This information is intended for ultrasound sonographers, physician sonologists and directors or supervisors of those obtaining NT measurements.

1. To educate providers on methods to obtain reproducible NT measurements
2. To provide a method to evaluate and track provider proficiency
3. To provide ongoing NT quality review

1. Register and select appropriate program track
2. Take educational course (if applicable)
3. Pass on-line exam (if applicable)
4. Submit images and corresponding data for review by Quality Review (QR) personnel (if applicable)

1. Register and select appropriate program track

To become NTQR credentialed, a provider must first register by visiting www.ntqr.org and clicking on the "Register Now" button. He/She will then enter the required information, such as practice location, clinical role, and appropriate program track.

1. Track A: Standard - Educational Course, Exam and Image Submission ($350 for doctors, $275 for sonographers)
   This option is geared toward providers who have had little or no prior NT training. This track provides access to course materials and requires that providers pass an online exam and submit at least 5 images for review by Quality Review personnel.
   
   
2. Track B: Previously Trained - Exam and Image Submission Only ($200)
   This option is geared toward providers who have prior NT training (e.g., took an equivalent course) but have not participated in an ongoing quality review program. Verification of previous NT training is required. Providers must pass the online exam and submit images for review. Course materials will only be available after the exam has been passed.
   
   
3. Track C: Currently Credentialed - Exam and Image Submission Waived ($50)
   This option is offered to providers who are previously credentialed by FMF, BUN, FASTER, or Lenetix. Providers who qualify for this track are not required to take the exam or submit images for Quality Review. The majority of providers currently credentialed are on file at NTQR. In the event that a provider is credentialed and not on file, verification of credentials will be required.

Current payment method options are VISA, MasterCard, or personal check. VeriSign technology is used to ensure the most secure form of web-based transactions. If paying by check, a $10 processing fee will be added and payment must be received within 3 weeks or the account will be deactivated.
2. Take educational course (if applicable)

The educational course instructs providers on the techniques and theories involved in obtaining accurate NT measurements from the 11-14 week ultrasound scan. The course content was developed by the NT Oversight Committee, which is made up of recognized experts in the field of prenatal screening and diagnosis.

The course consists of six training modules for Physicians and four training modules for Sonographers. Each module can be viewed as slides only or as slides accompanied by a video of the faculty member who developed the course. The course is approximately 4½ hours long if all videos are viewed, but can be shorter if the slides are viewed alone. Upon completion of the education modules, providers should be familiar with the following learning objectives:

• Requirements for participation in the NTQR program
• Principles of screening, use of MoMs, likelihood ratios, screen cutoffs, role of genetic counseling
• Significance of data obtained in first trimester screening for fetal aneuploidy
• How to obtain optimal nuchal translucency images
• Quality review maintenance over time
• How to combine first trimester & second trimester screens for Down Syndrome; pitfalls of screening
• Down Syndrome screening options in multiple gestations
• Invasive testing methods for fetal aneuploidy; genetic counseling aspects
• Other benefits of first trimester screening

Upon successful completion of the educational portion of the program, providers are able to print a Certificate of Attendance, issued by NTQR.

3. Pass on-line exam (if applicable)

Providers who are not currently credentialed are required to take the exam. The exam tests a provider's knowledge of obtaining NT measurements and of prenatal screening. The exam questions have been designed to be as unambiguous and broad as possible in order to cater to providers who have been trained with or without NTQR.
The exam questions are multiple-choice and true/false. The sonographer's exam consists of 25 questions, the doctor's exam consists of 35 questions. The exam will take approximately 30 minutes to complete and must be completed during one session (i.e., responses will be reset if provider signs off website).
Providers will have three attempts to pass the exam. Each exam will be unique. Providers who fail the exam three times must review the course material before taking the exam again. Once the course material has been reviewed providers will have three more opportunities to pass the exam.

• Doctors who have not already paid for access to course materials will be required to pay an additional $150 in order to obtain access.
• Sonographers who have not already paid for access to course materials will be required to pay an additional $75 in order to obtain access.

4. Submit images and corresponding data for review by QR personnel (if applicable)

Track A and Track B providers are required to submit images with corresponding NT measurements for Quality Review. All submitted images and NT measurements must be obtained by the provider.

NTQR initially requires that 5 ultrasound images from 5 different fetuses (e.g., a provider may not submit more than one image from the same fetus) be submitted and reviewed to indicate mastery of NT technique. Images may be uploaded over time in separate sessions; however, review of images will only occur once the full batch of 5 images has been submitted. Before submitting the batch for review, a provider has the option of deleting and replacing images or editing the accompanying NT data (see below). Once 5 images have been submitted, the provider may no longer edit the batch; it is considered complete and is flagged for Quality Review.
Images may be submitted in two ways:

• Electronic Submission (Preferred Method): Upload .jpg or .gif images and enter corresponding NT data into the website.
• Mail Submission to NTQR: A $20 processing fee will be charged at the time of registration. After entering NT data into the website, mail images directly to NTQR (directions and address provided at time of mailing). All thermal images mailed to NTQR must be stapled to the corresponding NT data form (printed from the website) after data entry has been completed. NTQR will scan the images and upload them to the website for Quality Review. Images will not be mailed back to the provider.

