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

• To educate providers on methods to obtain reproducible NT measurements
• To provide a method to evaluate and track provider proficiency
• 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 Personnel (if applicable)

• NT Measurement Criteria
• Pay Participation Fee
• Submit NT Data via Requisition Form to Participating Laboratories
• View Reports and Charts Containing NT Quality Review Information
• Continuing Medical Education Credits
• Privacy and Confidentiality
• Contact Information

To become NTQR credentialed, a provider must first register by visiting ntqr.perinatalquality.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 American Express, MasterCard or VISA. VeriSign technology is used to ensure the most secure form of web-based transactions.

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), current practice standard and the role of genetic counseling
• Significance of data obtained in first trimester screening for fetal aneuploidy
• How to obtain optimal nuchal translucency and nasal bone images
• Quality review maintenance over time
• How to combine first trimester screening by NT or cell free DNA with diagnostic testing
• Genetic screening options in multiple gestations
• Diagnostic genetic testing methods including microarray and whole exome sequencing
• Case studies showing 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.

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.

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.
• Case studies showing benefits of first trimester screening
• Images submitted by mail will be reviewed within 4 weeks from the date NTQR receives and uploads the images.

1. Fetus occupies majority of image:

• The fetal head, neck, and upper thorax should fill the majority of the image. The fetus should occupy greater than 50% of the image space. The image should NOT show the entire fetus or crown-rump length. A second fetus of the same magnitude should not fit in the surrounding space.

2. Margins of NT edges clear:

• The ultrasound image should be clear with thin NT membranes (lines). The angle of insonation should be perpendicular to the NT line. The following techniques will help achieve this:

1. Decrease depth
2. Narrow sector width
3. Use fetal echo settings if needed
4. Use magnification box
5. Magnify then freeze
6. Decrease gain at the level of the NT
7. Avoid membrane shadows (try turning harmonics off if shadows persist)

3. Fetus in midsagittal plane:

• Midsagittal view of fetal spine seen in cervical and thoracic region
• Tip of nose and rectangular shaped palate seen
• Third and fourth ventricle seen in fetal CNS
• Should NOT see zygoma, ribs, stomach, or heart

4. Fetal head in 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

5. Fetus observed away from the amnion:

• This is a frequent source of error and if not properly measured, may overestimate or underestimate the NT. Patience should be used to allow for spontaneous fetal movement away from the amnion. The amnion should be seen as a separate line from the nuchal membrane.

6 – 8. Correct caliper placement: The following guidelines should be followed:

• Use the "+" calipers.
• Measure the NT at the widest translucent space
• The horizontal crossbars of the calipers must be placed on the echogenic inner borders of the nuchal membranes with none of the horizontal crossbars protruding into the NT space. A vertical line connecting the two calipers should be perpendicular to the long axis of the fetus.

9. ALARA

• The output display standard (ODS) which consists of MI and TI must be left on each image submitted
• TIB should be displayed at this gestational age and its value should be less than or equal to 0.7.

• Measure the NT three times and report the largest of three acceptable measurements
• 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.

• 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.

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.

• 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.

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.

NTQR participants whose quality monitoring reports are out of range for 2 or more quarters may be placed in the Required Quality Monitoring (RQM) module that requires educational review and submission of additional images.

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.

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.

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.

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%.

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.

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.

All providers must participate in ongoing QR monitoring, if chosen, to remain in good standing with NTQR.

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 3.75 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.

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.

For more information about this program, please contact an NTQR representative at support@perinatalquality.org.