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  • Measure Summary
  • NQMC:010707
  • Jan 2016

Overuse of imaging: ratio of the number of MRI scans to the number of CT scans obtained on or within the 30 days after the date of evaluation for atraumatic headache for children, ages 4 through 17 years old, within the measurement year.

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2016 Jan. 57 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the ratio of the number of magnetic resonance imaging (MRI) scans to the number of computed tomography (CT) scans obtained on or within the 30 days after the date of evaluation for atraumatic headache for children, ages 4 through 17 years old, within the measurement year.

A higher ratio of MRI to CT scans indicates better performance, as reflected by a smaller number of children being exposed to radiation as a result of neuroimaging.

Rationale

Headaches are common in the pediatric population (Lateef et al., "Headache in a national," 2009), and children with headaches are frequently evaluated in emergency departments and primary care settings (DeVries et al., 2013; National Hospital Ambulatory Medical Care Survey, 2011). Although most headaches are not symptomatic of underlying disease, the differential diagnosis list for headache is long, with over 300 different types and causes (Evans, 1996). Headaches are divided into two main classifications: primary headaches, such as migraine or tension headaches, and secondary headaches, which include headaches attributed to a separate condition, such as infection, trauma, tumors, or vascular problems (International Headache Society [IHS], 2014). For the purposes of this measure, atraumatic headaches are considered to be primary headaches or secondary headaches unrelated to injury.

Computed tomography (CT) and magnetic resonance (MR) of the brain are the neuroimaging modalities at the center of this overuse measure. Both are radiologic modalities used to create images of internal structures in a slice-by-slice manner. CT uses X-ray radiation (hereafter simply called radiation), and MR uses magnetic fields and radio waves. CT scans are simple to order because the technology is readily available (Ginde et al., 2008), fast, and less expensive to perform than magnetic resonance imaging (MRI). MRI, however, has advantages for the assessment of children with atraumatic headache, because it does not involve radiation and offers better spatial resolution for identifying structural causes of headaches. This measure is focused on the overuse of CT in the setting of headache, a problem that has gained national attention in recent years (Loder et al., 2013). Overuse has been defined as any patient who undergoes a procedure or test for an inappropriate indication (Lawson et al., 2012).

While there are valid reasons for obtaining neuroimaging to characterize atraumatic headaches—specifically when concern exists regarding an underlying condition such as an arteriovenous malformation or tumor—in general, the yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low (Hayes et al., 2012; Chu & Shinnar, 1992; Evans, 1996; Gandhi et al., 2015; Lateef et al., "Headache in young," 2009; Lateef et al., 2012). Yet, neuroimaging is increasingly used to evaluate for structural abnormalities of the brain in pediatric patients who experience headache (Broder, Fordham, & Warshauer, 2007; Graf et al., 2008; Larson et al., 2011). Such neuroimaging studies rarely result in a change in care management, suggesting overuse in the evaluation of children who have experienced an atraumatic headache (Lateef et al., "Headache in young," 2009). In its guidelines for imaging children with secondary headaches accompanied by neurological signs or symptoms of increased intracranial pressure, the American College of Radiology (ACR) recommends MRI; CT is suggested as an alternative in instances where MRI is unavailable or problems with sedation arise (Hayes et al., 2012).

Imaging overuse subjects children to a number of risks (Malviya et al., 2000; Mathews et al., 2013; Pearce et al., 2012; Wachtel, Dexter, & Dow, 2009). Children who undergo CT scans in early life tend to be at greater risk for developing leukemia, primary brain tumors, and other malignancies later in life (Mathews et al., 2013; Pearce et al., 2012). Children are also at risk for complications from sedation or anesthesia, which are often required for MRI and longer CT imaging sequences. These complications include compromised airway, hypoxia leading to central nervous system injury, and death. Additionally, overuse of imaging creates cost burdens for the patient, as well as for payers. Providers should carefully consider the risks and benefits of neuroimaging before ordering. The overuse of CT imaging when MRI is a reasonable alternative for the characterization of atraumatic headache is the central focus of this measure.

