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  • Measure Summary
  • NQMC:011366
  • Jan 2018
  • NQF-Endorsed Measure

Outpatient colonoscopy: facility-level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy.

Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 11.0. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2018 Jan. various p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 10.0a. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2017 Jan 1. various p.

Primary Measure Domain

Related Health Care Delivery Measures: Use of Services

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the facility-level rate of risk-standardized, all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy among Medicare fee-for-service (FFS) patients aged 65 years and older.

Rationale

Colonoscopy is a common and costly procedure performed at outpatient facilities and is frequently performed among relatively healthy patients to screen for colorectal cancer. Given the widespread use of colonoscopy, understanding and minimizing procedure-related adverse events is a high priority. These adverse events, such as abdominal pain, bleeding, and intestinal perforation, can result in unanticipated hospital visits post procedure. Physicians performing colonoscopies are often unaware that patients seek acute care at hospitals following the procedure and thus underestimate such events. This risk-standardized quality measure will address this information gap and promote quality improvement by providing feedback to facilities and physicians, as well as transparency for patients on the rates of and variation across facilities in unplanned hospital visits after colonoscopy.

This measure will reduce adverse patient outcomes associated with preparation for colonoscopy, the procedure itself, and follow-up care by capturing and making more visible to providers and patients all unplanned hospital visits following the procedure. The measure score will assess quality and inform quality improvement.

Evidence for Rationale

Centers for Medicare and Medicaid Services (CMS). Facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: a quality measure for profiling facility performance using claims data. Measure technical report. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); 2014 Jan 31. 54 p.

Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 11.0. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2018 Jan. various p.

Primary Health Components

Colonoscopy; unplanned hospital visit

Denominator Description

The target population for this measure includes low-risk colonoscopies performed in the outpatient setting for Medicare fee-for-service (FFS) patients aged 65 years and older.

See the related "Denominator Inclusions/Exclusions" field.

Numerator Description

The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or unplanned inpatient admission.

See the related "Numerator Inclusions/Exclusions" field.

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18 to 75 years receiving one or more hemoglobin A1c tests per year); thus, the developer is using this field to define the outcome. See the 2017 Measure Updates and Specifications Report: Facility 7-day Risk-standardized Hospital Visit Rate after Outpatient Colonoscopy External Web Site Policy for more details (see the "Companion Documents" field).

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Colonoscopy is a common and costly procedure. In 2002 alone, physicians performed an estimated 14 million colonoscopies in the United States (Seeff et al., 2004). The vast majority (90%) are done in the outpatient settings of hospital outpatient departments (HOPDs), ambulatory surgical centers (ASCs), and physician offices (Russo et al., 2006). While colonoscopy is used for the diagnosis and treatment of a wide range of conditions, most outpatient colonoscopies are for the screening of colorectal cancer (CRC) among relatively healthy patients. The United States Preventive Services Task Force (USPSTF) (2008) recommends CRC screening every 10 years for the general population aged 50 to 75 years and more frequently for individuals at higher risk. While many modalities are available for CRC screening, colonoscopy is the most widely used (Shapiro et al., 2012) and is recommended by professional organizations as the optimal screening method due to the ability to visualize the bowel and the capacity to remove precancerous lesions (polyps) detected on examination (Rex et al., 2009). Given the widespread use of colonoscopy in the outpatient setting, often among patients without a known illness, understanding and minimizing procedure-related adverse events is a high priority.

Colonoscopies are associated with a range of well described adverse events that lead to hospital visits, repeat procedures, or surgical intervention for treatment. The most severe adverse events reported after colonoscopy are colonic perforation; gastrointestinal (GI) bleeding; and cardiopulmonary events such as hypoxia, aspiration pneumonia, and cardiac arrhythmias (Day et al., 2011; Ko & Dominitz, 2010; ASGE Standards of Practice Committee et al., 2011). Furthermore, 20% to 34% of patients report a range of less severe adverse events such as abdominal pain, abdominal distension, nausea, vomiting, and other non-specific symptoms post colonoscopy (Baudet et al., 2009; Ko et al., 2007). Yet clinicians performing colonoscopies underreport these clinical outcomes (Leffler et al., 2010), in part because they lack information about patients seeking follow-up care from other providers in settings such as a hospital ED. Hospital visits are generally unexpected after outpatient colonoscopy, yet reported hospital visit rates after outpatient colonoscopy range from 0.8% to 1% at 7 to 14 days and 2.4% to 3.8% at 30 days post procedure (Ko et al., 2007; Leffler et al., 2010; Chukmaitov et al., 2008).

