VA Ann Arbor Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
BMJ Qual Saf. 2023 Jul;32(7):414-424. doi: 10.1136/bmjqs-2021-014236. Epub 2022 Oct 3.
Low-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by reducing procedural demand. The objective of this study was to develop and validate an electronic measure of screening colonoscopy overuse using International Classification of Diseases, Tenth Edition codes and then apply this measure to estimate facility-level overuse to target quality improvement initiatives to reduce overuse in a large integrated healthcare system.
Retrospective national observational study of US Veterans undergoing screening colonoscopy at 119 Veterans Health Administration (VHA) endoscopy facilities in 2017. A measure of screening colonoscopy overuse was specified by an expert workgroup, and electronic approximation of the measure numerator and denominator was performed ('electronic measure'). The electronic measure was then validated via manual record review (n=511). Reliability statistics (n=100) were calculated along with diagnostic test characteristics of the electronic measure. The measure was then applied to estimate overall rates of overuse and facility-level variation in overuse among all eligible patients.
The electronic measure had high specificity (99%) and moderate sensitivity (46%). Adjusted positive predictive value and negative predictive value were 33% and 95%, respectively. Inter-rater reliability testing revealed near perfect agreement between raters (k=0.81). 269 572 colonoscopies were performed in VHA in 2017 (88 143 classified as screening procedures). Applying the measure to these 88 143 screening colonoscopies, 24.5% were identified as potential overuse. Median facility-level overuse was 22.5%, with substantial variability across facilities (IQR 19.1%-27.0%).
An International Classification of Diseases, Tenth Edition based electronic measure of screening colonoscopy overuse has high specificity and improved sensitivity compared with a previous International Classification of Diseases, Ninth Edition based measure. Despite increased focus on reducing low-value care and improving access, a quarter of VHA screening colonoscopies in 2017 were identified as potential low-value procedures, with substantial facility-level variability.
低价值的筛查结肠镜检查既浪费又对患者潜在有害。减少低价值结肠镜检查可以预防程序并发症，节省患者时间并减轻患者不适，并可以通过减少程序需求来改善获得途径。本研究的目的是开发和验证一种使用国际疾病分类第 10 版代码的筛查结肠镜检查过度使用的电子测量方法，然后应用该方法估计医疗机构层面的过度使用情况，以确定质量改进措施的目标，从而减少大型综合医疗保健系统中的过度使用。
对 2017 年在美国退伍军人事务部（VHA）的 119 个内窥镜设施中接受筛查结肠镜检查的 119 名美国退伍军人进行的全国性回顾性观察研究。一个专家工作组专门制定了一种筛查结肠镜检查过度使用的衡量标准，并对该衡量标准的分子和分母进行了电子近似（“电子衡量标准”）。然后通过手动记录审查（n=511）对电子衡量标准进行验证。计算了可靠性统计数据（n=100）以及电子衡量标准的诊断测试特征。然后，该衡量标准用于估计所有合格患者的过度使用总体率和医疗机构层面的过度使用情况。
电子衡量标准具有高特异性（99%）和中度敏感性（46%）。调整后的阳性预测值和阴性预测值分别为 33%和 95%。评分者间可靠性测试显示评分者之间存在近乎完美的一致性（k=0.81）。2017 年，VHA 共进行了 269572 例结肠镜检查（88143 例为筛查程序）。将该衡量标准应用于这 88143 例筛查结肠镜检查，发现有 24.5%的检查可能为过度使用。中位数机构层面的过度使用率为 22.5%，各机构之间存在较大差异（IQR 19.1%-27.0%）。
与之前基于国际疾病分类第 9 版的衡量标准相比，一种基于国际疾病分类第 10 版的电子筛查结肠镜检查过度使用的衡量标准具有较高的特异性和改进的敏感性。尽管越来越关注减少低价值护理和改善获得途径，但 2017 年 VHA 筛查结肠镜检查中有四分之一被确定为潜在的低价值程序，各机构之间存在较大差异。
