American College of Emergency Physicians Quality Measures. Status: Draft For Public Comment Do Not Cite. Available: September 16, 2014

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1 American College of Emergency Physicians Quality Measures Status: Draft For Public Comment Do Not Cite Available: September 16, 2014 Obsolete After: October 17, 2014

2 Page 2 of 23 Table of Contents Table of Contents Page Disclaimer 3 Quality Measures Technical Expert Panel Objectives & Acknowledgments 4 Quality Measures Technical Expert Panel Roster 5 Measure #1: Emergency Department Utilization of CT for Minor Blunt Head Trauma for 6 Patients Aged 18 Years and Older Measure #2: Emergency Department Utilization of CT for Minor Blunt Head Trauma for 10 Patients Aged 2 Through 17 Years Measure #3: Coagulation Studies in Adult Patients Presenting with Chest Pain with No 15 Coagulopathy or Bleeding Measure #4: Appropriate Emergency Department Utilization of CT for Pulmonary 18 Embolism References for All Measures 22

3 Page 3 of 23 Disclaimer Physician Performance Measures (Measures) and related data specifications developed by the American College of Emergency Physicians (ACEP) are intended to facilitate quality improvement activities by physicians. These measures are intended to assist physicians in enhancing quality of care. These Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. ACEP encourages testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by ACEP. The measures may not be altered without prior written approval from ACEP. The measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by health care providers in connection with their practices). Commercial use is defined as the sale, license, or distribution of the measures for commercial gain, or incorporation of the measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the measures require a license agreement between the user and ACEP. Neither ACEP nor its members shall be responsible for any use of the measures. THESE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND American College of Emergency Physicians. All rights reserved. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets should obtain all necessary licenses from the owners of these code sets. ACEP and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. ICD-10 copyright 2012 International Health Terminology Standards Development Organization CPT is a registered trademark of the American Medical Association and is copyright CPT codes contained in the Measure specifications are copyright American Medical Association.

4 Page 4 of 23 Quality Measures Technical Expert Panel Objectives The ACEP Board of Directors approved the development of quality measures to protect and enhance emergency care in February 2013 with the following objectives: To define the value of emergency care and develop a set of performance measures that will meet the criteria for the CMS value-based payment modifier (VBPM), which must apply to all physicians by legislative mandate by 2017 based on the 2015 quality reporting period. To develop new performance measures for inclusion in the Physician Quality Reporting System (PQRS) and other programs to enhance and protect emergency care. To continue the ongoing cyclical work of, testing, updating and maintaining ACEP s current performance measures for CMS reporting programs. To identify areas for internal quality improvement through MOC Part IV, OPPE, and other QI and data collection activities for important topics. Acknowledgement This measure set was made possible in part by the generous support of the American Board of Emergency Medicine(ABEM) and the Emergency Medicine Action Fund (EMAF). Quality Measures The American College of Emergency Physicians (ACEP) convened a Quality Measures Technical Expert Panel (TEP) to assess opportunities for the development of evidence-based performance measures. The ACEP QMs TEP proposes this set of measures to address gaps in care around emergency medicine with a focus on appropriateness and with the aim of optimizing clinical outcomes.

5 Page 5 of 23 Technical Expert Panel Roster Co-Chairs Jeremiah D. Schuur, MD, MHS, FACEP Stephen V. Cantrill, MD, FACEP American College of Emergency Physicians James Augustine, MD, FACEP Robert I. Broida, MD, FACEP Kathleen Brown, MD, FACEP Vidor E. Friedman, MD, FACEP Michael Granovsky, MD, FACEP Joseph A. Halpern, MD, FACEP Timothy C. Hsu, MD, FACEP Richard Newell, MD, MPH, FACEP Michael P. Phelan, MD FACEP William E Reisinger, III, DO, FACEP Paul Sierzenski, MD, RDMS, FACEP Joshua Howland Tamayo-Sarver, MD, FACEP Arjun Venkatesh, MD, MBA L. Kendall Webb, MD AIM Specialty Health Susan Nedza, MD, MBA, FACEP American Academy of Family Physicians Andrew Eisenberg, MD, MHA American Academy of Neurological Surgeons David Okonkwo, MD, PhD American Academy of Neurology Steven Mandel, MD, FAAN Becky Schierman, MPH (Staff) American Academy of Pediatrics Evaline Alessandrini, MD, FAAP Council of Medical Specialty Societies Sharon Hibay, RN, DNP American Board of Emergency Medicine Michael L Carius, MD, FACEP Terry Kowalenko, MD, FACEP Robert Philip Wahl, MD, FACEP American College of Radiology American College of Neuroradiology Ari Blitz, MD Judy Burleson, MHSA (Staff) American Society of Hematology Neil Zakai, MD, MSc Robert Plovnick, MD (Staff) Emergency Medicine Action Fund Wesley Fields, MD, FACEP The Joint Commission Dan Castillo, MD, MBA, FACEP Quality Measures Methodology Sharon Hibay, RN, DNP Society of Critical Care Medicine Julie Mayglothling, MD, FACEP, FCCM AMA-PCPI Consultants Kendra Hanley, MS Jennifer Heffernan, MPH Meredith Jones, MPH Kimberly Smuk, RHIA Samantha Tierney, MPH ACEP Staff Dainsworth Chambers Diana Crowley, MPH Stacie Schilling Jones, MPH David McKenzie

