Quality Measures in Gastroenterology

Quality measures are tools used to evaluate how well healthcare services are being delivered. The quality measures adopted are those endorsed by the National Quality Forum, a nonprofit, nonpartisan public service organization formed by all those interested in healthcare (consumers and providers of health care). Among the goals of creating these measures are to generate data that will help consumers make informed choices about their healthcare. In addition, these measures are expected to enhance transparency and accountability.

In 2011, the NQF and the U.S. Department of Health and Human Services created the National Quality Strategy, which resulted in the National Performance Measure Set (NPMS), a group of quality measures to assess health outcomes, patient experience, and resources used. Most of the Quality Measures used by the Center for Medicare & Medicaid Services (CMS) and commercial insurances are contained in the NPMS.

CMS was required by the Patient Protection and Affordable Care Act (ACA) of 2010 to establish the Physician Compare website, which was launched on December 30, 2010. CMS plans to add quality data, and will post the first set of measured data in 2014 from data collected not sooner than 2012.

The Gastroenterology (GI) part of the National Performance Measures Set (GI-NPMS) was developed by the cooperation among the different gastroenterology societies (AGA, ASGE, ACG, AASLD), and the Crohn’s and Colitis foundation of America (CCFA) for the measures related to Inflammatory Bowel Disease.

Currently the quality measures which are specific to gastroenterology have to do with Colorectal Cancer (CRC), Hepatitis C infection (HCV), Inflammatory Bowel Disease (IBD), and Gastroesophageal Reflux Disease (GERD). They are not the only care a patient with these conditions should receive, but they are indicators of the quality of care being given.

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common cancer diagnosed among men and women, and the second leading cause of death from cancer in the United States. CRC may be prevented by early detection and removal of adenomatous polyps. Screening colonoscopy refers to the endoscopic exam of the colon in people without symptoms or history of CRC or polyps, while surveillance colonoscopy refers to the same type of exam but to people with history of colon polyps or CRC. Colonoscopy has been shown to reduce the mortality associated to CRC by detecting and removing significant colon polyps, and diagnosing early lesions when they are more amenable to a curative approach.

The current CRC screening recommendations are based on the following:

1) Adenomatous polyps are common in adults over age 50, but the majority of polyps will not develop into colorectal cancer; tissue type (histology) and size determine their risk of evolving to CRC.

2) Adenomatous polyps, or “adenomas”, represent approximately one half to two thirds of all colorectal polyps, and are associated with a higher risk of CRC.

3) Advanced adenomas (higher risk of malignant transformation) are those polyps larger than 10mm, histologically (tissue) having high-grade dysplasia, or showing a significant villous components (villous adenoma, or tubulovillous adenoma).

Colonoscopy

Currently, colonoscopy is the best screening option for early detection of CRC and adenomatous polyps for asymptomatic adults age 50 or older. The CRC quality measures (see table) try to assess that a screening colonoscopy starts at the appropriate age. The age of 50 years or older is used for average risk patients, defined as lack of a personal or family history of CRC or colon adenomas. The age of 40 years, or 10 years before the youngest case in the immediate family, is used for patients with either CRC or adenomatous polyps in a first-degree relative before age 60 or in 2 or more first-degree relatives at any age. The time interval to repeat a colonoscopy will depend on the findings, with 10 years for a negative colonoscopy, and usually between 3-5 years for those with polyps removed, depending on number of polyps and whether they were considered advanced.

Adenoma Detection Rate

The detection of adenomatous polyps depends on the quality of the colonoscopy. The quality measure called the Adenoma Detection Rate (ADR) is the proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas detected. The recommended benchmarks for a quality colonoscopy have been an ADR on screening colonoscopies of at least 15% in women and at least 25% in men. There is an increased risk of a CRC lesion appearing before the next screening colonoscopy is indicated when the procedure is performed by an endoscopist with a lower than 20% ADR.

Lastly, an adequate bowel preparation (cleansing) is a critical element in the accuracy and cost-effectiveness of CRC screening. Either splitting the preparation in 2 equal parts with the second part taken four hours before the colonoscopy, or taking the entire preparation the same day of the procedure, have been shown to improve the quality of the preparation and increase the detection of significant polyps.