Evidence for Rationale

Broder J, Fordham LA, Warshauer DM. Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006. Emerg Radiol. 2007 Sep;14(4):227-32. PubMed External Web Site Policy

Chu ML, Shinnar S. Headaches in children younger than 7 years of age. Arch Neurol. 1992 Jan;49(1):79-82. PubMed External Web Site Policy

DeVries A, Young PC, Wall E, Getchius TS, Li CH, Whitney J, Rosenberg A. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics. 2013 Jul;132(1):e1-8. PubMed External Web Site Policy

Evans RW. Diagnostic testing for the evaluation of headaches. Neurol Clin. 1996 Feb;14(1):1-26. PubMed External Web Site Policy

Gandhi R, Lewis EC, Evans JW, Sell E. Investigating the necessity of computed tomographic scans in children with headaches: a retrospective review. CJEM. 2015 Mar;17(2):148-53. PubMed External Web Site Policy

Ginde AA, Foianini A, Renner DM, Valley M, Camargo CA. Availability and quality of computed tomography and magnetic resonance imaging equipment in U.S. emergency departments. Acad Emerg Med. 2008 Aug;15(8):780-3. PubMed External Web Site Policy

Graf WD, Kayyali HR, Alexander JJ, Simon SD, Morriss MC. Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters. Pediatrics. 2008 Nov;122(5):e1001-5. PubMed External Web Site Policy

Hayes LL, Coley BD, Karmazyn B, Dempsey-Robertson ME, Dillman JR, Dory CE, Garber M, Keller MS, Kulkarni AV, Meyer JS, Milla SS, Myseros JS, Paidas C, Raske ME, Rigsby CK, Strouse PJ, Wootton-Gorges SL, Expert Panel on Pediatric Imaging. ACR Appropriateness Criteria® headache - child. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 8 p. [41 references]

International Headache Society (IHS). The International Headache Classification (ICHD-2). [internet]. London (UK): International Headache Society (IHS); 2014 [accessed 2015 Mar 09].

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

Lateef TM, Grewal M, McClintock W, Chamberlain J, Kaulas H, Nelson KB. Headache in young children in the emergency department: use of computed tomography. Pediatrics. 2009 Jul;124(1):e12-7. PubMed External Web Site Policy

Lateef TM, Kriss R, Carpenter K, Nelson KB. Neurologic complaints in young children in the ED: when is cranial computed tomography helpful?. Am J Emerg Med. 2012 Oct;30(8):1507-14. PubMed External Web Site Policy

Lateef TM, Merikangas KR, He J, Kalaydjian A, Khoromi S, Knight E, Nelson KB. Headache in a national sample of American children: prevalence and comorbidity. J Child Neurol. 2009 May;24(5):536-43. PubMed External Web Site Policy

Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012 Nov;65(11):1133-43. PubMed External Web Site Policy

Loder E, Weizenbaum E, Frishberg B, Silberstein S, American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question. Headache. 2013 Nov-Dec;53(10):1651-9. PubMed External Web Site Policy

Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth. 2000 Jun;84(6):743-8. PubMed External Web Site Policy

Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013;346:f2360. PubMed External Web Site Policy

National Hospital Ambulatory Medical Care Survey (NHAMCS): 2011 emergency department summary tables. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2011. 39 p.

Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. PubMed External Web Site Policy

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2016 Jan. 57 p.

Wachtel RE, Dexter F, Dow AJ. Growth rates in pediatric diagnostic imaging and sedation. Anesth Analg. 2009 May;108(5):1616-21. PubMed External Web Site Policy

Primary Health Components

Atraumatic headache; computed tomography (CT); magnetic resonance imaging (MRI); overuse; children

Denominator Description

The denominator is the number of computed tomography (CT) scans of the head obtained on or within 30 days after the date of evaluation for atraumatic headache among children, ages 4 through 17 years old, within the measurement year. See the related "Denominator Inclusions/Exclusions" field.

Numerator Description

The numerator is the number of magnetic resonance imaging (MRI) scans of the head obtained on or within 30 days after the date of evaluation for atraumatic headache among children, ages 4 through 17 years old, within the measurement year. 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
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Atraumatic Headache Prevalence and Incidence
Headaches are common in the pediatric population (Lateef et al., 2009), and children with headaches are frequently evaluated in emergency departments and primary care settings (DeVries et al., 2013; National Hospital Ambulatory Medical Care Survey, 2011). Headaches occur more often as children grow older (Hayes et al., 2012). At age 7 years, prevalence ranges from 37% to 51%. By age 15 years, 57% to 82% of children have experienced headaches. And among 16-year-olds, 93% or more have reported experiencing a severe headache (Hayes et al., 2012). Before puberty, boys are more likely than girls to experience headache. The situation is reversed after puberty, when headaches are more commonly reported in girls (Hayes et al., 2012).

