Radiology: Exposure Time Reported for Procedures Using Fluoroscopy (NQF 0510)

EMeasure Name Radiology: Exposure Time Reported for Procedures Using Fluoroscopy EMeasure Id 2F3D6199-9D4D-4393-8E3F-076A5AAE0877
Version number 1 Set Id A76C940A-9ECC-4FE4-8D21-37E78862C24A
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward American Medical Association - Physician Consortium for Performance Improvement
Endorsed by National Quality Forum
Description Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.
Copyright
© 2010 American Medical Association and/or National Committee for Quality Assurance. All Rights Reserved
Measure scoring Proportion
Measure type Process
Stratification
None
Risk Adjustment
None
Data Aggregation
Rationale
Data suggests that the lifetime risk for cancer can be increased, albeit by a small amount, with frequent or repeated exposure to ionizing radiation, including procedures using fluoroscopy.18 The BEIR report concluded that "the linear no-threshold model (LNT) provided the most reasonable description of the relation between low-dose exposure to ionizing radiation and the incidence of solid cancers that are induced by ionizing radiation."19 In order to monitor these long term effects, the exposure time or radiation dose that a patient receives as a result of the procedure should be measured and recorded in the patient's record.
Clinical Recommendation Statement
Radiation dose related information provided by automated dosimetry systems should be recorded in the patient’s permanent record for procedures involving more than 10 minutes of fluoroscopic exposure. If automated dosimetry data is not available, fluoroscopic exposure times should be recorded in the patient’s medical record for such procedures. (ACR, 2003)

[ACR] should now encourage practices to record actual fluoroscopy time for all fluoroscopic procedures. The fluoroscopy time for various procedures (eg, upper gastrointestinal, pediatric voiding cystourethrography, diagnostic angiography) should then be compared with benchmark figures…More complete patient radiation dose data should be recorded for all high-dose interventional procedures, such as embolizations, transjugular intrahepatic portosystemic shunts, and arterial angioplasty or stent placement anywhere in the abdomen and pelvis. (Amis et al., ACR, 2007)
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
American College of Radiology. ACR technical standard for management of the use of radiation in fluoroscopic procedures. Reston, VA: American College of Radiology, 2003. Available at: www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx
Reference
Amis E Jr, Butler P, Applegate K, Birnbaum S, Brateman L, Hevezi J, Mettler F, Morin R, Pentecost M, Smith G. American College of Radiology white paper on radiation dose in medicine. Journal of the American College of Radiology. 2007;4:272-284.
Definition
Guidance
The procedures included in the Initial Patient Population for this measure are those for which fluoroscopy is ALWAYS used, each time the procedure is performed. The measure developer acknowledges that fluoroscopy may be used in other procedures that are not included in this measure; however to reduce the burden of reporting, we have elected not to include these additional procedures where fluoroscopy may or may not be used. 

Eligible cases for this measure include every final report for procedures using fluoroscopy (that are included in the "Procedures Requiring Fluoroscopy" Code List) performed during the measurement period.  Each final report for "Procedures Requiring Fluoroscopy" counts separately in the denominator.

Table of Contents


Population criteria

Data criteria (QDS Data Elements)

Summary Calculation

Calculation is generic to all measures:



Measure set CLINICAL QUALITY MEASURE SET 2011-2012