Colorectal Cancer Screening Clinical Benefit Key to Screening Quality

Quality measures for colorectal cancer screening should look at patient benefit rather than age range alone

medwireNews: Health status should be considered alongside age when designing quality assessments for colorectal cancer screening programmes, US researchers recommend.

The team, led by Sameer Saini, from Veterans Affairs (VA) Ann Arbor Healthcare System in Michigan, found that targeting colorectal cancer screening to patients aged 70 to 75 years led to excessive screening of patients with poor health but underuse of screening in older patients in good health.

“Future quality measures should focus on clinical benefit rather than simply chronological age 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,” they write in BMJ.

The researchers examined data for 399,067 patients aged 50 years or older within the VA Health Care System who were eligible for colonoscopy, sigmoidoscopy or faecal occult blood testing in 2010.

Overall, 38% underwent screening within 2 years of qualifying for the service, with screening uptake highest in younger and healthier patients and dropping significantly in patients aged over 75 years, regardless of comorbidity, number of primary care visits, and other demographical characteristics.

Of concern, 40% of the 8,814 patients aged 70 to 75 years with a Charlson comorbidity index indicating poor health and a reduced life expectancy underwent colorectal cancer screening despite being unlikely to benefit.

By contrast, screening was performed in just 16.5% of the 24,088 patients aged over 75 years with a Charlson comorbidity index indicating excellent health and a good life expectancy, and a perceived benefit from screening.

Indeed, an unhealthy 75-year-old patient was 1.64 times more likely to receive colorectal cancer screening than a healthy 76-year-old patient, Sameer Saini et al write.

The team notes that both the US Preventive Services Task Force guideline and the VA Clinical Preventive Services Guidance statement “encourage an individualized approach to screening for colorectal cancer in patients aged 76–85, but this nuance had not been explicitly incorporated into the quality measure.”

Recognising that the VA has now altered the quality measure for colorectal cancer screening to account for patients with severe comorbidity or poor life expectancy, the researchers conclude: “Though this is an important first step towards a more individualized approach, future patient centered quality measures will need to incorporate more explicit measures of clinical benefit and ultimately help guide clinical decision making.”

Reference

Saini S, Vijan S, Schoenfeld P, et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ 2014: 348:g1247 26 February. doi: http://dx.doi.org/10.1136/bmj.g1247

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