Atraumatic Headache Pathology and Severity
Headaches can be classified as either primary (not a symptom of an underlying disease, condition or trauma) or secondary (related to an existing issue). Examples of primary headaches include migraine and tension headaches. Examples of secondary headaches include headaches associated with dehydration, sinusitis, tumor, and vascular malformations. For the purposes of this measure, atraumatic headaches are considered to be primary headaches or secondary headaches unrelated to injury.

The precise pathophysiology of headaches is still not fully understood, but research suggests that complex interactions between the neural and vascular systems are involved (Edvinsson, 2001). The manifestation and perception of headache is unique and specific to the child who experiences it. Correspondingly, the management approach for children with headaches often focuses on reassurance and education by the clinician who evaluates the child (Brna & Dooley, 2006; Raieli et al., 2010).

Burdens of Using Computed Tomography (CT) Instead of Magnetic Resonance Imaging (MRI) for Characterization of Atraumatic Headache: Radiation, Sedation/Anesthesia, and Intravenous Contrast Risks; Cost
MRI is generally preferred to CT because of its superior resolution, versatility, and lack of radiation dose (Hayes et al., 2012; Gaillard et al., 2011). An MRI for optimally resolving neurologic structures takes approximately 30 minutes or more to accomplish and will often require sedation to successfully image younger children. CT can be favored in some situations, for example, when imaging must be obtained emergently or there is concern for intracranial hemorrhage.

The literature offers many examples of the potential risks associated with overuse of imaging. Chief among these are risks related to radiation (Mathews et al., 2013; Pearce et al., 2012), sedation and/or anesthesia (Malviya et al., 2000; Wachtel, Dexter, & Dow, 2009), and intravenous contrast media (Zo'o et al., 2011).

Radiation-Related Burden and Risk. Radiation exposure associated with CT-imaging introduces the possibility of chronic health risks related to malignancies sustained from radiation effects (Berrington de González et al., 2009; Mathews et al., 2013; Pearce et al., 2012). Radiosensitive organs including the brain, bone marrow, lens of the eye, and thyroid gland can be exposed to radiation during CT of the head (Papadakis et al., 2011). In children younger than 5 years, about 20% of the active bone marrow is in the cranium, compared with 8% in adults (Cristy, 1981). CT-based radiation dose for pediatric patients is highly problematic because developing cellular structures and tissues of children are significantly more radiosensitive than those of adults; children, therefore, will be at substantially elevated risk for malignancy (Hayes et al., 2012).

To conduct imaging studies with radiation dosing that is appropriate for children, many facilities follow policies and protocols using the concept of ALARA—as low as reasonably achievable. ALARA principles deem any additional radiation beyond the minimum needed for interpretable images both detrimental and non-efficacious (American College of Radiology [ACR], 2009). Professional practice and patient advocacy groups, including the ACR, the American Academy of Neurology (AAN), and the American Academy of Pediatrics (AAP), have developed and promoted ALARA protocols and policies. These guidelines support the use of CT imaging only when clinically indicated in children, decreasing the risk of harm from radiation.

Sedation- and Anesthesia-Related Burden and Risk. Some children will require sedation to ensure minimal movement during CT and MRI studies. Use of sedation is necessary to avoid motion artifacts, which invariably occur if the child moves during the image acquisition, thus interfering with image quality. Motion artifacts sometimes undermine imaging quality to the point of rendering images unreadable. In the case of CT imaging, this may result in additional radiation exposure to obtain images sufficient for interpretation. Although the sedation used for pediatric imaging has been identified as low risk, it does have potential attendant complications (Cravero et al., 2006; Malviya et al., 2000). Levels of sedation are on a continuum from minimal anxiolysis (administration of an anxiety reduction agent) to deep sedation, in which the patient can be roused only via vigorous stimuli (Arthurs & Sury, 2013). Compared with minimal sedation, moderate and deep sedation carry a greater risk of airway compromise, hypoxia resulting in central nervous system injury, and death (Cravero et al., 2006).

