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 of the report describes the criteria applied for report data.
Page 4 summarizes the tables and box plots included.
Page 5 explains how dose index data are standardized for head and body exams, using phantoms.
Page 6 defines the metrics provided in tables and box plots:
CT Dose Index (CTDIvol),
Dose Length Product (DLP), and
Size-Specific Dose Estimate (SSDE).
Page 7 provides U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations, created using DIR data, as benchmarks.
Tables and Box Plots
The report is grouped by age cohort, with data for adult exams (patients aged 18 and over at the time of the exam) listed first.
The Executive Summary table lists the exams having at least 10,000 records across all DIR facilities for the period. The exam counts and quartiles are shown for CTDIvol, DLP, and SSDE for your facility compared to the quartiles for the registry overall.
Note: SSDE is computed only for body exams and is not available for head exams (e.g. CT C SPINE).
Note: Data are shown by the standardized RPID Shortname to which each exam was mapped. Exams not mapped are not included in tables or box plots.
Box plots provide more detailed information for the 10 highest-volume exams in the DIR. Each box plot shows the median for your registry compared to the mean, median, maximum, minimum, 25th percentile, and 75th percentile for the entire DIR.
Separate box plots are shown for CTDIvol, DLP, and SSDE data.
The Executive Summary table and box plots for pediatric exams (patients aged 18 and under) are provided for exams having at least 2,000 records across the DIR. The table and box plots are 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 interim 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.
The last column of the table shows your decile rank, computed by scoring your non-MIPS performance against the CMS benchmark for that quality measure. Your decile rank ultimately determines how many points you receive for your MIPS Quality score, with higher deciles yielding more points.
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 for 2017 and use that for determining the measure score.