Early Implementation Performance of the CMS Electronic Clinical Quality Measure for Excessive Radiation Dose or Inadequate Image Quality in Diagnostic CT: An Evaluation of 254 Facilities

Why clinicians should know about it

• Picked for Medical Physics (paper of the day, 5 November 2026): Large-scale evaluation of CT dose and image-quality monitoring

Abstract

OBJECTIVE: To evaluate early facility performance on the CMS-adopted Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults (ExRad) measure, the first automated radiology outcome measure in CMS payment programs, during the first 16 months of the measure's inclusion in CMS programs. METHODS: ExRad evaluates each adult diagnostic CT examination in three steps: assignment to 1 of 19 CT categories defined by anatomic region and clinical indication; computation of size-adjusted radiation dose and image noise from the DICOM radiation dose-structured report and pixel data; and comparison of both against category-specific thresholds. Because the clinical and radiology data sit in separate systems, translation software inside the health system firewall may be used to perform the linkage. An examination is out of range if its dose or noise exceeds its category threshold; a facility's score is the percentage of eligible examinations out of range (lower is better). We analyzed all facilities reporting between May 2025 and August 2026. RESULTS: Across 254 facilities and 783,634 examinations in 16 CT categories, 30.7% were out of range: 240,409 (30.7%) exceeded the dose threshold and 446 (0.06%) the noise threshold. Facility scores varied widely: median 29.5% (interquartile range [IQR] 18.4-44.7; range 1.8-82.4), with facilities at the 90th percentile scoring 4.6 times more out-of-range scans than those at the 10th percentile. Median out-of-range percentages by category ranged from 0% (routine and low-dose cardiac) to 82.6% (high-dose head; IQR 23.5-100.0); routine abdomen and pelvis, the highest-volume category, had a median of 43.9% (IQR 30.1-61.3). Within facilities, the median gap between best- and worst-performing category was 74 percentage points (IQR 49-89; intraclass correlation coefficient = 0.12). DISCUSSION: Early ExRad performance varied widely across facilities and across CT categories within the same facility. Most variation reflected particular facility-category combinations, so facilities need their own category-level results to identify which protocols to target.

Abstract as published, via PubMed.