In certain instances, sedation may not be sufficient, and anesthesia will be required to complete imaging. Anesthesia includes administration of medication that results in some degree of respiratory suppression and potential for cardiac depression; the patient cannot be roused by external stimuli or commands (Arthurs & Sury, 2013). Administration of anesthesia raises risks related to the process of intubation for respiratory support. These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries, veins, or nerves; alterations in blood pressure; and/or irregular heart rhythms (Society for Pediatric Anesthesia, 2014). The most severe risks, though rare, include brain damage and death (Society for Pediatric Anesthesia, 2014).

Intravenous Contrast-Related Burden and Risk. During the course of CT and MRI studies, intravenous (IV) contrast media may be used to enhance visualization of vascular structures and provide important information about neurologic anatomy. It is possible the child may experience an allergic reaction to IV contrast or subcutaneous fluid leakage (extravasation) during administration of IV contrast. IV contrast administration also includes the risk of contrast-induced nephrotoxicity (CIN) (Bansal et al., 2014; Zo'o et al. 2011). Children with poor kidney function are at greater risk for developing CIN and, in rare cases, will develop renal failure requiring dialysis.

Cost-Related Burden. Overuse of imaging is costly and places additional strain on an already heavily burdened health care system (Callaghan et al., 2014). As an example, charges for a CT scan of the head can be as much as $2,000 and can vary substantially by region of the country. In addition, the likelihood that neuroimaging will result in the identification of clinically important structural abnormalities in this patient population is low. Incidental findings, however, may require follow-up testing with associated charges and potential complications (Lumbreras, Donat, & Hernández-Aguado, 2010; Rogers et al., 2013).

Performance Gap
Currently, professional guidelines do not support neuroimaging for atraumatic headache in the absence of documented neurologic signs or symptoms that suggest increased intracranial pressure or persistent neurological deficits. While many children with headaches will not benefit from neuroimaging, children experiencing secondary headaches associated with trauma, new neurologic deficits, or signs and symptoms of increased intracranial pressure may require timely imaging. CT is usually the initial imaging modality of choice for patients who require timely imaging in the acute clinical setting or when intracranial hemorrhage is a concern (Hayes et al., 2012). CT imaging is readily available in most emergency departments (Ginde et al., 2008).

The ACR Appropriateness Criteria (Hayes et al., 2012) rank MRI as more appropriate than CT in patients with atraumatic headache. MRI will usually be the preferred modality instead of CT, because MRI does not use radiation and tends to have improved spatial resolution. Even for the evaluation of time-sensitive conditions such as failure of a ventricular-peritoneal shunt, MRI may be a reasonable alternative to CT for children with atraumatic headaches (Boyle et al., 2014; Kim et al., 2015).

Drivers of Overuse
Atraumatic headache experienced by a child, especially when recurrent, can be a stressful event that may prompt a parent to seek the assistance of a health care provider, at times emergently. Some providers may feel pressured by the parent to order imaging despite the lack of benefit (Daymont et al., 2014; Raieli et al., 2010). This circumstance has a close parallel to parents who seek out antibiotics for a child who has viral respiratory symptoms. In these circumstances, the provider may deviate from established practice guidelines to placate the parent. In recent decades, this phenomenon has reached such wide-spread prominence as to prompt multidisciplinary initiatives targeted at fostering discussion and identifying common practices that should be questioned by parents and providers (AAP, 2013). An ongoing dialogue between providers and parents regarding the risks and benefits of neuroimaging for the evaluation of children who experience an atraumatic headache is a key feature of avoiding overuse.

The practice of defensive medicine is another reason an imaging study may be ordered. Physicians may be uncomfortable facing uncertainty regarding the etiology of headache in children they are evaluating and treating. Assurance behaviors (e.g., ordering of additional tests) are expected when a malpractice-sensitive physician is faced with a potentially worrisome condition (e.g., a brain tumor) that can cause the symptom in question (e.g., a headache) (Carrier et al., 2013). In a survey of physicians from six specialties at high risk of liability, emergency physicians ordered more unnecessary diagnostic tests than clinicians from any other specialty (Studdert, et al. 2005). Physicians practicing in the emergency department have the added challenge of limited access to detailed medical records, which increases uncertainty about prior evaluation of patients who are referred from an out-of-network provider or hospital. Overuse of neuroimaging is a potential result.

See the original measure documentation for additional evidence supporting the measure.

Evidence for Additional Information Supporting Need for the Measure

American Academy of Pediatrics (AAP). Choosing Wisely: An initiative of the ABIM Foundation. Ten things physicians and patients should question. [internet]. Philadelphia (PA): American Academy of Pediatrics (AAP); 2013 Feb 21 [accessed 2015 Feb 24].

