in such spending between 2004 and 2005. The majority of the growth occurred for advanced imaging (GAO, 2008).
  • In 2006, advanced imaging, including CT and MRI, accounted for 54% of total Medicare imaging expenditures, up from 43% in 2000. This translates to an increase in Medicare spending on advanced imaging from about $3 billion in 2000 to about $7.6 billion in 2006 (GAO, 2008).

Disparities
There is variation according to age, sex, and health care market in the proportion and mean dose of patients undergoing medical imaging procedures. One study concluded that the proportion of subjects undergoing at least one imaging procedure was higher in older patients, rising from 49.5% of those who were 18 to 34 years old to 85.9% of those who were 60 to 64 years old. The study also found that women underwent procedures significantly more often than men, with a total of 78.7% of women undergoing at least one procedure during the study period, as compared with 57.9% of men (Fazel et al., 2009).

Opportunity for Improvement
One retrospective cross-sectional study describing radiation dose associated with some of the most common types of diagnostic CT found variable radiation doses. The study found variability in the following exams: 1) routine chest exam without contrast, the CT effective doses ranged from 2 mSv to 24 mSv; 2) routine abdomen-pelvis, no contrast - CT effective dose ranged from 3 mSv to 43 mSv; 3) routine head exam - CT effective dose ranging from 0.3 mSv to 6 mSv (Smith-Bindman et al., 2009).

A central database established for collecting dose indices as a function of patient qualities (i.e., gender, age, size, etc.) and exam type (i.e., lateral lumbar spine, pelvis CT, etc.), would allow the relative range of radiation dose indices to be analyzed and compared against established benchmarks.

Evidence for Additional Information Supporting Need for the Measure

American Board of Medical Specialties (ABMS), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), American College of Radiology (ACR). Optimizing patient exposure to ionizing radiation performance measurement set. Reston (VA): American College of Radiology; 2016 Jan. 51 p. [53 references]

Amis ES Jr, Butler PF, American College of Radiology. ACR white paper on radiation dose in medicine: three years later. J Am Coll Radiol. 2010 Nov;7(11):865-70. PubMed External Web Site Policy

Amis ES Jr, Butler PF, Applegate KE, Birnbaum SB, Brateman LF, Hevezi JM, Mettler FA, Morin RL, Pentecost MJ, Smith GG, Strauss KJ, Zeman RK, American College of Radiology. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol. 2007 May;4(5):272-84. PubMed External Web Site Policy

Center for Devices and Radiological Health (CDRH). Initiative to reduce unnecessary radiation exposure from medical imaging. Silver Spring (MD): U.S. Food and Drug Administration, Center for Devices and Radiological Health; 2010 Feb. 12 p.

Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK. Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med. 2009 Aug 27;361(9):849-57.

Frush DP, Applegate K. Computed tomography and radiation: understanding the issues. J Am Coll Radiol. 2004 Feb;1(2):113-9. PubMed External Web Site Policy

Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007. JAMA. 2010 Oct 6;304(13):1465-71. PubMed External Web Site Policy

Larson DB, Johnson LW, Schnell BM, Goske MJ, Salisbury SR, Forman HP. Rising use of CT in child visits to the emergency department in the United States, 1995-2008. Radiology. 2011 Jun;259(3):793-801. PubMed External Web Site Policy

Linton OW, Mettler FA, National Council on Radiation Protection and Measurements. National conference on dose reduction in CT, with an emphasis on pediatric patients. AJR Am J Roentgenol. 2003 Aug;181(2):321-9. PubMed External Web Site Policy

Mettler FA Jr, Wiest PW, Locken JA, Kelsey CA. CT scanning: patterns of use and dose. J Radiol Prot. 2000 Dec;20(4):353-9. 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

National Council on Radiation Protection and Measurement (NCRP). Ionizing radiation exposure of the population of the United States. Bethesda (MD): National Council on Radiation Protection and Measurement (NCRP); 2009.

Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de Gonzalez A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009 Dec 14;169(22):2078-86.

Townsend BA, Callahan MJ, Zurakowski D, Taylor GA. Has pediatric CT at children's hospitals reached its peak?. AJR Am J Roentgenol. 2010 May;194(5):1194-6. PubMed External Web Site Policy

U.S. Government Accountability Office (GAO). Medicare Part B imaging services: rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices. Washington (DC): U.S. Government Accountability Office (GAO); 2008 Jun. 49 p.

Extent of Measure Testing

The measures in this set are being made available without any prior formal testing. However, many of the measures in this set (Utilization of a Standardized Nomenclature for CT Imaging Description, Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies, CT Images Available for Patient Follow-Up and Comparison Purposes, Search for Prior CT Studies through a Secure, Authorized, Media-free, Shared Archive, Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines and Reporting to a Radiation Dose Index Registry) have been in use in the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System program since 2013 indicating the feasibility of collecting the data elements required for measure calculation.

