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Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.