American College of Radiology (ACR). Statement on recent studies regarding CT scans and increased cancer risk. [internet]. Reston (VA): American College of Radiology (ACR); 2009 Dec 15 [accessed 2015 Jul 14].

Arthurs OJ, Sury M. Anaesthesia or sedation for paediatric MRI: advantages and disadvantages. Curr Opin Anaesthesiol. 2013 Aug;26(4):489-94. PubMed External Web Site Policy

Bansal R. Contrast-induced nephropathy. In: Medscape Drugs & Diseases [internet]. New York (NY): WebMD LLC; 2014 [accessed 2015 Apr 20].

Berrington de Gonzalez A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, Land C. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009 Dec 14;169(22):2071-7. PubMed External Web Site Policy

Boyle TP, Paldino MJ, Kimia AA, Fitz BM, Madsen JR, Monuteaux MC, Nigrovic LE. Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics. 2014 Jul;134(1):e47-54. PubMed External Web Site Policy

Brna PM, Dooley JM. Headaches in the pediatric population. Semin Pediatr Neurol. 2006 Dec;13(4):222-30. PubMed External Web Site Policy

Callaghan BC, Kerber KA, Pace RJ, Skolarus LE, Burke JF. Headaches and neuroimaging: high utilization and costs despite guidelines. JAMA Intern Med. 2014 May;174(5):819-21. PubMed External Web Site Policy

Carrier ER, Reschovsky JD, Katz DA, Mello MM. High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Aff (Millwood). 2013 Aug;32(8):1383-91. PubMed External Web Site Policy

Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B, Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006 Sep;118(3):1087-96. PubMed External Web Site Policy

Cristy M. Active bone marrow distribution as a function of age in humans. Phys Med Biol. 1981 May;26(3):389-400. PubMed External Web Site Policy

Daymont C, McDonald PJ, Wittmeier K, Reed MH, Moffatt M. Variability of physicians' thresholds for neuroimaging in children with recurrent headache. BMC Pediatr. 2014;14:162. PubMed External Web Site Policy

DeVries A, Young PC, Wall E, Getchius TS, Li CH, Whitney J, Rosenberg A. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics. 2013 Jul;132(1):e1-8. PubMed External Web Site Policy

Edvinsson L. Pathophysiology of primary headaches. Curr Pain Headache Rep. 2001 Feb;5(1):71-8. PubMed External Web Site Policy

Gaillard WD, Cross JH, Duncan JS, Stefan H, Theodore WH, Task Force on Practice Parameter Imaging Guidelines for International League Against Epilepsy [TRUNC. Epilepsy imaging study guideline criteria: commentary on diagnostic testing study guidelines and practice parameters. Epilepsia. 2011 Sep;52(9):1750-6. PubMed External Web Site Policy

Ginde AA, Foianini A, Renner DM, Valley M, Camargo CA. Availability and quality of computed tomography and magnetic resonance imaging equipment in U.S. emergency departments. Acad Emerg Med. 2008 Aug;15(8):780-3. PubMed External Web Site Policy

Hayes LL, Coley BD, Karmazyn B, Dempsey-Robertson ME, Dillman JR, Dory CE, Garber M, Keller MS, Kulkarni AV, Meyer JS, Milla SS, Myseros JS, Paidas C, Raske ME, Rigsby CK, Strouse PJ, Wootton-Gorges SL, Expert Panel on Pediatric Imaging. ACR Appropriateness Criteria® headache - child. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 8 p. [41 references]

Kim I, Torrey SB, Milla SS, Torch MC, Tunik MG, Foltin JC. Benefits of brain magnetic resonance imaging over computed tomography in children requiring emergency evaluation of ventriculoperitoneal shunt malfunction: reducing lifetime attributable risk of cancer. Pediatr Emerg Care. 2015 Apr;31(4):239-42. PubMed External Web Site Policy

Lateef TM, Grewal M, McClintock W, Chamberlain J, Kaulas H, Nelson KB. Headache in young children in the emergency department: use of computed tomography. Pediatrics. 2009 Jul;124(1):e12-7. PubMed External Web Site Policy

Lumbreras B, Donat L, Hernández-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Br J Radiol. 2010 Apr;83(988):276-89. PubMed External Web Site Policy

Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth. 2000 Jun;84(6):743-8. PubMed External Web Site Policy

Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013;346:f2360. PubMed External Web Site Policy

National Hospital Ambulatory Medical Care Survey (NHAMCS): 2011 emergency department summary tables. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2011. 39 p.

