Tracking and Improving Colonoscopy Quality

WILLIAM E. KARNES, MD, AGAF ASSOCIATE CLINICAL PROFESSOR OF MEDICINE

HH CHAO COMPREHENSIVE DIGESTIVE DISEASE CENTER UCI HEALTH

Disclosures

I am a colonoscopist It is what I’m paid to do

Objectives

Does quality colonoscopy makes a difference?

Quality reporting is The New Expectation What’s expected of us? What if I choose not to participate? How do I make participation as easy as

possible and work to my advantage?

Colorectal Cancer 2015 Key Facts

Remains the leading cause of cancer deaths among nonsmokers

One in 20 people develop colorectal cancer in their lifetimes

Risk factors Non-modifiable: age, race, family history Modifiable: diet, obesity, lifestyle, chronic

inflammatory bowel disease

Colorectal Cancer 2015 Key Facts

Polyps are the precursors to colorectal cancer Over half of us will develop polyps by age 70! Most precancerous polyps provide a 10-year

“window of opportunity” before they become cancer

Colorectal Cancer 2015 Key Facts

70-90% of colorectal cancers are preventable through lifestyle changes and removal of precancerous polyps

Colonoscopy is the “gold standard” for finding polyps and is the only test that allows their removal

40-50% of us do not get recommended screening

Declining CRC Incidence

Patel, Clinical Gastroenterology and Hepatology 2014;12:7–15.

Screening

CRC Incidence

Colonoscopy Prevents CRC National Polyp Study (1993) 70-90% reduction of

expected CRC incidence National Polyp Study (2012) 53% reduction of

expected CRC-related deaths

Winawer, et al, N Engl J

Zauber et al 2012

Colonoscopy in Practice

5% of the unscreened population will get CRC 0.6 % of the screened population will get CRC

within 4 years (Martinez ME Gastroenterology 2009;136:832-841)

In a typical career, a colonoscopist can expect to prevent 880 CRCs.

We will fail to prevent 120 CRCs!!

85%

Why not better? Four Plausible Explanations

0% 25% 50% 75%

Robertson DJ et al Gastroenterology 2008;134:111-112 Pabby A et al Gastrointestinal Endoscopy 61:385-391 Pohl H & Robetson DJ Clin Gastroenterol Hepatol 2010;8858-864

• Missed polyps or CRC

• Incomplete polypectomy

• Inaccurate pathology

• Rapid de novo progression

Interval Cancers Colonoscopist-dependent factors

Protective factors >95% completion rate O.R. 0.72 (0.53 - 0.97)

>30% polypectomy rate O.R. 0.61 (0.42 - 0.89)

Risk factors Incomplete exam O.R. 7.24 (1.78 - 29.34) vs Complete

Rural surgeon O.R 3.34 (1.69 - 6.61) vs GI

Family practice O.R. 2.92 (1.29 - 6.60) vs GI

Internist O.R. 2.09 (1.09 - 4.02) vs GI

Urban surgeon O.R. 1.68 (1.03 - 2.74) vs GI

Adenoma Detection Rate

The Colonoscopists Batting Average?

Adenoma Detection Rate (ADR) and Interval Cancers • Kaiser Permanente 1998-2010 • 136 gastroenterologists

• >300 colonoscopies each

• 314,872 colonoscopies • 712 interval CRCs • 147 deaths from CRC

• Highest ADR associated lowest

rates of interval cancers and fatal interval cancers

ADR(%) 7-19 19-24 24-28 28-34 34-53

Fatal Interval CRC

Interval CRC

Adenoma Detection Rate (ADR) Extreme variability between colonoscopists (7-55%)

Polyp miss-rate is 22-25% on back-to-back colonoscopy

Mean ADR for screening: 25% Mean ADR for surveillance: 37%

(Anderson JC et al Clin Gastroenterol and Hepatol 2013;11:1308-1312)

True adenoma prevalence is probably > 50%

GI docs have highest performance Not affected by GI Fellow involvement

(Meta-analysis - Ho Y Dig Dis Sci 2013;58:3413–3421 )

