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Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Facility Level)

CBE ID
3663e
1.4 Project
Patient Safety
Endorsement Status
Endorsed
1.1 New or Maintenance
Maintenance
Previous Endorsement Cycle
Fall 2021
Is Under Review
No
Next Maintenance Cycle
Fall 2025
1.3 Measure Description

This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam. All diagnostic CT exams of specified anatomic sites performed in inpatient and hospital outpatient care settings are eligible.

    • 1.14 Numerator

      Diagnostic CT exams that have a size-adjusted radiation dose value greater than the threshold specific to the CT category (reflecting the body region imaged and the radiation dose and image quality required for that exam given the reason for the exam), or a global noise value greater than a threshold specific to the CT Category. 

    • 1.15 Denominator

      All diagnostic CT exams performed on adults (aged 18 years and older) during the measurement period of one year that have an assigned CT category, a size-adjusted radiation dose value, and a global noise value. 

    • Exclusions

      Denominator exclusions are CT exams that simultaneously include multiple body regions outside of four commonly encountered multiple region groupings (specified as LOINC code 96914-7, CT Dose and Image Quality Category, Full Body). Denominator exclusions are also CT exams with missing patient age, missing size-adjusted radiation dose, or missing global noise. These are technical exclusions (“missing data”) from the initial population. Technical exclusions will be flagged, corrected whenever possible, and tracked at the level of the accountable entity. 

    • Most Recent Endorsement Activity
      Endorsed Patient Safety Fall Cycle 2021
      Initial Endorsement
      Last Updated
    • Steward
      Alara Imaging
      Steward Organization POC Email
      [email protected]
      Steward Organization Copyright

      Copyright (C) 2021 Alara Imaging, Inc. All Rights Reserved. 

      Alara Imaging, Inc. is not responsible for any use of the Measure. Alara Imaging, Inc. makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and Alara Imaging, Inc. has no liability to anyone who relies on such measures or specifications. 

      The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by Alara Imaging, Inc. and are subject to a license at the discretion of Alara Imaging, Inc.