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One of every four deaths in the United States is due to cancer. In 2016, colorectal cancer was the fourth leading cause of death by cancer, and the fourth leading “new” cancer among both males and females in the United States.1 Moreover, during the last 20 years the incidence of CRC, while falling in persons 50 years old and older, has risen steadily among individuals younger than age 50.2
Quality improvement is optimized when there are valid, standardized sources of clinical data that can inform how providers improve the care they deliver to their patients. Measurement Science QUERI has been a national leader in the procurement and implementation of common models of electronic data to inform quality enhancement, notably for major medical conditions including colorectal cancer.
Colorectal cancer (CRC) prevention is a top VA priority, and the effectiveness of screening colonoscopy in CRC prevention relies on its quality. The adenoma detection rate (ADR)—defined as the proportion of screening colonoscopies performed by a physician that have one or more histologically-confirmed adenomatous polyps or CRC—is the primary benchmark for colonoscopy inspection quality. Increased ADR correlates with a lower risk of CRC incidence and mortality in large studies, including recent VA data. An Office of the Inspector General (OIG) report highlighted colonoscopy quality deficiencies in VA, and strongly recommended that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.”
How to Better Measure and Report CRC Quality of Care
Currently, national VA and local facilities cannot ensure Veterans receive high-quality colonoscopy for CRC prevention, as there is no automated mechanism to continually measure or report quality. Thus, the Measurement Science QUERI team collaborated with HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VHA National Gastroenterology Program, and the VA Colonoscopy Cohort to improve Veterans’ access to high-quality colonoscopy for cancer screening and polyp surveillance. They have developed a novel informatics infrastructure for centralized colonoscopy quality reporting across VA, which will enable the implementation of the VA Endoscopy Quality Improvement Program (VA-EQuIP) to directly address the OIG recommendations and VA’s critical need to implement evidence-based colonoscopy quality measurement and reporting. Specific aims of this project are to:
The Measurement Science QUERI National Program was created to integrate measurement science (i.e., theory, practice, and application of metrics) into healthcare for Veterans, thereby enhancing VA’s Learning Healthcare System.
- Generate a standardized assessment of colonoscopy quality metrics (i.e., ADR, cecal intubation rate, and bowel preparation quality) that can be applied to national VHA data;
- Test the validity of these metrics (as compared with chart review) at VA facilities; and
- Develop a colonoscopy quality report card that is useful to frontline providers and facilities.
Measurement Science QUERI investigators have developed the operational informatics infrastructure to accurately measure and report colonoscopy quality across the VA healthcare system. VA’s current infrastructure includes a framework for scalability, prospective updates, and a secure website to visually present quality metrics for sites and providers. For example, using 2017 data, they identified and processed 170,886 colonoscopy notes for 73 VA sites spanning the VA healthcare system (see Figure 1 below). An example quality report is shown Figure 2.
The robust measurement infrastructure will support the implementation of VA-EQuIP to provide VA sites and endoscopists with bi-annual audit and feedback of colonoscopy quality. In addition, it will offer individual provider benchmarking to local and national performance, as well as collaborative learning sessions moderated by national experts in colonoscopy training and quality. Future efforts also will focus on the identification of low-performing providers, and their subsequent training. Colonoscopy quality improvements have tremendous potential to impact healthcare for Veterans by reducing the risk for CRC incidence and mortality. This study on the implementation and impact of these key quality metrics also supports VA’s learning health system.
For more information about Measurement Science QUERI, please contact Mary Whooley, MD, at Mary.Whooley@va.gov; for more information about Colonoscopy Quality Measurement and Reporting and implementing VA-EQuIP, please contact Tonya Kaltenbach, MD, MAS, at Tonya.Kaltenbach@va.gov or Andrew Gawron MD, PhD, MS, at Andrew.Gawron@va.gov.
- United States Cancer Statistics: Data Visualizations. Centers for Disease Control and Prevention. June 11, 2019.
- Estimating Risk of Sporadic Colorectal Cancer in Veterans Under Age 50. HSR&D study IIR 14-011; Principal Investigator, Thomas Imperiale, MD, Richard L. Roudebush VAMC, Indianapolis, IN.