Papadakis AE, Perisinakis K, Oikonomou I, Damilakis J. Automatic exposure control in pediatric and adult computed tomography examinations: can we estimate organ and effective dose from mean MAS reduction?. Invest Radiol. 2011 Oct;46(10):654-62. PubMed External Web Site Policy

Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505. PubMed External Web Site Policy

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2016 Jan. 57 p.

Raieli V, Compagno A, Pandolfi E, La Vecchia M, Puma D, La Franca G, Ragusa D. Headache: what do children and mothers expect from pediatricians?. Headache. 2010 Feb;50(2):290-300. PubMed External Web Site Policy

Rogers AJ, Maher CO, Schunk JE, Quayle K, Jacobs E, Lichenstein R, Powell E, Miskin M, Dayan P, Holmes JF, Kuppermann N, Pediatric Emergency Care Applied Research Network. Incidental findings in children with blunt head trauma evaluated with cranial CT scans. Pediatrics. 2013 Aug;132(2):e356-63. PubMed External Web Site Policy

Society for Pediatric Anesthesia. Frequently asked questions: What are the risks of anesthesia?. [internet]. 2014 [accessed 2015 Feb 24].

Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005 Jun 1;293(21):2609-17. PubMed External Web Site Policy

Wachtel RE, Dexter F, Dow AJ. Growth rates in pediatric diagnostic imaging and sedation. Anesth Analg. 2009 May;108(5):1616-21. PubMed External Web Site Policy

Zo'o M, Hoermann M, Balassy C, Brunelle F, Azoulay R, Pariente D, Panuel M, Le Dosseur P. Renal safety in pediatric imaging: randomized, double-blind phase IV clinical trial of iobitridol 300 versus iodixanol 270 in multidetector CT. Pediatr Radiol. 2011 Nov;41(11):1393-400. PubMed External Web Site Policy

Extent of Measure Testing

Reliability
To evaluate the reliability of using administrative claims for the calculation of this measure, a signal-to-noise analysis was conducted. This analysis was focused on assessing the ability to confidently distinguish the performance of one state health plan from that of another state. To perform the signal-to-noise analysis, the Medicaid Analytic eXtract (MAX) administrative claims data provided by the Centers for Medicare & Medicaid Services (CMS) from 2006 to 2010 for seven state Medicaid programs were used: Colorado, Florida, Illinois, Massachusetts, Michigan, Texas, and Utah. The number of magnetic resonance imaging (MRI) and computed tomography (CT) scans per state and year are summarized in Table 7 of the original measure documentation. Ratios varied between states, ranging from a low of 0.25 in Illinois (2007) to a high of 0.67 in Utah (2009, 2010). Lowest to highest ratios of MR to CT imaging within each state across the 5-year period were as follows: Colorado (0.33 vs. 0.47), Florida (0.44 vs. 0.54), Illinois (0.25 vs. 0.31), Massachusetts (0.50 vs. 0.60), Michigan (0.30 vs. 0.49), Texas (0.37 vs. 0.40), and Utah (0.34 vs. 0.67).

For this approach, reliability was estimated with a beta-binomial model (RAND Corporation, TR-653-NCQA, 2009). This approach is applicable in instances where the numerator is a subset of the denominator; for reliability testing, the numerator was defined as the number of MRIs and the denominator was defined as (number of CTs + number of MRIs). The reliability was tested using aggregate data from these seven states, 2006 to 2010.

Reliability Results. Reliability results are detailed in Table 8 of the original measure documentation. These results show that the reliability based on signal-to-noise analysis ranged from 0.90 to 1.00 with a median of 0.99.

Reliability Conclusions. The reliability is very good; observed reliability was consistently greater than 0.90. In general, reliability scores can range from 0.0 (all variation is attributable to measurement error) to 1.0 (all variation is caused by real differences). While there is not a clear cut-off for a minimum reliability level, values above 0.7 are considered sufficient to distinguish differences between some health plans and the mean; reliability values above 0.9 are considered sufficient to see differences between health plans (RAND Corporation, TR-653-NCQA, 2009). The median reliability observed across state Medicaid programs tested for this measure was 0.99 (range: 0.90-1.00), which is consistent with a high degree of reliability.