6 Page 6 of 23 For Public Commnet: ACEP Draft Quality Measures Measure #1: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older For this measure higher score indicates higher quality Measure Description Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT Measure Components Numerator Statement emergency department visits for patients who have an indication for a head CT Indications for a head CT in patients presenting to the emergency department for minor blunt head trauma: Patients with any one of the following: Severe headache Vomiting Age 65 years and older Physical signs of a basilar skull fracture (signs include haemotympanum, panda eyes, cerebrospinal fluid leakage from the ear or nose, Battle s sign) Focal neurological deficit Coagulopathy Thrombocytopenia Currently taking any of the following anticoagulant medications: apixaban, argatroban, bivalirudin, dabigatran, dalteparin, desirudin, enoxaparinm fondaparinux, heparin, lepirudin, low molecular weight heparin, rivaroxaban, tinzaparin, warfarin Dangerous Mechanism (ie, ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs) OR Patients with either loss of consciousness OR posttraumatic amnesia AND any one of the following: Headache Age 60 years and older, and less than 65 years Drug/alcohol intoxication Short-term memory deficits Evidence of trauma above the clavicles (physical location, any trauma to the head or neck [ie, laceration, abrasion, bruising, ecchymosis, hematoma, swelling, fracture]) Posttraumatic seizure

7 Page 7 of 23 Statement All emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Definition: Presented within 24 hours - The 24 hour timeframe is based on the time of injury reported by the patient or caregiver or guardian. Exclusions Exceptions Rationale for the Measure note: Minor blunt head trauma includes only non-penetrating injuries. Patients with any of the following: Ventricular shunt Brain tumor Multisystem trauma Pregnancy Currently taking any of the following antiplatelet medications: ASA/dipyridamole clopidogrel prasugrel ticlopidine None This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times. This measure is an appropriateness measure, and as such is one for which a higher score indicates higher quality. The technical expert panel (TEP) considered an alternate measure construction, such that this measure would more closely match the pediatric measure; however, the feasibility issues posed by the alternate construction resulted in the construction as seen here. Supporting Guideline & Other Evidence The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references: Level A recommendations. A noncontrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia only if one or more of the following is present: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic deficit, or coagulopathy (ACEP, 2008).i Level B recommendations. A noncontrast head CT should be considered in head trauma patients with no loss of consciousness or posttraumatic amnesia if there is a focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical

8 Page 8 of 23 Measure Importance signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a dangerous mechanism of injury.* *Dangerous mechanism of injury includes ejection from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet or 5 stairs (ACEP, 2008).ii Relationship to desired outcome Opportunity for Improvement Exception Justification Though it is difficult to directly attribute the effects of smaller dosages of radiation, such as that received through computed tomography (CT), the dosage of radiation from CTs has increased in recent years, in part due to the increased speed of image acquisition. Additionally, there is evidence to suggest that the radiation doses from CTs are higher and more variable than generally quoted. iii Further, as radiation doses associated with commonly used CT examinations resemble doses received by individuals in whom an increased risk of cancer was documented, iv the use of some CT scans is associated with a nonnegligible lifetime attributable risk of cancer. v vi As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually vii, it is critical that CT scans only be utilized when clinically appropriate. Through measurement of the share of CT scans that are performed inappropriately, a focus can be brought to quality improvement and increased application of clinical decision tools around this topic. About 2.5 million traumatic brain injuries occur each year, where 75% of these are considered mild. viii There is data to suggest that 70% of head injury patients receive a head CT ix, and it is estimated that 10-35% of head CTs obtained in head injury patients do not follow recognized guidelines. x Some estimate that as many as 55, ,000 CT scans are possibly avoidable annually. xi The ACEP Measure Work Group agreed to include appropriate medical reasons as an exception so that clinicians can exclude patients for whom CT imaging may be justified. Harmonization with Existing Measures Measure Designation Measure purpose (check all that apply) Type of measure National Quality Strategy Priority/CMS Measure Domain (check all that apply) Staff has considered harmonization with NQF 0668 Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury. Quality improvement Accountability MOC Process Outcome Structure Clinical Process-Effectiveness Patient Safety Patient Experience Care Coordination Efficiency: Overuse