Both patients and providers will benefit from outcome measures that capture the full range of adverse experiences associated with outpatient colonoscopy and illuminate quality differences. Currently, there are no publicly available quality reports on outcomes among providers or facilities that conduct outpatient colonoscopies. Thus, there is an opportunity to enhance the information available to patients choosing among providers who offer this elective procedure. Further, providing outcome rates to providers will make visible to clinicians meaningful quality differences and incentivize improvement.

Evidence for Additional Information Supporting Need for the Measure

ASGE Standards of Practice Committee, Fisher DA, Maple JT, Ben-Menachem T, Cash BD, Decker GA, Early DS, Evans JA, Fanelli RD, Fukami N, Hwang JH, Jain R, Jue TL, Khan KM, Malpas PM, Sharaf RN, Shergill AK, Dominitz JA. Complications of colonoscopy. Gastrointest Endosc. 2011 Oct;74(4):745-52. [119 references] PubMed External Web Site Policy

Baudet JS, Diaz-Bethencourt D, Avilés J, Aguirre-Jaime A. Minor adverse events of colonoscopy on ambulatory patients: the impact of moderate sedation. Eur J Gastroenterol Hepatol. 2009 Jun;21(6):656-61. PubMed External Web Site Policy

Centers for Medicare and Medicaid Services (CMS). Facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: a quality measure for profiling facility performance using claims data. Measure technical report. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); 2014 Jan 31. 54 p.

Chukmaitov AS, Menachemi N, Brown SL, Saunders C, Tang A, Brooks R. Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes?. J Ambul Care Manage. 2008 Oct-Dec;31(4):354-69. PubMed External Web Site Policy

Day LW, Kwon A, Inadomi JM, Walter LC, Somsouk M. Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis. Gastrointest Endosc. 2011 Oct;74(4):885-96. PubMed External Web Site Policy

Ko CW, Dominitz JA. Complications of colonoscopy: magnitude and management. Gastrointest Endosc Clin N Am. 2010 Oct;20(4):659-71. [93 references]

Ko CW, Riffle S, Shapiro JA, Saunders MD, Lee SD, Tung BY, Kuver R, Larson AM, Kowdley KV, Kimmey MB. Incidence of minor complications and time lost from normal activities after screening or surveillance colonoscopy. Gastrointest Endosc. 2007 Apr;65(4):648-56.

Leffler DA, Kheraj R, Garud S, Neeman N, Nathanson LA, Kelly CP, Sawhney M, Landon B, Doyle R, Rosenberg S, Aronson M. The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy. Arch Intern Med. 2010 Oct 25;170(19):1752-7. PubMed External Web Site Policy

Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, American College of Gastroenterology. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009 Mar;104(3):739-50. [133 references] PubMed External Web Site Policy

Russo A, Elixhauser A, Steiner C, Wier L. Hospital-based ambulatory surgery, 2007: statistical brief #86. Healthcare Cost and Utilization Project (HCUP) statistical briefs. Rockville (MD): Agency for Healthcare research and Quality (AHRQ); 2006.

Seeff LC, Richards TB, Shapiro JA, Nadel MR, Manninen DL, Given LS, Dong FB, Winges LD, McKenna MT. How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity. Gastroenterology. 2004 Dec;127(6):1670-7. PubMed External Web Site Policy

Shapiro JA, Klabunde CN, Thompson TD, Nadel MR, Seeff LC, White A. Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2012 Jun;21(6):895-904. PubMed External Web Site Policy

U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Nov 4;149(9):627-37. PubMed External Web Site Policy

Extent of Measure Testing

The developer tested the measure against the National Quality Forum's (NQF's) criteria for scientific soundness and importance, including testing the risk adjustment model properties and evaluating the measure score variation in four states for which data were available. The model showed good fit and discrimination across risk groups. The median risk-standardized measure score was 12.3 hospital visits per 1,000 colonoscopies and the measure score ranged from 8.4 to 20.0 hospital visits per 1,000 colonoscopies among hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) in California, Florida, Nebraska and New York.

Refer to the Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy: A Quality Measure for Profiling Facility Performance using Claims Data. Measure Technical Report for additional information (see the "Companion Documents" field).

Evidence for Extent of Measure Testing

Centers for Medicare and Medicaid Services (CMS). Facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: a quality measure for profiling facility performance using claims data. Measure technical report. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); 2014 Jan 31. 54 p.

