Quality measures for colonoscopy: where should we be in 2015?
Colonoscopy is an effective colorectal cancer (CRC) screening and prevention modality as evidenced by a 30-year decline in both incident colon cancers and CRC mortality in the USA. The USA is unique among the developed countries in its use of colonoscopy as the most common method to screen for CRC. Individual patients gain maximum value from their colonoscopy experience when they undergo a comfortable exam that is of highest quality, during which all polyps are found and removed safely and completely, where their physicians adhere to all appropriate guidelines and when they (or their insurance) pay a reasonable amount for their care. Colonoscopy "quality" publications to date have been focused on how to improve the individual physician's procedural results and this narrow focus has birthed an entire industry (usually based on entering data into a national registry) that is focused on demonstrating a physician's success in achieving a certain threshold performance metric that is usually (a) marginally related to true health outcomes, (b) can be captured from the myriad electronic medical records (EMR) in existence today, and (c) is attainable by most practicing gastroenterologists. Medical societies have worked diligently to link these registries and recognition programs to commercial or federal payer-based incentive funds. As health care reform drives massive consolidation of delivery systems and reimbursement moves toward population-level two-sided financial risk models, our current measurement infrastructure will become irrelevant. The focus on "value" and the Triple Aim will drive development of a radically different approach. The process by which individual gastroenterologists (or practices) demonstrate the value of colonoscopy as a colorectal cancer (CRC) prevention tool will change dramatically. Essentially, six measures will be reported by a health system: (1) percent of eligible population screened, (2) access to colonoscopy services, (3) complication rates, (4) patient experience scores, (5) episode (bundle) cost, and (6) frequency with which interval cancers occur after a colonoscopy exam (likely using a 3-year interval). Each gastroenterologist within a health system will be evaluated using familiar metrics (cecal intubation, withdrawal time, adenoma detection rate) but these results will likely be used internally to determine whether they are included in a provider network. If they continue to be used in commercial or government incentive programs, then the enterprise electronic medical record will be constructed to populate external programs directly. Population-level metrics (listed above) will determine whether higher cost provider networks (including academic health centers) who might deliver better health outcomes can compete successfully for regional market share with lower cost providers. This article will outline a plan for a health system initiative focused on provision of colonoscopy for CRC prevention; a plan that will help a group of gastroenterologists (whether employed within a health system or independent) demonstrate why they should be a preferred provider and whether they will survive and thrive in the coming world of accountable care.