Validity
The face validity of this measure concept was established by a national panel of experts and parent representatives for families of children with headaches and seizures convened by the Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC). The Q-METRIC panel included nationally recognized experts in the area of imaging children, representing general pediatrics, pediatric radiology, pediatric neurology, pediatric neurosurgery, pediatric emergency medicine, general emergency medicine, and family medicine. In addition, face validity of this measure concept was considered by experts in state Medicaid program operations, health plan quality measurement, health informatics, and health care quality measurement. In total, the Q-METRIC imaging panel included 15 experts, providing a comprehensive perspective on imaging children and the measurement of quality metrics for states and health plans.

The Q-METRIC expert panel concluded that this measure concept has a high degree of face validity through a detailed review of concepts and metrics considered to be essential to appropriately imaging children. Concepts and draft measures were rated by this group for their relative importance. This measure received an average score of 6.7 (with 9 as the highest possible score).

Validity of the Performance Measure Score: Overview. The validity of the measure performance score was assessed using administrative claims compared with the gold standard of the medical record.

Conclusion. The ratio of MRI to CT derived from the gold standard of medical records (0.71) compared with the ratio of MRI to CT obtained solely from administrative claims (0.76) suggests that administrative claims have a high degree of validity. In addition, administrative claims are highly specific in respect to the exclusion criteria compared with the gold standard of medical records. Therefore, it is concluded that administrative claims alone can be used to calculate this measure.

Refer to the original measure documentation for additional information.

Evidence for Extent of Measure Testing

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2016 Jan. 57 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Emergency Department

Hospital Inpatient

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age 4 to 17 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Safety

Case Finding Period

The measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Clinical Condition

Diagnostic Evaluation

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
The denominator is the number of computed tomography (CT) scans of the head obtained on or within 30 days after the date of evaluation for atraumatic headache among children, ages 4 through 17 years old, within the measurement year.

Note:

  • Eligible children must be ages 4 through 17 years old during the measurement year for which imaging is obtained and must be continuously enrolled in their insurance plan during both the measurement year and the year prior.
  • Imaging may be obtained in any department of the hospital or at sites outside the hospital, such as free-standing imaging facilities and emergency departments. Each scan obtained on or within the 30 days after the date of evaluation for atraumatic headache is the event used in the calculation. A list of codes for imaging studies of the head (CT) are shown in Table 1 of the original measure documentation. Codes to identify atraumatic headache are shown in Table 2 of the original measure documentation. Atraumatic headache must be diagnosed on the day of or up to 30 days prior to imaging. Atraumatic headaches are those not associated with trauma occurring in the past 7 days.

Exclusions
Exclusions based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes captured in administrative claims data:

  • Trauma-related headache or pain (refer to Table 2 of the original measure documentation) on the day of or within the 7 days prior to imaging
  • Head injury by related ICD-9-CM codes (refer to Table 3 of the original measure documentation) or by the presence of an E-code on the day of or within the 7 days prior to imaging
  • Thunderclap headache (refer to Table 2 of the original measure documentation), on the day of or within 365 days prior to imaging
  • Vascular disease (refer to Table 4 of the original measure documentation) on the day of or within 365 days prior to imaging
  • Relative contraindications to magnetic resonance imaging (MRI) (refer to Table 5 of the original measure documentation) on the day of or within 365 days prior to imaging. (Note: Some contraindications are guidelines rather than strict rules. As such, a provider may determine that a child should undergo an MRI despite a contraindication.)

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
The numerator is the number of magnetic resonance imaging (MRI) scans of the head obtained on or within 30 days after the date of evaluation for atraumatic headache among children, ages 4 through 17 years old, within the measurement year.

Note:

  • Eligible children must be ages 4 through 17 years old during the measurement year for which imaging is obtained and must be continuously enrolled in their insurance plan during both the measurement year and the year prior.
  • Imaging may be obtained in any department of the hospital or at sites outside the hospital, such as free-standing imaging facilities and emergency departments. Each scan obtained on or within the 30 days after the date of evaluation for atraumatic headache is the event used in the calculation. Table 1 of the original measure documentation lists Current Procedural Terminology (CPT) codes associated with brain imaging (MRI). International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes to identify atraumatic headache are shown in Table 2 of the original measure documentation. Atraumatic headache must be diagnosed on the day of or up to 30 days prior to imaging. Atraumatic headaches are those not associated with trauma occurring in the past 7 days.