State of Use

Current routine use

Current Use

External oversight/Medicare

Monitoring and planning

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory Procedure/Imaging Center

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than or equal to 65 years

Target Population Gender

Either male or female

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Encounter dates: January 1 through December 31

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Diagnostic Evaluation

Encounter

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
The target population for this measure includes low-risk colonoscopies performed in the outpatient setting for Medicare fee-for-service (FFS) patients aged 65 years and older. For implementation in the Hospital Outpatient Quality Reporting (OQR) Program, the measure will be calculated among hospital outpatient departments (HOPDs).

Included Populations: Centers for Medicare & Medicaid Services (CMS) FFS beneficiaries with an outpatient colonoscopy are included if the patient has been enrolled in Part A and Part B Medicare for the 12 months prior to the date of procedure to ensure a full year of administrative data for risk-adjustment.

The measure is focused on low-risk colonoscopies. The measure did not include colonoscopy Current Procedural Terminology (CPT) procedure codes that reflected fundamentally higher-risk or different procedures. Qualifying colonoscopies billed with a concurrent high-risk colonoscopy procedure code were not included in the measure.

Note:

Exclusions

  • Colonoscopies for patients who lack continuous enrollment in Medicare FFS Parts A and B in the 7 days after the procedure
  • Colonoscopies that occur concurrently with high-risk upper gastrointestinal (GI) endoscopy procedures
  • Colonoscopies for patients with a history of inflammatory bowel disease (IBD) or diagnosis of IBD at time of index colonoscopy or on a subsequent hospital visit outcome claim
  • Colonoscopies for patients with a history of diverticulitis or diagnosis of diverticulitis at time of index colonoscopy or on a subsequent hospital visit outcome claim
  • Colonoscopies followed by a subsequent outpatient colonoscopy procedure within 7 days
  • Colonoscopies that are billed on the same hospital claim as an emergency department (ED) visit, unless the ED visit has a diagnosis indicative of a complication of care (applies to colonoscopies at OPDs only)
  • Colonoscopies that are billed on a separate claim on the same day and at the same facility as an ED visit, unless the ED visit has a diagnosis indicative of a complication of care (applies to colonoscopies at OPDs only)
  • Colonoscopies that are billed on the same hospital outpatient claim as an observation stay

Note:

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
The outcome for this measure is all-cause, unplanned hospital visits within 7 days of an outpatient colonoscopy. The measure defines a hospital visit as any emergency department (ED) visit, observation stay, or unplanned inpatient admission.

Note: This outcome measure does not have a traditional numerator and denominator like a core process measure (e.g., percentage of adult patients with diabetes aged 18 to 75 years receiving one or more hemoglobin A1c tests per year); thus, the developer is using this field to define the outcome. See the 2017 Measure Updates and Specifications Report: Facility 7-day Risk-standardized Hospital Visit Rate after Outpatient Colonoscopy External Web Site Policy for more details (see the "Companion Documents" field).

Exclusions
Admissions identified as planned by the planned admission algorithm are not counted in the outcome. The "algorithm" is a set of criteria for classifying admissions as planned using Medicare claims. The algorithm identifies admissions that are typically planned and may occur within 7 days of an outpatient colonoscopy. Centers for Medicare & Medicaid Services (CMS) based the planned admission algorithm on three principles:

  1. A few specific, limited types of care are always considered planned (transplant surgery, maintenance chemotherapy, rehabilitation);
  2. Otherwise, a planned admission is defined as a non-acute admission for a scheduled procedure; and
  3. Admissions for acute illness or for complications of care are never planned.

The planned admission algorithm uses a flowchart and four tables of procedures and conditions to operationalize these principles and to classify inpatient admissions as planned. ED visits and observation stays are never considered planned. The flowchart and tables are available in the 2017 Measure Updates and Specifications Report: Facility 7-day Risk-standardized Hospital Visit Rate after Outpatient Colonoscopy External Web Site Policy (see the "Companion Documents" field).

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Type of Health State

Proxy for Outcome

Instruments Used and/or Associated with the Measure

Planned Admission Algorithm Version 3.0 – Colonoscopy Population – Flow Chart

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Case-mix adjustment

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

The measure's approach to risk adjustment is tailored to, and appropriate for, a publicly reported outcome measure as articulated in published scientific guidelines.

The measure uses a two-level hierarchical logistic regression model to estimate facility-level risk-standardized hospital visit rates. This approach accounts for the clustering of patients within facilities and variation in sample size across facilities.