05

101520253035404550

0-1 2-3 4-5 6-7 8-9A

DR

Boston Prep Score

Boston Prep Score vs Adenoma Detection Rate UCI Experience

Factors Affecting ADR

Prep quality Withdrawal time Assistive Techniques

Underwater

Second looks

Retroflex in cecum

NBI

Chromendoscopy

Endocuff

N ADR Polyps/procedure

Historical 2404 42 ± 5 1.8 ± 0.2 No Endocuff 398 41 ± 11 1.8 ± 0.6

Endocuff 199 58 ± 17 3.2 ± 1.3

Colonoscopy vs Other Screening Tests

Balancing Costs More is Not Better

Costs/C

omplications

CRC

Rat

e

Frequency of Colonoscopy

Colonoscopists Payers

Colonoscopy is superior

Patient

Colonoscopy is inferior

Factors Affecting Cost

Poor preps necessitating repeat colonoscopy Inappropriate colonoscopies

Too early Too often

Quality Measurements The New Normal

All endoscopists performing colonoscopy should measure the quality of their colonoscopies

Institutions should reasonably expect all endoscopists (regardless of their specialty) to participate and achieve recommended quality benchmarks

Rex DK et al Am J Gastroenterol 2015; 110:72-90

Colonoscopy Quality Indicators Why Should We Care?

We all want to protect our patients from: Interval cancers Adverse effects of colonoscopy Financial burden

Quality measures are evidence-based and intended to reflect the best possible outcome at the lowest possible cost

Colonoscopy Quality Indicators Why Should We Care?

Payers will demand it Reimbursement will decrease if we fail to report quality measures to CMS.

Private payers are already following. By 2016, reimbursement for colonoscopy will be pegged to specific targets

Screening colonoscopy must be cost-effective to survive Our quality measures will be publically available

You Could Look Like This Colonoscopy Quality Rate National Adenoma Detection Rate 55% BEST Complete Exam 99% BEST Interval Cancer Rate 0.01% BEST Complications .001 BEST

Colonoscopy Quality Rate National Adenoma Detection Rate 15% WORST Complete Exam 85% WORST Interval Cancer Rate 2.5% WORST Complications 0.2% WORST

Or This …

20 reviews

20 reviews

Physician Quality Reporting System (PQRS) Provides payment adjustments based on quality

measures Affordable Care Act imposes penalties beginning in 2015 PQRS is the basis of “Physician Compare” – the public

portal to our quality Value-Based Payment Modifier is tied to participation

Value-based Payment Modifier (VBPM)

• Applies to all eligible professionals by 2017 (currently affects groups ≥ 10) • Compares Quality/Cost criteria among participants to determine:

• Bonus payments (TBD) • Neutral payments (0%) • Downward payments (1-2%)

• By 2017, failure to participate in PQRS and VBPM with result in a 4% cut! Another 3% cut if not using a qualified EHR.

We are Locked In

Colonoscopy PQRS Measures (2015) Measure Measure Description Reporting CRC Screening (128) % of patients screened (age 50-75) Registry, EHR, GPRO

Screening Colonoscopy (320) % of normal screening colonoscopies with recommended follow-up ≥ 10y

Registry

Screening ADR (343) % of screening colonoscopies with one or more adenomas

Registry

Polyp Surveillance (185) % surveillance interval >3 years Registry

And This is Only The Beginning!

Colonoscopy Quality Targets

Quality Indicator Target

Bowel prep quality reported >98%

Withdrawal time measured and reported >98%

Attempt endoscopic removal of pedunculated polyps and large (< 2cm) sessile polyps before surgical referral

>98%

Cecal intubation with photodocumentation >95%

Adequate bowel preparation >85%

Appropriate indication documented >80%

Average withdrawal time in negative screening colonoscopy ≥ 6 minutes

Colonoscopy Quality Targets

Quality Indicator Target

Adenoma detection rate (30% in men, 20% in women) 25%

Perforation rate < 0.1%

Post-polypectomy bleeding rate < 1%

Appropriate interval recommendation after completing procedure and reviewing histology

90%

Frequency of inadequate preparation necessitating repeat colonoscopy < 15%

Appropriate Colonoscopy Interval

Assumption of Quality on Prior Colonoscopy Cecal intubation Adequate bowel preparation Complete clearance of neoplasia

Suboptimal prior colonoscopy by any of these criteria warrants repeat colonoscopy within 1 year. But, if you do this in more than 15% of cases you will miss your target!

