Developing and Testing an Electronic Measure of Screening Colonoscopy Overuse in a Large Integrated Healthcare System

Abstract

BACKGROUND: Most existing performance measures focus on underuse of care, but there is growing interest in identifying and reducing overuse. OBJECTIVE: We aimed to develop a valid and reliable electronic performance measure of overuse of screening colonoscopy in the Veterans Affairs Health Care System (VA), and to quantify overuse in VA. DESIGN: This was a cross-sectional study with multiple cross-sections. SUBJECTS: U.S. Veterans who underwent screening colonoscopy between 2011 and 2013. MAIN MEASURES: Overuse of screening colonoscopy, using a validated electronic measure developed by an expert workgroup. KEY RESULTS: Compared to results obtained from manual record review, the electronic measure was highly specific (97 %) for overuse, but not sensitive (20 %). After exclusion of diagnostic and high-risk screening or surveillance procedures, the validated electronic measure identified 88,754 average-risk screening colonoscopies performed in VA during 2013. Of these, 20,530 (23 %) met the definition for probable (17 %) or possible (6 %) overuse. Substantial variation in colonoscopy overuse was noted between Veterans Integrated Care Networks (VISNs) and between facilities, with a nearly twofold difference between the maximum and minimum rates of overuse at the VISN level and a nearly eightfold difference at the facility level. Overuse at the VISN and facility level was relatively stable over time. CONCLUSIONS: Overuse of screening colonoscopy can be measured reliably and with high specificity using electronic data, and is common in a large integrated healthcare system. Overuse measures, such as those we have specified through a consensus workgroup process, could be combined with underuse measures to improve the appropriateness of colorectal cancer screening.

Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

“…However, prior data suggest that many older adults with comorbidities, limited life expectancy, and previous normal screening results may not benefit from ongoing screening colonoscopies. 1,5,6,7,8,9,14,15 Moreover, these patients may be at increased risk for screening-related harms and burdens. Thus, experts recommend that screening decisions be individualized in older adults.…”

“…4 However, one unintended consequence has been overuse of low-value CRC screening, particularly in older and less healthy patients who have limited life expectancy. 1,5,6,7,8,9 …”

The Next Generation of Clinical Performance Measures

“…3 They found that, compared to results obtained from manual record review, the electronic measure was highly specific (97 %) for overuse, but was not sensitive (20 %). To some extent, the fact that the electronic measure had low sensitivity reflects limitations in the ability to electronically ascertain screening indication.…”

Improving the Quality of Quality Measurement

“…The studies by Saini et al . 9 and Farmer et al . 10 in this issue of JGIM also show the potential of eCQMs for monitoring overuse and patient-reported outcomes, respectively.…”