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Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

CBE ID
2539
Endorsement Status
E&M Committee Rationale/Justification

When the measure returns for maintenance, the committee would like to see: 

  • Consider additional approaches for the reliability assessment that inform the reliability- validity (e.g. shrinkage) and reliability- usability (e.g. stability) tradeoffs
1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2029
1.6 Measure Description

This measure was developed to improve the quality of care delivered to patients undergoing outpatient colonoscopy procedures. The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure, estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a colonoscopy procedure performed at a hospital outpatient department (HOPD) or ambulatory surgical center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. The measure is calculated separately for HOPDs and ASCs. The measure is also reported stratified by dual eligibility for the HOPD setting.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.10 Measure Rationale

The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy measure (CBE #2539) (hereafter “Colonoscopy measure”) captures unplanned hospital visits 7 days after a colonoscopy procedure performed at an HOPD, or separately, at an ASC. The measure focuses on the outcome of unplanned hospital visits because this is a broad, patient-centered outcome that captures the full range of hospital visits resulting from adverse events or poor care coordination following the procedure. By providing HOPDs and ASCs with detailed information about patients who have an unplanned hospital visit, this measure supports quality improvement at facilities, and through public reporting of the measure allows for assessment and illumination of the variation in risk-adjusted hospital visits following colonoscopy.

 

Colonoscopy is a common and costly procedure performed at outpatient facilities and is frequently performed among relatively healthy patients to screen for colorectal cancer (CRC). Given the widespread use of colonoscopy, understanding and minimizing procedure-related adverse events is a high priority. These adverse events, such as abdominal pain, bleeding, and intestinal perforation, can result in unanticipated hospital visits after the procedure. Furthermore, physicians performing colonoscopies may be unaware that patients seek acute care at hospitals following the procedure and thus underestimate such events. This risk-standardized quality measure addresses this information gap and promotes quality improvement by providing feedback to facilities and physicians, including patient-level details for each post-procedure visit.  Public reporting transparency for patients on the rates of and variation across facilities in unplanned hospital visits after colonoscopy.

 

Patients may experience a range of potential adverse events after an outpatient colonoscopy, which could lead to unplanned hospital visits, including ED visits, observation stays, and unplanned inpatient admissions. This measure provides the opportunity to improve the quality of care and to lower rates of adverse events leading to hospital visits after an outpatient colonoscopy. Below we describe the complications that patients may experience; pathways for improvement by measured entities, and improvement through public reporting.

                                                                                                                                     

Colonoscopy Complications 

Gastrointestinal complications are common and range from severe to mild. Complications such as colonic perforation and gastrointestinal (GI) bleeding are relatively rare but severe adverse events; other GI complications are considerably more common (Olaiya et al., 2020; Kothari et al., 2019). A recent meta-analysis found that perforation rates ranged from 1.6 to 11.9 per 10,000 procedures and that the risk of perforation was not associated with age; study authors suggested that characteristics of the procedure itself were underlying this adverse event (Kothari et al., 2019).  Other adverse events are more common but less severe; among surveyed patients, the reported frequency of complications was 25% by the second day following the procedure (Sewitch et al., 2018). These complications include abdominal pain, abdominal distension, nausea, vomiting, and other nonspecific symptoms. In addition, the overall risk of a complication is higher in older adults (Causada-Calo et al., 2020).

 

Cardiopulmonary complications are rare (Kothari et al., 2019) but can occur as a complication of the sedation given at the time of the procedure. It has been shown that aspiration is more common with deep sedation with anesthesia assistance (0.14% in Medicare-aged patients) compared to moderate sedation without anesthesia assistance (0.10%) (Cooper et al., 2013).

 

Post-procedural infection can also occur as a result of a colonoscopy.  For example, a 2018 study found rates of infection within 7 days of a screening colonoscopy performed at an ASC to be 1.1 per 1,000 colonoscopies (Wang et al., 2018).  Furthermore, the study authors found that the rates of infection varied widely by ASC, from 0 to 115 per 1,000 colonoscopies. Infection can occur due to lapses in infection control procedures, as well as defective equipment (Petersen et al., 2017).

