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.
