Measure for measure: Improving assessments of colon cancer screening quality

You can’t improve what you can’t measure, the saying goes.

In healthcare, standardized measures have become essential for determining how well services are being delivered. Measures are used by physicians, hospitals, and insurers to improve quality, transparency, and accountability within healthcare, and they allow patients and families to make comparisons and informed choices.

Quality measures of preventive care – which includes screening tests, vaccines, and counseling – most often focus on the proportion of patients who receive these services according to standard guidelines. However, these measures are rarely nuanced enough to consider that individuals benefit from preventive services unequally, and that for some, the risks can outweigh those benefits.

A team of researchers from the University of Michigan and VA Ann Arbor Center for Clinical Management Research (CCMR) led by Sameer D. Saini, M.D., M.S., will develop a more refined measure to assess quality in colorectal cancer screening that better incorporates individual benefit and patient preferences, and could help ensure more appropriate use of this and other preventive services.

“We know that colorectal cancer screening substantially reduces rates of illness and death,” says Saini, a U-M associate professor of internal medicine and research scientist at CCMR. “Our work is about trying to find ways to be more thoughtful about screening people who are likely to benefit, and not screening those who are unlikely to benefit.”

The team has received a 2017 National Quality Forum (NQF) Innovation Challenge Award to support this work. NQF is a recognized, trusted convener of stakeholders from across the healthcare system. The organization works to improve quality by setting consensus-based standards and encouraging sharing of best practices and innovation.  NQF’s Innovation Challenge winners will present their work nationally as part of the NQF Learning Collaborative, which shares knowledge, lessons learned, and best practices to inform, improve, accelerate, and measurably improve healthcare quality.

The U.S. Preventive Services Task Force recommends that all adults age 50-75 be screened for colorectal cancer, and as a result, most large U.S. healthcare organizations have quality systems in place to encourage screening for people in this age group.

Accordingly, the existing NQF-endorsed measure for colorectal cancer screening performance looks at the percentage of adults within this age range who are appropriately screened through any of a number of different tests, using a single target rate for the entire – and very diverse – screen-eligible population.

However, this measure does not factor in important patient characteristics that affect how beneficial these tests are likely to be, such as prior disease history or family history of disease, whether the patient has been screened before, or other patient preferences – all of which can influence screening decisions, and therefore screening rates.

Previous work by Saini’s team found that the measure’s focus on a single patient age group alone may contribute to underuse of screening in healthy, older people and overuse in unhealthy, older people.

Saini’s team will design the new measure of colorectal cancer screening quality to include more than just a strictly defined age range, in part by incorporating health status and prior screening history, as well as preferences among people who have been systematically informed about the benefits and harms of screening through a decision-making tool.

“The way that quality measures are defined has very important implications for how care is actually delivered,” says Saini, who is also a member of the U-M Institute for Healthcare Policy & Innovation. “This project gives us the opportunity to ensure that colorectal cancer screening is delivered in a way that is patient-centered and focused on clinical benefit.”