 

 

Hospital visits following colonoscopy

The symptoms described above can result in the need for acute care. A 2018 retrospectively review of 50,319 colonoscopies performed on 44,082 individuals (47% male, median age 59 years) reported an ED visit rate within 7 days of a colonoscopy of 0.76% (Grossberg et al., 2018), and a claims-based analysis found an average 7-day hospital visit rate (defined as an ED visit, observation stay, or inpatient hospitalization) of 1.63% (Ranasinghe et al., 2016). A recent study found that older patients are more likely to experience a hospital visit after colonoscopy and reported a rate of inpatient admission or an ED visit within 30 days of 6.8% in people aged 75 and older (Causada-Calo et al, 2020). The rate of hospitalization varies by type of complication; hospitalization rates were nearly 100% among patients who developed perforation and between 50.8% and 70.7% among patients who developed lower GI bleeding (Wang et al., 2018). In contrast, hospitalizations among patients with abdominal pain or nausea diagnosis were less common.

 

Studies have shown that many of the reasons for post-procedural hospital visits are related to the colonoscopy. For example, a 2018 single-center study examined the medical records (including medication information) of patients who experienced an emergency department (ED) visit within 7 days of an outpatient colonoscopy (Grossberg et al., 2018). The study authors extracted patients’ chief complaint from medical records, assigned the chief complaints as related or unrelated to the colonoscopy, and found that 68% of the reasons for the ED visit were due to the colonoscopy. The most common reasons for related ED visits were abdominal pain (38.2%), gastrointestinal bleeding (29.7%), cardiopulmonary disorders (12.7%), and nausea/vomiting (4.2%). In another study, the authors examined the most frequent diagnoses in claims data associated with an unplanned hospital visit within 7 days, which included hemorrhage (6.4% of all unplanned visits), accidental operative laceration (3.0%), abdominal pain (3.0%), GI hemorrhage (2.7%), chest pain (1.9%), and urinary tract infection (1.8%) (Ranasinghe et al., 2016). CORE’s updated analysis (see Section 4.3, Validity) shows a similar pattern of complications 7 days following a screening colonoscopy, with recent data.

 

 

Pathways for improvement

Provider- and facility-level factors can affect the outcome of complications and hospital visits related to a colonoscopy. For example, provider-level factors such as low provider volume and fellow involvement in the procedure were significantly associated with a higher risk of an ED visit in one study (Grossberg et al., 2018), and another study found that low procedure volume was associated with a higher risk of infection (Wang et al., 2018), suggesting facilities can influence the patients’ outcome through these modifiable pathways. 

 

Providers may be unaware of complications for which patients visit the hospital, leading to understated complication rates and suggesting the need for better measurement to drive quality improvement. Both patients and providers can benefit from outcome measures that capture the full range of adverse experiences associated with outpatient colonoscopy and illuminate quality differences. 

 

Public reporting and facility feedback

CMS provides the public with data to help people make more informed decisions about their healthcare. As of December 2017, measure results have been publicly available; results have been available to facilities since 2015 in the form of facility-specific quality reports. Thus, it is important to continue to make this information transparent to patients choosing among providers who offer this elective procedure, and to facilities that can use the detailed feedback for quality improvement.

 

Importantly, providing outcome rates to providers will make meaningful quality differences visible to clinicians, thus incentivizing improvement.  In this submission we show improvement across the five performance periods captured by this measure since it was implemented. For example, the national rate of hospital visits per 1,000 colonoscopies among HOPDs declined from 16.4 in 2018 reporting to 14.8 in 2019 reporting, and 13.2 for 2023 reporting, and the distribution of risk-standardized rates also declined. 