NT information to be entered for each image submitted:

Date of Ultrasound	Time of Ultrasound
Practice Name	Single or Multiple Pregnancy
NT Measurement in mm	Crown Rump Length (CRL) in mm

• All patient identifying information (i.e., name, MRN) must be removed prior to submission.
• Images submitted by mail will be reviewed within 4 weeks from the date NTQR receives and uploads the images.

An email will be sent when the image quality review is complete. After all images within a batch have been reviewed, the results will be available on the website. Names of providers and reviewers will be kept anonymous to reduce any potential bias and protect confidentiality.
Each image is scored according to nine items. To pass quality review, a batch must meet the following criteria:

• Total score must be 80% or greater
• All images must satisfy at least 7 out of 9 criteria and pass criteria (g)
• No individual criteria can fail on all images

The nine scoring items are listed below:

Scoring Item	Details
a. NT margin of     edges clear	Clear U/S image Angle of insonation perpendicular to NT space (fetal spine in horizontal position) Clear NT lines
b. Midsagittal plane	Midsagittal view of fetal spine seen in cervical and thoracic region Tip of nose seen in face area Third and forth ventricle seen in fetal CNS
c. Image area     maximized	Not be able to fit a second (same size) fetus in the ultrasound space surrounding the fetus; this implies that the fetus occupies > 50% of image
d. Neutral position	The fetal head must be neutral without hyperflexion or hyperextension Hyperflexion: Fetal head is flexed with no free space (amniotic fluid) seen between lower chin and anterior neck Hyperextension: Fetal is extended with an angle between lower chin and anterior neck of greater than 90 degrees (subjective assessment by reviewer)
e. Away from Amnio	Amnion seen separate from NT line
f. + calipers used	"+" calipers should be used for NT measurement
g. Horizontal     crossbar placed     correctly	Calipers placed on the inner borders of the nuchal space with none of the horizontal crossbar itself protruding into the space; the horizontal crossbar of the calipers on either side should not be in the black space
h. Calipers     perpendicular	A vertical line connecting the 2 calipers should be perpendicular to the long axis of fetus
i. Measured at     widest space	Measurement obtained at widest space of NT

If the initial batch is failed, the computer will calculate the number of additional images required for further review. This will be communicated in an auto-email to the provider as well as on the results page. If three consecutive batches are deemed unacceptable, the provider will be required to pay a $50 fee, take the Technical Aspects lecture and submit additional images.
Upon successful completion of the image review, the provider will be NTQR credentialed and a Certificate of Completion will be awarded.

1. Pay participation fee
   
   Credentialed Physicians will be required to pay a flat yearly participation fee of $150.
   Credentialed Sonographers will be required to pay the same yearly fee of $35.00.
   
   
2. Submit NT data via requisition form to participating laboratories
   
   Once a provider is credentialed, NTQR will monitor and provide feedback about the quality of the provider's NT data. To provide NTQR with data, the provider will send the data to a participating laboratory using the lab's first trimester requisition form. Each participating laboratory will send relevant NT data to NTQR on a weekly basis. NTQR will generate ongoing quality review reports to ensure NT quality. For more information about the laboratory's role and responsibilities, please click here.
   
   
   Notes:
   • Image submission will not be required during this process.
   • The provider who initially obtains the NT image is the provider that should be indicated as performing the NT on the requisition form. This will prevent a subspecialist's or supervisor's medians from being systematically higher than the rest of the population.
   
   
3. View reports and charts containing NT quality review information
   
   Quality monitoring reports will be provided by NTQR to both the provider and to the provider's supervisor via email on a periodic basis. Laboratories will also have access to these reports, but only for the providers who submit data to their laboratory. The report templates and procedures are undergoing final review, but two sample reports and a description of the reports have been provided below.
   
   Members of the quality review team will be making policies and decisions regarding the requirements for additional image review to stay in good standing with NTQR. There may be occasions when a provider is “under review,” meaning they must be retrained in NT sonography. Options for the provider will vary (e.g., resubmit images to the quality review team, go to an NT training center, or submit a videotape).
   
   NTQR will periodically post listings of members in good standing on the website. Laboratories will receive a file from the NTQR containing provider IDs in good standing and beta coefficients for regression equations to use when combining serum analytes with NT measurements in calculating risk for Down syndrome.
   