The risk-standardization model has 15 patient-level variables (age, concomitant upper gastrointestinal [GI] endoscopy, polypectomy during the procedure, and 12 comorbidity variables). The measure defines comorbidity variables using condition categories (CCs), which are clinically meaningful groupings of the many thousands of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. Certain CCs are considered possible complications of care; therefore, the measure does not risk-adjust for them if they occur only at the time of the procedure. This is because only comorbidities that convey information about the patient at the time of the procedure or in the 12 months prior, and not complications that arose during the colonoscopy procedure are included in the risk adjustment. The 2017 Measure Updates and Specifications Report: Facility 7-day Risk-standardized Hospital Visit Rate after Outpatient Colonoscopy External Web Site Policy contains complete definitions of risk factors and CCs that are considered possible complications of care and are not risk-adjusted for if they occur only at the time of the procedure (see also the "Companion Documents" field).

The patient-level risk-adjustment variables are:

Patient-level Variables Risk-adjusted Variables
Demographics
  • Age (categorized; 65 to 69; 70 to 74; 75 to 79; 80 to 84; 85+)
Procedural factors
  • Concomitant Endoscopy
  • Polypectomy during Procedure
Comorbidities
  • Chronic Heart Failure
  • Ischemic Heart Disease
  • Stroke/Transient Ischemic Attack (TIA)
  • Chronic Lung Disease
  • Metastatic Cancer
  • Liver Disease
  • Iron Deficiency Anemia
  • Disorders of Fluid, Electrolyte, Acid-Base
  • Pneumonia
  • Psychiatric Disorders
  • Drug and Alcohol Abuse/Dependence
  • Arrhythmia
  • Age Categorized x Arrhythmia Interaction

Note: The relationship between age and risk of a hospital visit within 7 days was modified by the presence or absence of a cardiac arrhythmia (p-value for interaction less than 0.001). Therefore, the developer included an interaction term (age categorized x arrhythmia) in the final model.

Full details of the development of the risk-standardization model for this measure are available from the CMS Web site External Web Site Policy.

Standard of Comparison

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

OP-32: CMS outcome measures (claims-based): facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy.

Measure Collection Name

Hospital Outpatient Quality Measures

Measure Set Name

Colonoscopy

Submitter

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Developer

Centers for Medicare & Medicaid Services - Federal Government Agency [U.S.]

Funding Source(s)

United States Department of Health and Human Services

Composition of the Group that Developed the Measure

This measure was developed by a team of clinical and statistical experts from Yale University/Yale-New Haven Hospital Center for Outcomes Research and Evaluation (Yale-CORE) and Harvard University, under a contract with the Centers for Medicare & Medicaid Services (CMS).

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

2539

Date of Endorsement

2016 May 12

Measure Initiative(s)

Ambulatory Surgery Center Quality Reporting Program

Hospital Compare

Hospital Outpatient Quality Reporting Program

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2018 Jan

Measure Maintenance

Annual

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 10.0a. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2017 Jan 1. various p.

Source(s)

Centers for Medicare and Medicaid Services (CMS). Hospital outpatient quality reporting specifications manual, version 11.0. Baltimore (MD): Centers for Medicare and Medicaid Services (CMS); Effective 2018 Jan. various p.

Measure Availability

Source available from the QualityNet Web site External Web Site Policy.

Check the QualityNet Web site regularly for the most recent version of the specifications manual and for the applicable dates of discharge.

Companion Documents

The following are available:

  • Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE), Mathematica Policy Research. 2017 measure updates and specifications report: facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: a quality measure for profiling facility performance using claims data. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2017 Aug 18. 66 p. Available from the QualityNet Web site External Web Site Policy.
  • Centers for Medicare & Medicaid Services (CMS). Facility 7-day risk-standardized hospital visit rate after outpatient colonoscopy: a quality measure for profiling facility performance using claims data. Measure technical report. Baltimore (MD): Centers for Medicare & Medicaid Services (CMS); 2014 Jan 31. 54 p. Available from the QualityNet Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on December 22, 2015. The measure information was verified by the measure developer on February 9, 2016.

This NQMC summary was updated by ECRI Institute on March 7, 2017. The measure information was verified by the measure developer on April 6, 2017.

This NQMC summary was updated again by ECRI Institute on February 19, 2018. The measure information was verified by the measure developer on April 19, 2018.

Copyright Statement

No copyright restrictions apply.

The Hospital Outpatient Quality Reporting Specifications Manual is periodically updated by the Centers for Medicare & Medicaid Services. Users of the Hospital OQR Specifications Manual must update their software and associated documentation based on the published manual production timelines.

Current Procedural Terminology (CPT) codes, descriptions, and other data only are copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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