Guidelines suggest that stroke patients should have CT within 45 minutes of arriving at the hospital to determine whether thrombolytics should be given. So when the National Quality Forum (NQF) National Voluntary Consensus Standards for Outpatient Imaging Efficiency Steering Committee voted last July to reject the CT requirement for stroke care, neurologists in the stroke community took umbrage.
The NQF endorsement of a measure is used by the Centers for Medicare & Medicaid Services (CMS) and other private sector insurers to evaluate and reimburse US hospitals and physician networks, said Lawrence R. Wechsler, MD, professor and interim chair of the neurology department and director of the University of Pittsburgh Medical Center Stroke Institute, in an e-mail message to Neurology Today. When measures like the CT scan aren't passed by the NQF, they don't get included in CMS programs — possibly precluding reimbursement and compromising stroke care.
“The emergency department physician or neurologist relies upon a rapid CT reading to decide on acute stroke therapy,” said Dr. Wechsler, who did not serve on the NQF panel. “The inability to obtain a CT within 45 minutes would likely delay treatment and reduce the number of patients receiving thrombolytics.”
The AAN objected to the composition of the NQF Steering Committee that rejected the measure. Last July, then-AAN President Steven Sergay, MD, wrote to the NQF to protest the dearth of clinicians on the panel who had both stroke management and clinical expertise in interpreting CT for stroke patients.
In the letter, made available to Neurology Today, Dr. Sergay pointed out that the panel's 15 voting members had “disproportionate representation by a medical specialty (radiology) that primarily serves the role of providing technical skills and image interpretation expertise rather than clinical decision-making in the context of direct and ongoing patient care.”
Dr. Sergay noted that there were too few representatives on the steering committee with patient-centered medical expertise. [The AAN representative to the panel, Buffalo, NY, neurologist Eric Lindzen, MD, PhD, served as a technical advisor, but was not a voting member.]
According to NQF spokesperson Rebecca Fleischauer, the NQF is open to reconsidering the rule. “In its first meeting, the forum's Steering Committee agreed the CT scan measure would greatly benefit the field,” she told Neurology Today. But the committee felt the measure needed to be written more precisely.
The original measure states: “The pool of patients the measure applies to code stroke CT neuroimaging patients. CT studies for acute stroke should be done within 45 minutes of patient arrival with rapid CT interpretation within 15 minutes of study completion and comments on the CT report on inclusion or exclusion for acute stroke therapies based on the neuroimaging.”
CLARIFICATION OF RULE
The NQF committee wanted more precise clarification on what the 45-minute time limit for arriving at the hospital meant — crossing the threshold into the emergency department, or the point at which emergency room personnel in triage first interact with the patient, said Anne Alexandrov, PhD, professor of vascular neurology at the University of Alabama at Birmingham Comprehensive Stroke Center, who reviewed the transcripts from the NQF panel on imaging efficiency. Dr. Alexandrov did not serve on the NQF imaging efficiencies panel, but she co-chaired the NQF Steering Committee on the Prevention and Management of Stroke.
The panel also wanted to better define “acute stroke” and “code stroke” to clarify those patients presenting with acute stroke to the ED within three hours of symptom-onset,” said Dr. Alexandrov. The imaging panelists did not want the parameters to unintentionally limit CT in patients who arrived later than the 45-minute time window, she added.
“This is important, because some hospitals may only consider a patient who arrives within two hours of symptom onset to be considered ‘acute,’ while others may say it's those who arrive within six hours of symptom onset,” Dr. Alexandrov said.
“Members of AAN Stroke Systems Work Group and the AAN Quality Measurement and Reporting Subcommittee are working together to suggest appropriate revisions to the CT measure for resubmission,” said Sarah Tonn, senior manager of Quality Improvement at the AAN. “The AAN Practice Committee voted to endorse this approach at the AAN annual meeting in Seattle on April 29. Thus, the rewriting and suggestions from the AAN groups is happening now.”