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Quality Matters

Quality Matters: CMS Measure a Train Wreck for Emergency Medicine

Welch, Shari J MD

doi: 10.1097/01.EEM.0000394577.50377.03

    The Centers for Medicare & Medicaid Services recently adopted a new CT utilization measure that will perturb emergency physicians and radically change the way they diagnose patients with nontraumatic headaches.

    In essence, a physician who orders a CT scan and makes a final disposition of a patient with a diagnosis of nonspecific headache will be labeled “inefficient.” The translation? CMS is deeming the scan medically unnecessary. Initially, CMS will post that information on its web site, but it is quite possible that the physicians who ordered these scans would be financially penalized in the future.

    The most galling part of this development is that the National Quality Forum (NQF), whose recommendations CMS usually approves, rejected this quality measure.

    The “quality train” left the station at warp speed several years ago, and CMS proposes and adopts quality measures for emergency medicine in a rapid-fire way. Last year, the American College of Emergency Physicians' Quality and Performance Committee, now chaired by Brent Asplin, MD, of the Mayo Clinic, reviewed more than 140 proposed measures that are in various stages of approval and implementation. The process is rigorous even if the research behind it is not. Organizations vet the measures, and send them to the NQF, which serves as a final clearing center, for endorsement or rejection. Recommendations are then sent to CMS, which usually implements the NQF-endorsed measures, and they likely will be factored into the coming pay-for-performance (P4P) model being crafted by CMS. ACEP and the American Academy of Emergency Medicine have done due diligence in providing feedback on various measures; there also will be a period for public commentary. But despite these efforts, CMS adopted the CT utilization measure even after NQF rejected it. This will profoundly affect emergency physicians every day.

    Without a doubt, emergency physicians are aware of the attention paid to the use of high-cost imaging studies in the ED. (Radiology 2009;253[2]:520.) The use of medical imaging is increasing, and emergency physicians have been preoccupied with cost and safety. (N Engl J Med 2010;363[1]:1.) While no existing evidence guides our decisions for most imaging studies, CMS has become intensely interested in utilization and utilization measures as a proxy for quality, hoping these utilization measures will decrease costs.

    In the quality improvement world, it is commonly suggested that emergency physicians order too many imaging studies. Many QI experts refuse to make that claim because there are no data to support it. CMS has suggested that the physicians who order fewer studies are more efficient and better physicians. The thoughtful retort has always been, “How do we know that fewer studies or even ‘average’ utilization is the best care?” Utilization makes no nod to appropriate use. Perhaps the physician ordering the most imaging studies is a “better” physician. With no scientifically acceptable evidence, who can say?

    An important editorial in the Annals of Emergency Medicine (2010;56[6]:597) from the Brigham and Women's Hospital in Boston outlines the differences between utilization and appropriate use as quality measures. It describes in harrowing detail the coming train wreck for the specialty. CMS contracted with a consultant to develop “imaging efficiency measures.” In the proposed measure, a CT scan ordered on a patient with nontraumatic headache would be married to the ED CPT codes for the patient. If the scan performed were associated with an ED visit and if the final diagnosis were nonspecific headache (as opposed to subarachnoid hemorrhage or intracranial bleeding), it would be deemed “inefficient,” which, of course, is code for “medically unnecessary.”

    The authors of the editorial beautifully articulated the tension between utilization and appropriate use in this proposed measure. Suppose an emergency physician sees an 80-year-old patient on Coumadin with an acute headache. ACEP's clinical policy would support a head CT scan as appropriate. (Ann Emerg Med 2008;52[4]:407.) But if the test were negative, it would be labeled “inefficient,” according to CMS's proposed headache CT utilization measure. Emergency physicians would be expected to know the result of the test before ordering it!

    At the time the Annals editorial was published, the authors assumed that CMS would not adopt it because the measure had been rejected by the NQF. CMS unexpectedly granted it final approval, with plans for national implementation in 2012. And CT utilization will be reported on the CMS web site, Hospital Compare. (

    There are three take-home messages here: First, our specialty organizations are paying attention, and individuals like the authors of this editorial are championing the best interests of patients and practitioners. Secondly, the distinction needs to be made, and made loudly, between utilization and meaningful use. Third, get out your crystal ball.

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    Dr. Welch
    Dr. Welch:
    is a fellow with Intermountain Institute for Health Care Delivery Research, an em er gency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
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