DIR Executive Summary and QCDR Preview reports provide aggregate data for your facility compared to the entire registry. The first several pages provide the following background information:
Page 3 describes the criteria applied for report data.
Page 4 describes the Components of the report and summarizes the tables and boxplots included.
Page 5 describes the Phantom Size and explains how dose index data are standardized for head and body exams using phantoms.
Page 6 describes the Fundamentals of Radiation Dose in tables and boxplots including:
CT Dose Index (CTDIvol) - Radiation energy absorbed per unit mass.
Dose Length Product (DLP) - Absorbed dose multiplied by the length of exposure.
Size-Specific Dose Estimate (SSDE) - Corrections based on the size of the patient.
Page 7 provides U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations, created using DIR data, as benchmarks.
Note: A sample Facility report is available here.
Note: A sample Corporate report is available here.
Tables and Boxplots
The report is grouped by age, with data for Adult exams (patients aged 18 and over at the time of the exam) listed first. CTDIvol, DLP, and SSDE are also broken out into separate pages. The Executive Summary table lists the exams for the Top 10 RPID Shortname groups to compare with all DIR facilities for the period. Exam counts and quartiles are shown for CTDIvol, DLP, and SSDE for your facility compared to the quartiles for the registry overall.
Note: Data are shown by the standardized RPID Shortname to which each exam was mapped. Exams not mapped are not included in tables or boxplots. SSDE is computed only for body exams and is not available for head exams (e.g. CT C SPINE). Mapped exams can be looked up to corresponding RPID Group Name shown in the report with the Q3 2023 document available here.
Boxplots show a snapshot of your facility's performance in the DIR top 10 high volume Adult CT exams. There are 3 sets of boxplots, one for each dose index, representing the DIR values for an exam. Your facility median is depicted by a red line. Absence of red line means your facility did not perform that exam. The key of the numbered exams are given on the right hand side. SSDE only has values for body exams.
Boxplots provide more detailed information for the 10 highest-volume exams in the DIR. Each boxplot shows the median for your registry compared to the mean, median, maximum, minimum, 25th percentile, and 75th percentile for the entire DIR. Separate boxplots are shown for CTDIvol, DLP, and SSDE data.
Note: The table and charts are further subdivided into five Pediatric age groups due to the wide range of patient sizes and corresponding dose indices.
The QCDR Preview section of the report provides feedback on the QCDR (non-MIPS) measures available from the DIR for MIPS reporting. Descriptions of each measure are provided, along with benchmark information and year-to-date calculations for each non-MIPS measure.
Calculating the QCDR Measures from DIR
QCDR measures from DIR calculate percentage of exams that are equal to or lower than the benchmark (size specific diagnostic reference level for DLP). Reports contain comparisons of each facility’s score relative to other peer facilities.
For CMS reporting, physician or physician group performance is based on data across all locations at which they practice and will be benchmarked against other groups. The physician and group performance data is available in the NRDR MIPS participation portal for groups registered and enrolled in NRDR MIPS.
Note: The QCDR measure decile scores shown in this report are calculated at the facility level and are based on performance data across the entire DIR. The measure scores reported to CMS will be calculated at the TIN and TIN-NPI level which may span across data from multiple facilities where the physicians provide services. That level of performance scoring can be viewed in the MIPS Portal for groups and physicians registered for MIPS.
Since the new DIR measures do not have "historical" CMS benchmarks these decile scores are provided as an indication of where the TIN or NPI may fall but are not the final scores. CMS will calculate a performance year benchmark based on performance data actually reported to CMS and use that for determining the measure score.