Exclusions
Exclusions based on ICD-9-CM codes captured in administrative claims data:

  • Trauma-related headache or pain (refer to Table 2 of the original measure documentation) on the day of or within the 7 days prior to imaging
  • Head injury by related ICD-9-CM codes (refer to Table 3 of the original measure documentation) or by the presence of an E-code on the day of or within the 7 days prior to imaging
  • Thunderclap headache (refer to Table 2 of the original measure documentation), on the day of or within 365 days prior to imaging
  • Vascular disease (refer to Table 4 of the original measure documentation) on the day of or within 365 days prior to imaging

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

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

Ratio

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

Ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache.

Measure Collection Name

Overuse of Imaging for the Evaluation of Children with Headache or Seizures

Submitter

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Developer

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) - Academic Affiliated Research Institute

Funding Source(s)

This work was funded by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) under the Children's Health Insurance Program Reauthorization Act (CHIPRA) Pediatric Quality Measures Program Centers of Excellence grant number U18 HS020516.

Composition of the Group that Developed the Measure

Overuse of Imaging Expert Panels

Representative Panel

  • Dana Cook, Parent Representative, Paw Paw, MI
  • Peter Dayan, MD, MSc, Division of Pediatric Emergency Medicine, Morgan Stanley Children's Hospital, New York, NY
  • Lisa Dover, Parent Representative, Ann Arbor, MI
  • Danny Greig, MD, FAAFP, Emergency Room Physician, MidMichigan Medical Center, Midland, MI
  • Blaise Jones, MD, Director of Clinical Services, Chief of Neuroradiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
  • Steven Leber, MD, PhD, Professor of Pediatrics and Neurology, University of Michigan, Ann Arbor, MI
  • Cormac Maher, MD, Associate Professor of Neurosurgery, University of Michigan, Ann Arbor, MI
  • L. Kendall Webb, MD, Assistant Professor of Emergency Medicine, Director of IT for the Emergency Department, University of Florida, Jacksonville, Jacksonville, FL
  • Neal Weinberg, MD, FAAP, General Pediatrician, IHA Pediatric Healthcare – Arbor Park, Ann Arbor, MI

Feasibility Panel

  • Cathy Call, RN, BSN, MSEd, MSN, CPHQ, PMP, LSS, Practice Area Leader for Health Quality Research, Health Care Analytics Group, Altarum Institute, Alexandria, VA
  • Andrea DeVries, PhD, Director of Research Operations, HealthCore Inc., Wilmington, DE
  • J. Mitchell Harris, PhD, Director of Research and Statistics, Children's Hospital Association, (formerly NACHRI), Alexandria, VA
  • Don Lighter, MD, MBA, Director, The Institute for Health Quality Research and Education, Knoxville, TN
  • Sue Moran, BSN, MPH, Director of the Bureau of Medicaid Program Operations and Quality Assurance, Michigan Department of Community Health, Lansing, MI
  • Stuart Weinberg, MD, Assistant Professor of Biomedical Informatics, Assistant Professor of Pediatrics, Vanderbilt University, Nashville, TN

Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Investigators

  • Michelle L. Macy, MD, MS, Assistant Professor, Departments of Emergency Medicine and Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI
  • Gary L. Freed, MD, MPH, Professor of Pediatrics, School of Medicine and Professor of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (principal investigator)
  • Kevin J. Dombkowski, DrPH, MS, Research Associate Professor of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Jan

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

Quality Measurement, Evaluation, Testing, Review and Implementation Consortium (Q-METRIC). Basic measure information: ratio of magnetic resonance imaging scans to computed tomography scans for the evaluation of children with atraumatic headache. Ann Arbor (MI): Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC); 2016 Jan. 57 p.

Measure Availability

Source available from the Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) Web site External Web Site Policy. Support documents also available from the Q-METRIC Web site External Web Site Policy.

For more information, contact Q-METRIC at 300 North Ingalls Street, Room 6C08, SPC 5456, Ann Arbor, MI 48109-5456; Phone: 734-232-0657.

NQMC Status

This NQMC summary was completed by ECRI Institute on May 9, 2016. The information was verified by the measure developer on June 29, 2016.

Copyright Statement

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

Inform Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) if users implement the measures in their health care settings.

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