   
   Sample Quality Monitoring Report
   
   
   Figure 1: Box Graph Plotting Median MoM vs. Standard Deviation

   This graph displays the median MOM of your NT measurements along the “y-axis” and the standard deviation (SD) of your NT measurements along the “x-axis.” The blue and red dots indicate cumulative NT values and should lie within the box.

   The expected range of the median NT is 0.9-1.1 MoM. A median outside this range suggests that NTs are being either under- or over-measured. If a median falls just outside the range for a particular reporting period, then there is likely only a moderate discrepancy. However, if the median is significantly outside the range, the participant will be flagged and additional training will be recommended.

   The standard deviation of your NTs represents the variability in your measurements. If your SD is high (outside the box and to the right), it may indicate that you are not measuring NTs in a consistent manner. If the SD is low (outside and to the left), there is less variability than expected. For example, the SD may be high when there is more than one person using the same NT ID# (this is outside NTQR policy and should not occur) or one person is measuring on multiple machines or under different practice conditions. The SD may be low when equipment calipers are “sticking.”

   This graph may also be used to compare colleagues within your practice. The red dot indicates your cumulative NT values. The blue dots indicate your NT values sorted by colleagues (sonographers or sonologists) that you work with.

   If a Sonographer works with only one Sonologist or vice versa the red dot will be superimposed over the blue dot. Please note a dot representing a Sonographer or Sonologist may not be visible because it's x,y coordinates fall outside the graph.

   
   
   Figure 1
   
   
   Figure 2: Referent Curve Graph Displaying Observed NT Measurements as a Function of CRL

   This graph displays your observed NT measurements as a function of CRL. The solid line in the figure is the population referent derived by regression analysis, whereas the individual points are your NT measurements.

   It is important to note that the observed measurements are not expected to fall along the line, but that approximately half should be above and half below the line over the entire range of CRLs. If the majority of the data points fall below the curve of expected values, it suggests that NTs are being systematically under-measured. In contrast, if the majority of data points fall above the referent line, NT measurements are being systematically over measured.

   
   
   Figure 2
   
   
   Figure 3: Table Displaying Data Received to Date

   The last two lines of this table show the total number of data sets that NTQR has recorded for you during this reporting period and overall. NTQR sorts and reports these data by sonographers or sonologists to provide information on individual providers. If there are data attributed to an “unknown sonologist”, it means that the data came to us with a sonographer number only.

   NTQR monitoring is based on the Median NT MoM. The ideal median NT MoM is 1.0, and the expected range of the median NT is 0.9-1.1 MoM. A median outside this range suggests that NTs are being under- or over-measured. If a median falls just outside the range for a particular reporting period, then there is likely only a moderate discrepancy. However, if the median is significantly outside the range, the participant will be flagged and additional training will be recommended.

   The table also shows the proportion of NT measurements above the 95th percentile and below the 5th percentile. Ideally the table will indicate that the proportion of NT measurements below the 5th percentile or above the 95th percentile is 0-10%.

   .........
   
   
   Figure 3
   
   
   Figure 4: Report History of all Reports to Date

   Below are tables showing results of previous reports provided to you by NTQR. You may use the report history to look at trends in your data. We expect the NT median MOM to be consistently within range or to show improvement over time.

   
   
   Figure 4
   
   
4. Participate in ongoing quality review exercises (if applicable)
   
   As stated in Section 6, providers may need to undergo retraining based upon results of ongoing QR monitoring. A provider may be required to submit additional images for review.
   
   In addition, a random 10% of providers will be selected each year to submit 5 additional images.
   
   All providers must participate in ongoing QR monitoring, if chosen, to remain in good standing with NTQR.
Continuing Medical Education Credits

  Learning Objectives:

• To understand the data underlying first trimester screening, second trimester screening and a combination of first and second trimester screening for fetal aneuploidy.
• To become familiar with the standardized technique for imaging and measuring the fetal nuchal translucency.
• To understand the importance and methods underlying quality review for nuchal translucency sonography.
• To be aware of the pitfalls and implementation difficulties in applying nuchal translucency-based screening to a clinical practice.
This educational activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM).

The American College of Obstetricians and Gynecologists (ACOG) designates this educational activity for a maximum of 4 category 1 ACOG cognate credits. Each physician should claim only those credits that he/she actually spent in the activity.

Providers will receive a course evaluation and a certificate via email within a month of completing the course.


Privacy and Confidentiality

SMFM and NTQR are committed to securing your privacy. The information that you provide to us will remain confidential. Persons performing QR review or ongoing monitoring will not be given your name. However, if you become credentialed by NTQR, your name will be posted on the website to be made available for patients and shared with laboratories that accept your NT measurements.


Contact Information

For more information about this program, please contact an NTQR representative at [email protected] or call (866) 582-2755.