 

References

 

ASGE Standards of Practice Committee, Early, D. S., Lightdale, J. R., Vargo, J. J., 2nd, Acosta, R. D., Chandrasekhara, V., Chathadi, K. V., Evans, J. A., Fisher, D. A., Fonkalsrud, L., Hwang, J. H., Khashab, M. A., Muthusamy, V. R., Pasha, S. F., Saltzman, J. R., Shergill, A. K., Cash, B. D., & DeWitt, J. M. (2018a). Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal endoscopy87(2), 327–337. https://doi.org/10.1016/j.gie.2017.07.018

 

ASGE Quality Assurance in Endoscopy Committee, Calderwood, A. H., Day, L. W., Muthusamy, V. R., Collins, J., Hambrick, R. D., 3rd, Brock, A. S., Guda, N. M., Buscaglia, J. M., Petersen, B. T., Buttar, N. S., Khanna, L. G., Kushnir, V. M., Repaka, A., Villa, N. A., & Eisen, G. M. (2018b). ASGE guideline for infection control during GI endoscopy. Gastrointestinal endoscopy87(5), 1167–1179. https://doi.org/10.1016/j.gie.2017.12.009

 

Bielawska B, Hookey LC, Sutradhar R, Whitehead M, Xu J, Paszat LF, Rabeneck L, Tinmouth J. Anesthesia Assistance in Outpatient Colonoscopy and Risk of Aspiration Pneumonia, Bowel Perforation, and Splenic Injury. Gastroenterology. 2018 Jan;154(1):77-85.e3. doi: 10.1053/j.gastro.2017.08.043. Epub 2017 Sep 1. PMID: 28865733.

 

Causada-Calo, N., Bishay, K., Albashir, S., Al Mazroui, A., & Armstrong, D. (2020). Association Between Age and Complications After Outpatient Colonoscopy. JAMA network open, 3(6), e208958. https://doi.org/10.1001/jamanetworkopen.2020.8958

 

Grossberg LB, Vodonos A, Papamichael K, Novack V, Sawhney M, Leffler DA. Predictors of post-colonoscopy emergency department use. Gastrointest Endosc. Feb 2018;87(2):517-525.

Kothari ST, Huang RJ, Shaukat A, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Khashab MA, Jamil LH, Jue TL, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Thosani N, Yang J, DeWitt JM, Wani S; ASGE Standards of Practice Committee Chair. ASGE review of adverse events in colonoscopy. Gastrointest Endosc. 2019 Dec;90(6):863-876.e33. doi: 10.1016/j.gie.2019.07.033. Epub 2019 Sep 25. PMID: 31563271

 

Olaiya B, Adler DG. Adverse Events After Inpatient Colonoscopy in Octogenarians: Results From the National Inpatient Sample (1998-2013). J Clin Gastroenterol. 2020 Oct;54(9):813-818. doi: 10.1097/MCG.0000000000001288. PMID: 31764488

 

Ranasinghe I, Parzynski CS, Searfoss R, Montague J, Lin Z, Allen J, Vender R, Bhat K, Ross JS, Bernheim S, Krumholz HM, Drye EE. Differences in colonoscopy quality among facilities: Development of a post-colonoscopy risk-standardized rate of unplanned hospital visits. Gastroenterology. Jan 2016;150(1):103-13.

Petersen, B. T., Cohen, J., Hambrick, R. D., 3rd, Buttar, N., Greenwald, D. A., Buscaglia, J. M., Collins, J., & Eisen, G; Reprocessing Guideline Task Force,. (2017). Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update. Gastrointestinal endoscopy85(2), 282–294.e1. https://doi.org/10.1016/j.gie.2016.10.002

Sewitch MJ, Azalgara VM, Sing MF. Screening Indication Associated With Lower Likelihood of Minor Adverse Events in Patients Undergoing Outpatient Colonoscopy. Gastroenterol Nurs. 2018 Mar/Apr;41(2):159-164. doi: 10.1097/SGA.0000000000000308. PMID: 29596130.

 

Wang P, Xu T, Ngamruengphong S, Makary MA, Kalloo A, Hutfless S. Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut. 2018;67(9):1626–1636.

1.20 Types of Data Sources
1.25 Data Source Details

To calculate the measure score CMS uses final-action claims for Medicare FFS Part A and B and the Medicare Enrollment Database. 

 

This is a claims-based measure and the measure score is calculated automatically from 100% final-action claims; claims data are routinely generated during the delivery of care.  We did not encounter any difficulties with respect to data feasibility, reliability, or validity.