Quality Measure Brings Additional Risks for ED

EPs in "huge bind"

Quality measures from the Centers for Medicare & Medicaid Services (CMS) and other groups are putting EPs "in a huge bind," according to Sandra Schneider, MD, professor of emergency medicine at University of Rochester (NY) Medical Center.

Schneider is referring to Use of Brain Computed Tomography in the ED for Atraumatic Headache, included in CMS's Hospital Outpatient Quality Data Reporting Program. "Based on very loose data, measures are being promulgated that suggest we do far too many CT scans for atraumatic headache," explains Schneider.

According to the measures, patients should never be given a CT scan if certain criteria are not present, notes Schneider, but the problem is that 2% of people with subarachnoid hemorrhage will not meet the criteria. "So if the EP follows these guidelines, then they would miss 2% of subarachnoid hemorrhage cases, which would cause them to be sued," says Schneider.

Claims data were used to evaluate the quality indicator, adds Schneider, but this approach will miss some of the criteria that would show a CT scan was indicated for a given patient. According to the guidelines, for instance, one of the indications for a CT scan is a thunderclap headache. "I may have written 'thunderclap headache' on the history or the X-ray requisition, but not as a discharge diagnosis," says Schneider. "Since this measure will only look at discharge diagnosis, it will not pick that person up as meeting the criteria for a CT scan."

Schneider says that another problem is that the CMS measure pertains to patients over 65, "and there is absolutely no evidence that elderly people have an increased risk of cancer from CT scans. It doesn't make scientific sense to decrease the number of CT scans in this population. It just increases the liability for emergency physicians."


For more information, contact:

• Sandra Schneider, MD, Professor, Emergency Medicine, University of Rochester (NY) Medical Center. Phone: (585) 463-2970.  E-mail: Sandra_Schneider@URMC.Rochester.edu.