Gastroenterology

Gastroenterology

Volume 150, Issue 1, January 2016, Pages 103-113
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits

https://doi.org/10.1053/j.gastro.2015.09.009Get rights and content

Background & Aims

Colonoscopy is a common procedure, yet little is known about variations in colonoscopy quality among outpatient facilities. We developed an outcome measure to profile outpatient facilities by estimating risk-standardized rates of unplanned hospital visits within 7 days of colonoscopy.

Methods

We used a 20% sample of 2010 Medicare outpatient colonoscopy claims (331,880 colonoscopies performed at 8140 facilities) from patients ≥65 years or older, and developed a patient-level logistic regression model to estimate the risk of unplanned hospital visits (ie, emergency department visits, observation stays, and inpatient admissions) within 7 days of colonoscopy. We then used the patient-level risk model variables and hierarchical logistic regression to estimate facility rates of risk-standardized unplanned hospital visits using data from the Healthcare Cost and Utilization Project (325,811 colonoscopies at 992 facilities), from 4 states containing 100% of colonoscopies per facility.

Results

Outpatient colonoscopies were followed by 5412 unplanned hospital visits within 7 days (16.3/1000 colonoscopies). Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits. Fifteen variables were independently associated with unplanned hospital visits (c = 0.67). A history of fluid and electrolyte imbalance (odds ratio [OR] = 1.43; 95% confidence interval [CI]: 1.29−1.58), psychiatric disorders (OR = 1.34; 95% CI: 1.22−1.46), and, in the absence of prior arrhythmia, increasing age past 65 years (aged >85 years vs 65−69 years: OR = 1.87; 95% CI: 1.54−2.28) were most strongly associated. The facility risk-standardized unplanned hospital visits calculated using Healthcare Cost and Utilization Project data showed significant variation (median 12.3/1000; 5th−95th percentile, 10.5−14.6/1000). Median risk-standardized unplanned hospital visits were comparable between ambulatory surgery centers and hospital outpatient departments (each was 10.2/1000), and ranged from 16.1/1000 in the Northeast to 17.2/1000 in the Midwest.

Conclusions

We calculated a risk-adjusted measure of outpatient colonoscopy quality, which shows important variation in quality among outpatient facilities. This measure can make transparent the extent to which patients require follow-up hospital care, help inform patient choices, and assist in quality-improvement efforts.

Section snippets

Measure Overview

To develop the measure, we defined a clinically similar cohort of patients undergoing outpatient colonoscopy, defined the outcome to capture unplanned hospital visits, and identified risk variables that mediated the risk of hospital use and were unrelated to quality. We then developed and validated a patient-level risk-adjustment model. Lastly, we estimated a facility-level risk-standardized hospital visit rate (RSHVR) and examined variation in the RSHVR among facilities. A technical expert

Study Cohort and Outcome

In the study population, there were 331,880 colonoscopies (n = 8140 facilities) that met our inclusion and exclusion criteria (Appendix E; available in the Supplementary Material). Included patients had a mean age of 74.2 years and 54% were female (Table 1). As expected in a large dataset, we found small but statistically significant differences among ASCs, HOPDs, and physician office settings for all baseline characteristics except polypectomy during the procedure (P = .78). After colonoscopy,

Discussion

We developed a quality measure that profiles facility performance in outpatient colonoscopy by examining rates of risk-standardized unplanned hospital visits in the 7 days after colonoscopy among Medicare beneficiaries using claims data. Colonoscopy is an exceedingly common outpatient procedure, often performed among healthy patients for screening. Our findings show an unplanned hospital visit rate of 16.3 per 1000 colonoscopies in a Medicare 20% sample. Extrapolating our findings to a 100%

Acknowledgments

This work is a collaborative effort, and the authors gratefully acknowledge and thank the support of the members of the national Technical Expert Panel. These individuals provided guidance on key clinical and methodologic decisions and gave feedback on key measure decisions. Specifically, we would like to thank the following Technical Expert Panel members (in alphabetical order): Dr Joel Brill (Chief Medical Officer, Predictive Health and Medical Director, Fair Health, Phoenix, AZ), Dr Zahid

References (38)

  • Russo A, Elixhauser A, Steiner C, et al. Hospital-Based Ambulatory Surgery, 2007: Statistical Brief #86. Healthcare...
  • Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement

    Ann Intern Med

    (2008)
  • J.A. Shapiro et al.

    Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey

    Cancer Epidemiol Biomarkers Prev

    (2012)
  • D.K. Rex et al.

    American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]

    Am J Gastroenterol

    (2009)
  • J.S. Baudet et al.

    Minor adverse events of colonoscopy on ambulatory patients: the impact of moderate sedation

    Eur J Gastroenterol Hepatol

    (2009)
  • D.A. Leffler et al.

    The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy

    Arch Intern Med

    (2010)
  • A.S. Chukmaitov et al.

    Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes?

    J Ambul Care Manage

    (2008)
  • Healthcare Cost and Utilization Project (HCUP). Volume 2013

    (2015)
  • L. Horwitz et al.

    2014 Measures Updates and Specifications Report: Hospital-Wide All-Cause Unplanned Readmission—Version 3.0

    (2014)
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    Conflicts of interest These authors disclose the following: Drs Ranasinghe, Parzynski, Searfoss, Montague, Lin, Bhat, Ross, Bernheim, Krumholz, and Drye all work under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures. Dr Ranasinghe is supported by an Early Career Fellowship co-funded by the National Health and Medical Research Council and the National Heart Foundation of Australia. Dr Ross is supported by the National Institute on Aging (K08 AG032886) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Dr Krumholz is chair of a cardiac scientific advisory board for UnitedHealth. Drs Krumholz and Ross, through Yale University, receive research support from Medtronic, Inc. and Johnson & Johnson to develop methods of clinical trial data sharing and from the Food and Drug Administration and Medtronic to develop methods for post-market surveillance of medical devices. Dr Allen is President of the American Gastroenterological Association and reports consulting agreements with Pentax, Olympus, Myriad Genetics, AbbVie Pharmaceuticals and gMed. The remaining author discloses no conflicts.

    Funding This publication is based on analyses performed under contract number HHSM-500-2012-00025I, task order: HHSM-500-T0002 entitled “Measure & Instrument Development and Support-Development and Reevaluation of the Centers for Medicare & Medicaid Services Hospital Outcomes and Efficiency Measures,” funded by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of Department of Health and Human Services. The authors assume full responsibility for the accuracy and completeness of the data presented.

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