Colon Cancer: Improving Determinants of Who Should Be Screened

Sameer Saini MD Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USAMedicalResearch.com Interview with:
Sameer Saini MD
Veterans Affairs Center for Clinical Management Research,
VA Ann Arbor Healthcare System
Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA

MedicalResearch.com: What are the main findings of the study?

Dr. Saini: The way that quality measures are defined can have important implications for how care is actually delivered. Current colorectal cancer screening quality measures use age to identify screen-eligible patients, encouraging screening in patients between 50 and 75 years of age. But they do not explicitly incorporate health status. In this context, our study had two main findings.

  • First, by focusing on age alone, we are not screening everyone who is likely to benefit. Specifically, many healthy people over 75 years of age (who are outside the target age range of the quality measure) may benefit from screening, but the current measure does not encourage screening in this population, leading to low screening use.
  • Second, some people who are NOT likely to benefit are being screened unnecessarily, like those with serious health problems. For example, people between ages 70-75 with serious health problems (who have limited life expectancy) are unlikely to benefit from screening, and may even be harmed by it. But the current quality measure encourages screening in such individuals due to their age, yielding relatively high screening rates. If the system focused on age and health status (rather than age alone), screening use would be more aligned with screening benefit, and we would have better health outcomes.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Saini: The most striking and unexpected finding was that 75 year-olds in poor health were significantly more likely to be screened than 76 year-olds in good health (35% versus 21%). This is concerning because 75 year-olds in poor health, who have limited life expectancy, are unlikely to benefit from screening and may even be harmed by it. On the other hand, 76 year-olds in good health have good life expectancy and are likely to benefit from screening.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Saini: Quality measure specification can have important implications for clinical care, in some cases resulting in care that is inconsistent with benefit. Clinicians and patients should be aware of this potential unintended effect of quality measurement. When it comes to preventive care in older patients, clinicians should strive to make decisions that are clinically sensitive, taking the individual’s overall health and preferences into account. Of course, this is challenging when the system unintentionally encourages screening that is not clinically sensitive, which is why the quality measures themselves need to be modified.

MedicalResearch.com: What recommendations do you have for future research as a result of this study? 

Dr. Saini: Future quality measures should focus on individual risk/benefit to ensure that patients who are likely to benefit from a service receive it (regardless of age), and that those who are likely to incur harm are spared unnecessary and costly care. These measures should also incorporate patient preferences, particularly when the balance of benefits and harms is uncertain. Research will be needed to understand how to best design and implement such measures, and then to better understand how they actually impact clinical care.

Citation:

Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study

Saini SD ,Vijan S ,Schoenfeld P ,Powell AA ,Moser S ,Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ 2014;348:g1247