Setting: Outpatient
Numerator: Patients with a presenting complaint of headache who have a brain computed tomography (CT) and sinus CT study performed simultaneously (i.e., on the same date at the same facility)
Denominator: Patients with a presenting complaint of headache who have a brain CT study
Exclusions: Patients with trauma diagnoses, tumor, or orbital cellulitis

Clinical guidelines and literature indicate that there is a general consensus that neuroimaging is rarely productive for patients with normal physical and neurological exams and medical histories. Even when neuroimaging is required, there are no indications for simultaneous Brain CT and Sinus CT. Moreover, unnecessary CT imaging is costly financially, risks false positive interpretation, and exposes patients to excess radiation.

The lifetime prevalence of headache is over 90 percent for men and women; and according to some studies accounts for 16 million physician visits in the U.S. Nearly 75% of all Brain CT studies are requested for symptoms of headache in a commercial population. A CT scan exposes the patient to higher doses of radiation than conventional x-ray and increases their risk of cancer. Also, unnecessary or duplicative studies are sources of both inefficiency and lower quality care.

A recent report in the New England Journal of Medicine raised serious concerns about the use, and overuse, of CT scanning. It is estimated that 62 million scans are performed per year, compared with only 3 million in 1980. The researchers further estimate that a third of those CT scans are entirely unnecessary, many of them now performed by cautious doctors on worried patients in the emergency setting. The result is a patient safety issue involving:

• Unnecessary Radiation Exposure
• Unnecessary Contrast exposure
• The danger of "false-positive" findings

While clinical guidelines for headache and sinusitis (many "sinus headaches" are actually migraines) indicate circumstances where CT and/or endoscopy is indicated, there are no instances indicated in the guidelines where a patient presenting with headache should receive both brain CT and sinus CT. In fact, for most headaches or cases of sinusitis, no imaging is recommended at all. One article focusing on intracranial complications from sinusitis in a pediatric population in Singapore did recommend simultaneous brain CT and sinus CT. However, several articles reviewing protocols for an adult population in the U.S. with intracranial complications from sinusitis noted the possible necessity of MRI but did not recommend simultaneous brain CT and sinus CT. Finally, much of the sinus can be seen on a brain CT.

The guidelines list several findings resulting in an increased likelihood of significant intracranial pathology upon neuroimaging:

• Abnormal neurological examination
• Headache worsened by Valsalva maneuver
• Causing awakening from sleep
• New headache in the older population
• Progressively worsening headache

The guidelines indicate neuroimaging is not usually warranted for patients with migraine and normal neurological examination.

Evidence guidelines have been in existence for some time and are reviewed annually. No changes are anticipated. The science underlying the measure has not undergone significant changes, nor is new scientific evidence likely to emerge in the next 12 months.

Brain CT and sinus CT are specific procedures that must be ordered by a physician to be performed. Therefore, there is the distinct opportunity for the physician to not order the unnecessary study, and for the rendering physician to ensure that an unneeded study is not performed (controllability).

The intended audience (health care providers) will easily understand the results and find them useful in decision-making. The health care provider can use the results to reduce cost without compromising quality of care.

For non acute headaches with no additional findings, there is a recognized clinical benefit that would lead to both improved health and increased value of appropriately utilized brain CT studies for chronic headache in the ED. Likewise, imaging is not appropriate for most cases of sinusitis. Where sinus CT is appropriate, simultaneous brain CT is unnecessary.

There may be instances where it would be unclear from a claim what the nature of the headache was, making it difficult to determine whether or not a scan would be appropriate. Further, the potential for serious diagnostic error exists. The guidelines rely upon the completion of an appropriate history, a physical and neurological exam, and the experience of the practitioner. However, this uncertainty would not likely warrant simultaneous use of CT brain and CT sinus.

There are few measures that address imaging efficiency that have been developed despite the recent tremendous growth in imaging in the United States. There are no closely related existing measures.

Standard claims files may be used to determine the frequency of simultaneous brain CT and sinus CT in the management of headache. The provider identification, inclusion, and exclusion of the unique population can all be determined from the Medicare claims files.

Appropriate codes must be documented to assure that the population and studies are properly identified. We can expect some minimal distortion in the results due to imprecise coding.

There may be instances where it would be unclear from a claim what the nature of the headache was, making it difficult to determine whether or not a scan would be appropriate. Further, the potential for serious diagnostic error exists. The guidelines rely upon the completion of an appropriate history, a physical and neurological exam, and the experience of the practitioner. However, as there are no identified instances where both sinus CT and brain CT are appropriate, there is less opportunity for error.

To implement the measure, patient identifying information is used to link the procedure to antecedent claims or diagnostic claims. After this link has been determined and the numerators and denominators for the measure have been counted, the patient identifying information is eliminated from the file. The reporting of the measures is at an aggregate level that does not indicate any claim or person-level detail in compliance with HIPAA requirements.

While the measure is intended for the Outpatient Setting, it may be used in other settings. The measure could appropriately be constructed from chart abstraction or other electronic medical records. There are no existing measures that are available for harmonization.