9 Page 9 of 23 Level of Measurement (check all that apply) Care setting (check all that apply) Data source (check all that apply) Efficiency: Cost Population & Community Health Individual clinicians Clinician groups Hospital Outpatient/ED Emergency Departments Urgent Care Harmonize with other care settings o Physician Office Based Measures o Hospital Level Measure Electronic health record (EHR) data Administrative Data/Claims (inpatient, outpatient or multiple-source claims) Paper medical record/chart abstracted Registry

10 Page 10 of 23 Measure #2: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years For this measure lower score indicates higher quality Measure Description Percentage of emergency department visits for patients aged 2 through 17 years presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider and are classified as low risk according to the PECARN prediction rules for traumatic brain injury Measure Components Numerator Statement emergency department visits for patients classified as low risk according to the PECARN prediction rules for traumatic brain injury Definition: Low Risk for Traumatic Brain Injury according to PECARN prediction rules Patients can be classified as low risk if all of the following are met: No signs of altered mental status (eg, agitation, somnolence, repetitive questioning, slow response to verbal communication) No signs of basilar skull fracture (signs include haemotympanum, panda eyes, cerebrospinal fluid leakage from the ear or nose, Battle s sign) No loss of consciousness No vomiting No severe mechanism of injury (ie, motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 3 feet; or head struck by a highimpact object) No severe headache Statement All emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Definition: Presented within 24 hours - The 24 hour timeframe is based on the time of injury reported by the patient or guardian. Exclusions note: Minor blunt head trauma includes only non-penetrating injuries. Patients with any of the following: Ventricular shunt Brain tumor Coagulopathy Thrombocytopenia

11 Page 11 of 23 Exceptions Rationale for the Measure None This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.. This measure is an overuse measure its intention is to capture those instances in which a pediatric patient is characterized as low risk yet still receives a CT. As such, the measure is scored such that a lower score indicates higher quality. The measure is constructed in this manner due to the available evidence; the PECARN clinical policy defines the low-risk population, but though medium and high risk populations are less well-defined. The measure then uses the definable population as its numerator, necessitating an overuse construction. Supporting Guideline & Other Evidence The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references: Pediatric Emergency Care Applied Research Network (PECARN): Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of after head trauma:

12 Page 12 of 23 NICE: Head Injury Triage, assessment, investigation and early management of head injury in children and adultsxii For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: Suspicion of non-accidental injury Post-traumatic seizure but no history of epilepsy. On initial emergency department assessment, GCS less than 14. At 2 hours after the injury, GCS less than 15. Suspected open or depressed skull fracture or tense fontanelle. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). Focal neurological deficit For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified:

13 Page 13 of 23 Measure Importance Loss of consciousness lasting more than 5 minutes (witnessed). Abnormal drowsiness. Three or more discrete episodes of vomiting. Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object). Amnesia (antegrade or retrograde) lasting more than 5 minutes4. A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014] Relationship to Desired Outcome Opportunity for Improvement Exception Justification Though it is difficult to directly attribute the effects of smaller dosages of radiation, such as that received through computed tomography (CT), there is evidence to suggest that the low dose radiation emitted through the use of some CT scans is associated with a significant risk of cancer, particularly in children. xiii As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually xiv, it is critical that CT scans only be utilized when clinically appropriate. Through measurement of the share of CT scans that are performed inappropriately, a focus can be brought to quality improvement and increased application of clinical decision tools around this topic. About 2.5 million traumatic brain injuries occur each year, where 75% of these are considered mild. xv There is data to suggest that 70% of head injury patients receive a head CT xvi, and it is estimated that 10-35% of head CTs obtained in head injury patients do not follow recognized guidelines. xvii Some estimate that as many as 55, ,000 CT scans are possibly avoidable annually. xviii The ACEP Measure Work Group agreed to include appropriate medical reasons as an exception so that clinicians can exclude patients for whom CT imaging may be justified. Harmonization with Existing Measures Measure Designation Measure purpose Type of measure National Quality Strategy Priority-CMS Measure Domain (check all that apply) Staff have considered harmonization with NQF 0668 Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury. This measure will update NQF #0668 for implementation. Quality improvement Accountability MOC Process Outcome Structure Clinical Process-Effectiveness Patient Safety Patient Experience Care Coordination Efficiency: Overuse