The American College of Radiology (ACR) recognizes the importance of thorough testing all of its measures and encourages ongoing robust testing of the Optimizing Patient Exposure to Ionizing Radiation measurement set for feasibility and reliability by organizations or individuals positioned to do so. The ACR will welcome the opportunity to promote such testing of these measures and to ensure that any results available from testing are used to refine the measures on an ongoing basis.

Evidence for Extent of Measure Testing

American Board of Medical Specialties (ABMS), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), American College of Radiology (ACR). Optimizing patient exposure to ionizing radiation performance measurement set. Reston (VA): American College of Radiology; 2016 Jan. 51 p. [53 references]

State of Use

Current routine use

Current Use

Internal quality improvement

Professional certification

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Emergency Department

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age less than or equal to 17 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Diagnostic Evaluation

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All pediatric computed tomography (CT) imaging studies for patients aged 17 years and younger

Exclusions
Unspecified

Exceptions
Documentation of medical reason(s) for not performing CT studies with individualized equipment evaluation protocols (e.g., CT studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
Pediatric computed tomography (CT) imaging studies performed with individualized equipment evaluation protocols* that comply with a widely used guideline

*Equipment evaluation protocols should include at a minimum the following two documented components:

  • Baseline techniques for an adult head and abdomen CT
  • Determine the appropriate mAs for a pediatric thorax, abdomen and head CT

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

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 #8: utilization of pediatric CT imaging protocols.

Measure Collection Name

Optimizing Patient Exposure to Ionizing Radiation Performance Measurement Set

Submitter

American College of Radiology - Medical Specialty Society

Developer

American College of Radiology - Medical Specialty Society

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Optimizing Patient Exposure to Ionizing Radiation Work Group Members

  • Milton J. Guiberteau, MD (Co-chair) (nuclear radiology/diagnostic radiology)
  • David Seidenwurm, MD (Co-chair) (neuroradiology/pediatric and diagnostic radiology)
  • Dennis M. Balfe, MD (diagnostic radiology)
  • Dorothy Bulas, MD (pediatric radiology)
  • Philip N. Cascade, MD (cardiothoracic radiology)
  • C. Daniel Johnson, MD, MS, MMM (GI radiology)
  • Richard L. Morin, PhD (radiologic physics)
  • Robert D. Rosenberg, MD (diagnostic radiology)
  • Howard Sandler, MD, MS (physics) (radiation oncology)
  • Rebecca Smith-Bindman, MD (diagnostic radiology)
  • Christopher Wyatt, MHM (payer representative)

Advisory Group Members

  • Scott Jerome, DO (cardiology/internal medicine)
  • Paul M. Knechtges, MD (diagnostic radiology)
  • John R. Maese, MD (internal medicine/geriatrics)
  • Jason Sheehan, MD, PhD (neurosurgery)
  • Paul R. Sierzenski, MD, RDMS (emergency medicine)
  • Liana Watson, DM, RT(R)(M)(S)(BS), RDMS, RVT (radiography/sonography)
  • Sjirk J. Westra, MD (pediatric radiology)

Work Group Staff

American Board of Medical Specialties: Richard Hawkins, MD; Sheila Lazier; Katie Small; Robin Wagner, RN, MHSA; Kevin Weiss, MD, MPH

American Board of Radiology: Gary Becker, MD; Jennifer Bosma, PhD; Paul Wallner, DO

American College of Radiology: Judy Burleson, MHSA

American Medical Association: Mark Antman, DDS, MBA; Elvia Chavarria, MPH; Anu Gupta, JD; Kendra Hanley, MS; Samantha Tierney, MPH

American Medical Association-convened Physician Consortium for Performance Improvement (PCPI) Consultant: Rebecca Kresowik

Financial Disclosures/Other Potential Conflicts of Interest

None of the members of the Patient Optimizing Patient Exposure to Ionizing Radiation Work Group had any disqualifying material interests 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

2016 Jan

Measure Maintenance

This measure set is reviewed and updated every 3 years

Date of Next Anticipated Revision

2017

Measure Status

This is the current release of the measure.

Source(s)

American Board of Medical Specialties (ABMS), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®), American College of Radiology (ACR). Optimizing patient exposure to ionizing radiation performance measurement set. Reston (VA): American College of Radiology; 2016 Jan. 51 p. [53 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 November 4, 2015. The information was verified by the measure developer on December 29, 2015.

Copyright Statement

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

©2014 American Board of Medical Specialties, American College of Radiology and American Medical Association. All Rights Reserved. CPT® Copyright 2004-2013 American Medical Association.

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