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New Quality Measure Will Disincentivize Endoscopic Resection of Most Important Colorectal Lesions.

Dear Editor: Ranasinghe et al report a new facility measure for colonoscopy quality based on the rate of unplanned hospital visits within 7 days of outpatient colonoscopy. We have clinical and methodologic concerns about the effect of this measure on colorectal cancer prevention and procedural risk. A quality measure may distort clinical behavior or be gamed to show good performance without resulting in improved patient care. For example, the most common procedure-related complication was postpolypectomy bleeding. Although themodel adjusted for polypectomy, it did not adjust for the important features of (large) polyp size, proximal location, and anticoagulation, factors that many studies show predict postpolypectomy bleeding risk. Studies using techniques currently considered optimized for endoscopic mucosal resection (technique that minimizes thermal injury by increasing cutting current) show that the risk of delayed bleeding from proximal colon large polyp resection by expert colonoscopists still exceeds 10%. Rinasinghe et al contend that “Provider-level factors (such as the polypectomy technique).may also contribute to the risk of unplanned hospital visits,” an assertion that is incorrect for large polyps, for which there are no randomized trials demonstrating that electrocautery type, postresection site closure, or cautery of exposed vessels reduces bleeding risk. Expert colonoscopists are widely aware of polyp factors that increase polypectomy risk, andwill respond to the newquality measure in some cases by referring more high-risk polyps to expert endoscopists or for surgical resection. This adaptation will increase costs and patient risk, especially if it results in more unnecessary surgery, as surgical resection of benign colon polyps is more expensive and has greater associated morbidity and mortality than endoscopic resection. Further, age and several comorbidities were associated with unplanned hospital visits within 7 days of the procedure. However, elderly patients have a high prevalence of neoplasia, as may those with certain comorbidities, and may still benefit from polypectomy. Implementation of this measure could create a disincentive to perform colonoscopy and polypectomy on these patients or cause clinicians to choose screening or diagnostic strategies that are less effective. From a methodologic perspective, the measure uses administrative data to adjust for comorbid and polyprelated covariates, resulting in a model with only fair discrimination (c-statistic of 0.67). Further, the three most common reasons for an unexpected hospital visit within 7 days of colonoscopy—hemorrhage, abdominal pain, and perforation—combined represented <13% of all visits, a finding that may reflect poor specificity of the measure. Other issues include uncertain generalizability beyond Medicare recipients (younger patients will have less comorbidity and less anticoagulant use) and a lack of prospective validation. A measure that may be a valid statistical predictor of unanticipated hospital visits in retrospective cohorts does not necessarily translate to one that will improve clinical outcomes when applied prospectively, especially when gaming and changes in provider behavior are anticipated. The goal of screening and surveillance colonoscopy is to prevent colorectal cancer by identifying and effectively resecting precancerous lesions. Quality colonoscopy includes clearing the colon of the most challenging precancerous lesions, at times in the most challenging patients. Many expert colonoscopists understand the risks of endoscopic resection of resecting challenging lesions, accepting them for the benefit of preventing cancer and avoiding surgery. Implementation of any quality measure that disincentivizes endoscopic resection of the most important pre-cancerous lesions will adversely affect the goal of safe and low-cost prevention of colorectal cancer.