14 Page 14 of 23 Level of Measurement (check all that apply) Care setting (check all that apply) Data source (check all that apply) Efficiency: Cost Population & Community Health Individual clinicians Clinician groups Hospital Outpatient/ED Emergency Departments Urgent Care Harmonize with other care settings o Physician Office Based Measures o Hospital Level Measure Electronic health record (EHR) data Administrative Data/Claims (inpatient, outpatient or multiple-source claims) Paper medical record/chart abstracted Registry

15 Page 15 of 23 Measure #3: Coagulation Studies in Adult Patients Presenting with Chest Pain with No Coagulopathy or Bleeding For this measure lower score indicates higher quality Measure Description Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider Measure Components Numerator Statement Statement Exclusions Exceptions emergency department visits during which coagulation studies (PT, PTT, or INR tests) were ordered by an emergency care provider All emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain Patients with any of the following clinical indications for ordering coagulation studies: End stage liver disease Coagulopathy Thrombocytopenia Currently taking or newly prescribed any of the following anticoagulant medications: apixaban, argatroban, bivalirudin, dabigatran, dalteparin, desirudin, enoxaparin, fondaparinux, heparin, lepirudin, low molecular weight heparin, rivaroxaban, tinzaparin, warfarin Pregnancy Pulmonary or gastrointestinal hemorrhage Atrial fibrillation None

16 Page 16 of 23 Supporting Guideline & Other Evidence Rationale for the Measure Coagulation studies are often ordered out of habit as part of a blood panel with little value added to the patient. Ensuring that clinicians are purposefully ordering these studies may lead to significant reduction in resource utilization without any decrease in value of healthcare provided to the patient. Measure Importance Relationship to desired outcome Opportunity for Improvement Analyses have suggested that, in addition to the financial cost of performing unnecessary coagulation testing, there are other undesirable outcomes of unnecessary coagulation testing. These outcomes include increased false-positive results in low prevalence populations, an increase in unnecessary follow-up procedures, and an increase in unnecessary hospital days. xix In the United States, it is estimated that $114 million are spent annually on coagulation testing for patients presenting with chest pain and without any other indications in the Emergency Department. xx Across laboratory testing overall, between 15% to 56% of tests are considered to have been ordered inappropriately xxi ; in a study of coagulation studies specifically, it was found that 81% of coagulation tests were ordered inappropriately. xxii

17 Page 17 of 23 Exception Justification There are no exceptions for this measure. Harmonization with Existing Measures Harmonization with existing measures was not applicable to this measure. Measure Designation Measure purpose (check all that apply) Type of measure National Quality Strategy Priority/CMS Measure Domain (check all that apply) Level of Measurement (check all that apply) Care setting (check all that apply) Data source (check all that apply) Quality improvement Accountability MOC Process Outcome Structure Clinical Process-Effectiveness Patient Safety Patient Experience Care Coordination Efficiency: Overuse Efficiency: Cost Population & Community Health Individual clinicians Clinician groups Hospital Outpatient/ED Emergency Departments Urgent Care Harmonize with other care settings o Physician Office Based Measures o Hospital Level Measure Electronic health record (EHR) data Administrative Data/Claims (inpatient, outpatient or multiple-source claims) Paper medical record/chart Abstracted Registry

