The latest comment period for imaging appropriateness measures is underway.  CMS announced last week that through The Lewin Group and its subcontractors, the National Imaging Associates, Inc., (NIA) and Dobson | DaVanzo & Associates, LLC, it is developing a preliminary set of outpatient imaging efficiency measures, and is seeking input through December 14, 2008 at the Imaging Measures website, which has a wealth of information on the measures (descriptions of the four measures are excerpted below) which, interestingly enough, are entirely different from the four measures featured at the same URL a year agoThe measures may be used by CMS under MIPPA as part of the accreditation regime and are certainly preferable to the prior authorization regime currently in favor.

Here are the four measures:

MEASURE ONE: SPECT MPI AND Stress Echocardiography for Preoperative Evaluation for Low-Risk Non-Cardiac Surgery Risk Assessment

Setting: Outpatient
Numerator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy) preceded, within 30 days, by a single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), Stress Echocardiography, or Stress magnetic resonance imaging (MRI) study
Denominator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy)

A review of stress echocardiography appropriateness criteria for specific clinical scenarios was recently completed and published by The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE). Review of SPECT MPI appropriateness criteria for specific clinical scenarios was completed and published by ACCF and the American Society of Nuclear Cardiology (ASNC). The purpose of the published criteria is to "help guide a more efficient and equitable allocation of health care resources."

The proposed measure seeks to calculate relative use of stress echocardiography, stress MRI, and SPECT MPI prior to low-risk non-cardiac surgical procedures.

The appropriateness criteria provided specific guidance that use of stress echocardiography and SPECT MPI are not appropriate tests for preoperative evaluation of patients undergoing low risk non-cardiac surgical procedures. The appropriateness score assigned to the use of stress echocardiography and SPECT MPI for the indication is the lowest at one (1). Scores of 1-3 are defined as inappropriate (the test is generally not indicated).

The criteria define low risk surgery as cardiac death or MI in less than 1 percent of performed procedures — endoscopic procedures, superficial procedures, cataract surgery, and breast surgery (biopsy).

MEASURE TWO: Use of Stress Echocardiography or SPECT MPI Post-Revascularization Coronary Artery Bypass Graft

Setting: Outpatient
Numerator: Patients who have had a stress echocardiography or SPECT MPI study in the five-year period following a coronary artery bypass graft (CABG) procedure.
Denominator: Patients who have had a CABG procedure.
Exclusions: All tests performed in the first six months post-CABG; any patient with clinical risk predictors for silent ischemia or accelerated coronary artery disease (CAD) (e.g., diabetes); and any patient who undergoes a catheterization, percutaneous coronary intervention (PCI), or CABG procedure in the six months following the post-revascularization Stress Echocardiography or SPECT MPI.

A review of stress echocardiography appropriateness criteria for specific clinical scenarios was recently completed and published by The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE). Review of SPECT MPI appropriateness criteria for specific clinical scenarios was completed and published by ACCF and the American Society of Nuclear Cardiology (ASNC). The purpose of the published criteria is to "help guide a more efficient and equitable allocation of health care resources."

The proposed measure seeks to estimate relative use of stress echocardiography and SPECT MPI in asymptomatic patients less than five years after a CABG procedure.

The appropriateness criteria provided specific guidance that use of stress echocardiography is not appropriate for risk assessment within five years for asymptomatic patients. The appropriateness score assigned to the use of stress echocardiography for the indication is two (2). Scores of 1-3 are defined as inappropriate (the test is generally not indicated). Use of SPECT MPI for the indication was scored at six (6). Scores of 4 -6 are defined as uncertain.

MEASURE THREE: Use of Computed Tomography in Emergency Department for Headache

Setting: Emergency Department (ED)
Numerator: ED visits with a presenting complaint of headache with a coincident brain CT study
Denominator: ED visits with a presenting complaint of headache
Exclusions: Patients who are hospitalized (admitted), patients who are transferred to another acute care hospital, patients with a lumbar puncture, diagnosis codes indicative of dizziness, paresthesia, lack of coordination, subarachnoid hemorrhage, or thunderclap.

Clinical guidelines and literature indicate that there is a general consensus that neuroimaging is rarely
productive for [headache] patients with normal physical and neurological exams and medical histories.
Unnecessary CT is costly financially, in false positive interpretation, and in excess radiation. This measure seeks to identify inappropriate practice patterns.

MEASURE FOUR: Simultaneous Use of Brain Computed Tomography and Sinus Computed Tomography

Setting: Outpatient
Numerator: Patients with a presenting complaint of headache who have a brain computed tomography (CT) and sinus CT study performed simultaneously (i.e., on the same date at the same facility)
Denominator: Patients with a presenting complaint of headache who have a brain CT study
Exclusions: Patients with trauma diagnoses, tumor, or orbital cellulitis

Clinical guidelines and literature indicate that there is a general consensus that neuroimaging is rarely productive for patients with normal physical and neurological exams and medical histories. Even when neuroimaging is required, there are no indications for simultaneous Brain CT and Sinus CT. Moreover, unnecessary CT imaging is costly financially, risks false positive interpretation, and exposes patients to excess radiation.

(Emphasis supplied.)

David Harlow
The Harlow Group LLC
Health Care Law and Consulting