Colonoscopies Intervals Based on findings Indication Recommended Interval No prior polyps ≥ 10 years Hyperplastic polyps < 1cm in rectosigmoid, no FHx of polyps or CRC 10 years 1-2 small adenomas (<10 mm) 5-10 years 3-10 adenomas 3 years > 10 adenomas < 3 years* One or more tubular adenomas > 1cm 3 years One or more villous adenomas 3 years Serrated polyps (no dysplasia) proximal to rectosigmoid 5 years Serrated polyps > 10mm or dysplastic or traditional serrated adenoma 3 years Sessile precancerous polyp > 2cm 3-6 months, then 1 year

* May warrant genetic consultation

Colonoscopy Intervals Based on Family History and Genetics

Condition Interval FHx of CRC or advanced adenoma Q 5 years HNPCC/Lynch or FCCTX (between age 20 and 40)* Q 2 years HNPCC/Lynch or FCCTX (after age 40)* Q 1 year FAP Q 1 year Serrated polyposis syndrome** Q 1 year

**WHO criteria: 5 or more serrated polyps proximal to sigmoid with: 2 or more ≥ 10 mm, or FHx of SPS, or > 20 serrated polyps of any size

*Bethesda Criteria – GET GENETIC CONSULT AND GENETIC TESTING! • CRC in patient < 50 years old; • Synchronous or metachronous CRC or other Lynch-associated tumors, regardless of age; • CRC with MSI diagnosed < 60 years old; • CRC and other Lynch-associated tumor in one or more FDR, one diagnosed < 50 years old; • CRC and other Lynch-associated tumor in two or more FDR or SDR, regardless of age.

Feeling the Squeeze

Decide if you will participate Change your habits. Enter the data once!

Most endowriters can collect all of the data you need as long as you don’t free-text!

Be mindful of the data you need and make it part of your templates and routine

Identify how you will report your data to CMS Registry reporting Qualified Clinical Data Registries (QCDR)

GIQuIC (GI Quality Improvement Consortium)

DHRP (AGA Digestive Health Recognition Program Registry) $300-$750/provider/year

Number of Physicians Cost/year

1-5 physicians $4,000

6-10 physicians $5,400

11-15 physicians $9,400

16-20 physicians $10,800

>20 physicians www.giquic.org

GIQuIC Nonprofit entity sponsored by the ACG and ASGE Essentially writing the book on GI quality indicators Measures supported

Adenoma Detection Rate

Adequacy of bowel preparation

Photo-documentation of the cecum

Incidence of perforat ion

Appropriate follow-up interval for normal colonoscopy in average risk patients

Repeat colonoscopy recommended due to poor bowel preparation

Age appropriate screening colonoscopy

Documentation of history and physical rate

Appropriate indication for colonoscopy

Colonoscopy interval for patients with a history of adenomatous polyps – avoidance of inappropriate use

GIQuIC

Amkai CORI eMerge Health Solutions Endosoft gMed

MD Reports Olympus (version 7.4) Pentax (endoPRO iQ) ProVation (Version 5.0)

Data is collected and exported from current endowriters:

Data can also be uploaded from Excel using specific format

We Used to Take an Oath…

• Watched • Penalized • Incentivized

Now we’re being…

UCI Colonoscopy Quality Database

Reporting

Proposed California Colonoscopy Quality Registry

Purpose Provide service to endoscopists:

real-time collection of endoscopic quality indicators with minimal effort and cost

data readily available for: reporting to CMS by mechanism of choice quality improvement initiatives Research

Under development with Dr. Donald Patterson Associate Professor, Donald Bren School of Information and Computer Sciences, UC Irvine Laboratory for Ubiquitous Computing and Interaction

Proposed California Colonoscopy Quality Registry

Mechanism: Multi-tiered security

HIPAA-compliant

Web-based interface (Cloud-hosting vs Onsite webserver)

Tablet/mobile ready

Financial Model: Costs for development, server, maintenance and improvements

covered by: monthly usage fees (Cloud-hosted), or

subscription fees (Onsite webserver)

Proposed California Colonoscopy Quality Registry

Beta Testing Testing phase among providers is free Deep discounts for testers when “live” Testers have a voice in the direction of development

If you are interested in participating as a tester, please sign-up at:

http://signup.colonoscopymeasures.com Those who sign-up today will have beta-tester privileges/discounts

Randall W. Burt, MD

Randall W. Burt, MD

University of Utah since 1979 Began work with Mark Skolnick combining the Utah Cancer Registry

and the Utah Population Database to create large pedigrees of families with large numbers of colorectal cancers – now numbering over 2000 high risk patients

With Ray White, discovered APC locus on chromosome 5

Randall W. Burt, MD

Chief of Medicine, SLC VA Director of the High Risk Cancer Registry and Clinics at the

Huntsman Cancer Institute Chief GI Division, U of Utah Director of Prevention and Outreach, U of Utah Director of the Huntsman Cancer Institute Barnes Presidential Endowed Chair in Medicine Over 180 peer-reviewed original publications