18 Page 18 of 23 Measure #4: Appropriate Emergency Department Utilization of CT for Pulmonary Embolism For this measure higher score indicates higher quality Measure Description Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level Measure Components Numerator Statement Statement Exclusions Exceptions emergency department visits with either: 1. Moderate or high pre-test clinical probability for pulmonary embolism OR 2. Positive result or elevated D-dimer level All emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition Patients with any of the following: Pregnancy Medical reason for ordering a CTPA without moderate or high pre-test clinical probability for pulmonary embolism AND no positive result or elevated D-dimer level (eg, CT ordered for aortic dissection) Supporting Guideline & Other Evidence The following evidence statements are quoted verbatim from the referenced clinical guidelines: Suspected non-high risk PE: Plasma D-dimer measurement is recommended in emergency department patients to reduce the needfor unnecessary imaging and irradiation, preferably using a highly sensitive assay (Class I Level A recommendation) Suspect non-high risk PE and low-clinical probability: Normal D-dimer level using either a highly or moderately sensitive assay excludes PE (Class I Level A recommendation) Suspect non-high risk PE and intermediate-clinical probability: Normal D-dimer level using a highly sensitive assay excludes PE, (Class I Level A recommendation) Suspect non-high risk PE and intermediate-clinical probability: Further testing should be considered if D-dimer level is normal when using a less sensitive assay (Class IIa Level B recommendation) xxiii

19 Page 19 of 23 The following evidence statements are quoted verbatim from the ACEP 2011 Clinical Policy: What is the role of the CT pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? Patient Management Recommendations Level A recommendations. None specified. Level B recommendations. For patients with a low or PE unlikely (Wells score <=4) pretest probability for PE who require additional diagnostic testing (eg, positive D- dimer result, or highly sensitive D-dimer test not available), a negative, multidetector CT pulmonary angiogram alone can be used to exclude PE. Level C recommendations. (1) For patients with an intermediate pretest probability for PE and a negative CT pulmonary angiogram result in whom a clinical concern for PE still exists and CT venogram has not already been performed, consider additional diagnostic testing (eg, D-dimer,* lower extremity imaging, VQ scanning, traditional pulmonary arteriography) prior to exclusion of VTE disease. (2) For patients with a high pretest probability for PE and a negative CT angiogram result, and CT venogram has not already been performed, perform additional diagnostic testing (eg, D-dimer,* lower extremity imaging, VQ scanning, traditional pulmonary arteriography) prior to exclusion of VTE disease. *A negative, highly sensitive, quantitative D-dimer result in combination with a negative multidetector CT pulmonary angiogram result theoretically provides a posttest probability of VTE less than 1% Wells Canadian Score for Assessment of pretest probability for PE Rationale for the Measure The goal of this measure is to reduce the inappropriate ordering of CTPA for pulmonary embolism based on pre-test probability estimation. This measure does not require utilization of a structured clinical prediction rule such as the Wells Score or Geneva Score, however the measure aims to improve efficiency by guiding clinical practice towards use of initial d-dimer testing rather than immediate CTPA in low or intermediate probability patients as indicated. Measure Importance Relationship to desired outcome In addition to imaging efficiency, the overuse of CTPA in ED patients with suspected pulmonary embolism has tangible implications for patient safety. Ionizing radiation from CTPA can increase the lifetime risk of cancer, particularly in young women due to the added vulnerability of breast tissue xxiv. Also, the use of iodinated dye places patients at risk of contrast induced nephropathy, which a study by Mitchell and Kline estimated at approximately 8% of all patients undergoing CTPA in the ED xxv xxvi.

20 Page 20 of 23 Opportunity for Improvement Despite significant evidence supporting the use of structured clinical assessment in combination with d-dimer testing to develop an evaluation of patients with suspected PE, there remains poor application of these algorithms in the ED setting xxvii. There are numerous studies demonstrating poor application of clinical pre-test assessment to PE testing strategies including: Single-center study demonstrated suboptimal application of Wells criteria as 25% of patients with a normal or intermediate probability d-dimer assays subsequently had CTPA ordered to evaluate for PE, with only 2.7% (0.7% of cohort) subsequently having PE xxviii. A large (5,344 patient) single center cohort study demonstrated that of 2,285 patients with negative d-dimer testing, 166 (7%) underwent CTPA, demonstrating inappropriate use of radiography outside established clinical algorithms xxix. Use of an ED protocol that combined structured clinical assessment with d-dimer testing doubles the rate of testing for PE, without increased imaging xxx. Exception Justification Harmonization with Existing Measures Measure Designation Measure purpose (check all that apply) Type of measure National Quality Strategy Priority/CMS Measure Domain (check all that apply) Level of Measurement (check all that apply) Care setting (check all that apply) Data source The ACEP Measure Work Group agreed to include appropriate medical reasons as an exception so that clinicians can exclude patients for whom CTPA for pulmonary embolism may be justified. Quality improvement Accountability MOC (to be determined by ABEM) Process Outcome Structure Clinical Process-Effectiveness Patient Safety Patient Experience Care Coordination Efficiency: Overuse Efficiency: Cost Population & Community Health Individual clinicians Clinician groups Hospital Outpatient/ED Emergency Departments Urgent Care Harmonize with other care settings o Physician Office Based Measures o Hospital Level Measure Electronic health record (EHR) data

