Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study

Abstract

BackgroundLow-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by reducing procedural demand. The objective of this study was to develop and validate an electronic measure of screening colonoscopy overuse using International Classification of Diseases, Tenth Edition codes and then apply this measure to estimate facility-level overuse to target quality improvement initiatives to reduce overuse in a large integrated healthcare system.MethodsRetrospective national observational study of US Veterans undergoing screening colonoscopy at 119 Veterans Health Administration (VHA) endoscopy facilities in 2017. A measure of screening colonoscopy overuse was specified by an expert workgroup, and electronic approximation of the measure numerator and denominator was performed (‘electronic measure’). The electronic measure was then validated via manual record review (n=511). Reliability statistics (n=100) were calculated along with diagnostic test characteristics of the electronic measure. The measure was then applied to estimate overall rates of overuse and facility-level variation in overuse among all eligible patients.ResultsThe electronic measure had high specificity (99%) and moderate sensitivity (46%). Adjusted positive predictive value and negative predictive value were 33% and 95%, respectively. Inter-rater reliability testing revealed near perfect agreement between raters (k=0.81). 269 572 colonoscopies were performed in VHA in 2017 (88 143 classified as screening procedures). Applying the measure to these 88 143 screening colonoscopies, 24.5% were identified as potential overuse. Median facility-level overuse was 22.5%, with substantial variability across facilities (IQR 19.1%–27.0%).ConclusionsAn International Classification of Diseases, Tenth Edition based electronic measure of screening colonoscopy overuse has high specificity and improved sensitivity compared with a previous International Classification of Diseases, Ninth Edition based measure. Despite increased focus on reducing low-value care and improving access, a quarter of VHA screening colonoscopies in 2017 were identified as potential low-value procedures, with substantial facility-level variability.

Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults

“…Indeed, public health approaches are critically important when uptake is low and promotion of screening is the core need. But integrated systems such as Kaiser Permanente Northern California and the VA health care system now report very high CRC screening rates overall, and overuse and resource limitations are more immediate challenges, particularly in the COVID-19 pandemic recovery phase . In such systems, ongoing screening promotion is unlikely to benefit individual patients or the population at large and has the potential to cause unintended harm, both directly and indirectly (by diverting endoscopic resources away from patients with high estimated benefit).…”

“…But integrated systems such as Kaiser Permanente Northern California and the VA health care system now report very high CRC screening rates overall, 26,37 and overuse and resource limitations are more immediate challenges, particularly in the COVID-19 pandemic recovery phase. [38][39][40] In such systems, ongoing screening promotion is unlikely to benefit individual patients or the population at large and has the potential to cause unintended harm, both directly and indirectly (by diverting endoscopic resources away from patients with high estimated benefit). Testing and implementation of theorybased interventions to align screening use with screening benefit is necessary if we want to deliver the right care to the right patient at the right time.…”

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

“…We identified outpatient screening colonoscopies using a validated algorithm. [27][28][29] We excluded all colonoscopies that (1) had another colonoscopy within the last 12 months, (2) were performed for a diagnostic, high-risk screening, or surveillance indication (see ICD-9 and ICD-10 codes in Appendix Table 6 of Adams et al 29 ), or (3) occurred during a hospitalization.…”

Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act

“…Care coordination is particularly important in the case of screening colonoscopies as VHA enrollees using VHA-purchased care may need additional care coordination to reduce the risk of duplicate screening and ensure appropriate follow-up on positive tests. 3,[13][14][15][16] This study aims to investigate whether VHA enrollees undergoing a screening colonoscopy are more or less likely to choose a VHAdelivered procedure after the implementation of the MISSION Act and identify patient-level factors associated with choosing VHAdelivered care. To that end, we first document trends in the share of screening colonoscopies that are VHA-delivered (VHA-share), stratifying by whether an enrollee lives more than 60 min from the nearest VHA specialty care clinic (drive-time eligible, under the MISSION Act).…”