January 12, 2016
2 min read

Colonoscopy quality varies among outpatient facilities

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Significant variations in quality were found among outpatient facilities when the quality of colonoscopy procedures was examined using a calculated, risk-adjusted measure. The outcome measure of risk adjusted outpatient colonoscopy quality may assist patients in making choices and help with quality improvement efforts, according to researchers at Yale-New Haven Hospital and Yale University School of Medicine. 

Isuru Ranasinghe, MD, at the Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, and colleagues, examined 2010 Medicare colonoscopy claims from outpatient facilities. A 20% sample of all 2010 claims was used for a total of 331,880 colonoscopies performed at 8,140 U.S. facilities that met the inclusion criteria. Some high-risk patient groups were excluded. All patients were aged older than 65 years, and the outcome measured was the estimated risk-standardized rates of any all-cause hospital visits that were unplanned within seven days following the outpatient colonoscopies. The hospital visits included emergency department visits, observation stays or unplanned inpatient admission. The researchers then estimated the risk of unplanned hospital visits within 7 days of the colonoscopy by developing a patient-level logistic regression model.

The researchers then estimated facility rates of risk-standardized unplanned hospital visits by using a patient-level risk model variable and hierarchical logistic regression. They used data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) data, which included 325,811 colonoscopies at 992 facilities in New York, California, Florida and Nebraska. In this database, unique patient identifiers were available to link a procedure and the outcome to estimate facility-specific risk-standardized hospital visit rates. 

There were 5,412 unplanned hospital visits within 7 days (16.3/1,000 colonoscopies), according to the study. The most frequent causes of unplanned visits were hemorrhage, abdominal pain and perforation.

Of the 15 variables independently associated with unplanned hospital visits, those most significantly associated were a history of fluid and electrolyte imbalance (OR = 1.43; 95% CI, 1.29-1.58), psychiatric disorders (OR = 1.34; 95% CI, 1.22-1.46) and age older than 65 years when arrhythmia was not present (age > 85 years vs. age 65-69 years; OR = 1.87; 95% CI, 1.54-2.28), according to the researchers. 

“The number of colonoscopies performed at outpatient facilities varied widely,” the researchers wrote.

The median facility-level risk standardized unplanned hospital visits rate was 12.2 per 1,000 colonoscopies and 35% of the facilities performed less than 100 procedures. While the rate for the fifth percentile for unplanned hospital visits was 10.5 per 1,000 colonoscopies, the ninth percentile was 14.6 per 1,000 colonoscopies. The median rates of risk standardized unplanned hospital visits were similar between ambulatory surgery centers and hospital outpatient departments (10.2/1,000 for each), but differed according to region — 16.1 per 1,000 colonoscopies in the Northeast and 17.2 per 1,000 colonoscopies in the Midwest. 

“Our findings show an unplanned hospital visit rate of 16.3 per 1,000 colonoscopies in a Medicare 20% sample. Extrapolating our findings to a 100% nationwide sample would equate to approximately 1.7 million colonoscopies and nearly 27,000 unplanned hospitals visits within seven days of colonoscopy among Medicare [fee-for-service] beneficiaries. When applied to HCUP data in four states, the estimated facility [risk-standardized hospital visit rates] … varied significantly across facilities, suggesting there may be meaningful differences in patient outcomes due to variation in facility quality of care,” the researchers wrote. “This measure is a potentially useful tool for advancing patient-centered care.” – by Suzanne Reist

Disclosures: Ranasinghe reports he is under a contract with CMS to develop and maintain performance measures and that he is supported by an Early Career Fellowship co-funded by the National Health and Medical Research Council and the National Heart Foundation of Australia.