21 Page 21 of 23 (check all that apply) Administrative Data/Claims (inpatient, outpatient or multiple-source claims) Paper medical record/chart Abstracted Registry

22 Page 22 of 23 References i Jagoda AS, Bazarlan JJ, Bruns JJ, et al. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med. 2008;52: ii Jagoda AS, Bazarlan JJ, Bruns JJ, et al. Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting. Ann Emerg Med. 2008;52: iii Smith-Bindman, R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of internal medicine (2009): iv Smith-Bindman, R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of internal medicine (2009): v Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64- slice computed tomography coronary angiography. JAMA. 2007;298(3): vi Budoff MJ, Achenbach S, Blumenthal RS, et al. AHA scientific statement: Assessment of coronary artery disease by cardiac computed tomography. A scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation. 2006; 114: vii Melnick, ER, Szlezak, CM, Bentley, SK, et al. CT Overuse for Mild Traumatic Brain Injury. The Joint Commission Journal on Quality and Patient Safety. 2012; 38(11): viii Centers for Disease Control and Prevention. Injury Prevention and Control: Traumatic Brain Injury. March 21, ix Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ x Melnick, ER, Szlezak, CM, Bentley, SK, et al. CT overuse for mild traumatic brain injury. Jt Comm J Qual Patient Saf 38(11): xi Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ xii Head Injury: Triage, assessment, investigation and early management of head injury in infants, children and adults. National Institute for Health and Clinical Excellence. September xiii Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics (2003): xiv Melnick, ER, Szlezak, CM, Bentley, SK, et al. CT Overuse for Mild Traumatic Brain Injury. The Joint Commission Journal on Quality and Patient Safety. 2012; 38(11): xv Centers for Disease Control and Prevention. Injury Prevention and Control: Traumatic Brain Injury. March 21, xvi Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ xvii Melnick, ER, Szlezak, CM, Bentley, SK, et al. CT overuse for mild traumatic brain injury. Jt Comm J Qual Patient Saf 38(11): xviii Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ xix Pilsczek FH, Rifkin, WD, Walerstein S. Overuse of prothrombin and partial thromboplastin coagulation tests in medical inpatients. Heart and Lung. 2005; 34(6): xx Kochert E, Goldhahn L, Hughes I, Gee K, Stahlman B. Cost-effectiveness of routine coagulation testing in the evaluation of chest pain in the ED. American Journal of Emergency Medicine (2012) 30, xxi Pilsczek FH, Rifkin, WD, Walerstein S. Overuse of prothrombin and partial thromboplastin coagulation tests in medical inpatients. Heart and Lung. 2005; 34(6): xxii Kochert E, Goldhahn L, Hughes I, Gee K, Stahlman B. Cost-effectiveness of routine coagulation testing in the evaluation of chest pain in the ED. American Journal of Emergency Medicine (2012) 30, xxiii Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J Sep;29(18): xxiv Brenner DJ, Hall EJ. Computed tomography an increasing source of radiation exposure. N Engl J Med. 2007;357:

23 Page 23 of 23 xxv Mitchell AM, Kline JA. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost. 2007;5: xxvi Kline JA, Mitchell AM, Runyon MS, et al. Electronic medical record review as a surrogate to telephone followup to establish outcome for diagnostic research studies in the emergency department. Acad Emerg Med. 2005;12: xxvii Runyon MS, Richman PB, Kline JA. Emergency medicine practitioner knowledge and use of decision rules for the evaluation of patients with suspected pulmonary embolism: variations by practice setting and training level. Acad Emerg Med. 2007;14: xxviii Costantino MM, Randhall G, Gosselin M, et al. CT Angiography in the Evaluation of Acute Pulmonary Embolus. AJR 2008; 191: xxix Corwin MT, Donohoo JH, Patridge R, et al. Do Emergency Physicians Use Serum d-dimer Effectively to Determine the Need for CT When Evaluating Patients for Pulmonary Embolism? Review of 5,344 Consecutive Patients. AJR 2009; 192: xxx Kline JA, Webb WB, Jones AE, et al. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2004;44: