Study Suggests Underuse of Colorectal Cancer Screening among Healthy Veterans and Overuse among Unhealthy Veterans
Current guidelines recommend routine colorectal cancer (CRC) screening in average-risk individuals starting at age 50 and continuing through age 75, and most quality measures for CRC screening mirror these guidelines. Despite the use of these well-established, age-based quality measures, experts recommend that the decision to screen be informed by estimated life expectancy rather than by age alone, especially in older individuals, in whom life expectancy varies considerably according to health status. Therefore, this retrospective cohort study examined whether the upper age cutoff of the CRC screening quality measure is associated with overuse of screening among 70- to 75-year-olds who are in poor health (limited life expectancy, but within the target age range of the measure) and underuse in those older than age 75 who are in good health (longer life expectancy, but outside the target age range of the measure). Using VA data, investigators identified 399,067 average-risk Veterans > 50 years of age who were regular users of VA care, and who were due for repeat screening at a VA primary care visit in FY10. Investigators then assessed completion of a colonoscopy, sigmoidoscopy, or fecal occult blood testing (FOBT) within 24 months of the FY10 visit. Health status was assessed based on the presence of 17 common conditions.
- Approximately 38% (n=151,850) of the Veterans in this study had electronic documentation of CRC screening in the 24 months after their FY10 primary care visit.
- Screening rates were relatively stable for Veterans between ages 50-75, but dropped precipitously after age 75. On average, 39% of 75 year-old Veterans were screened, while only 21% of 76 year-old Veterans were screened. However, a Veteran who was 75 years of age and unhealthy – in whom life expectancy may be limited and screening is likely to result in net burden or harm – was significantly more likely to undergo screening than a Veteran who was 76 years of age and healthy (35% vs. 21%, respectively).
- Because Veterans may undergo screening outside VA, data likely underestimated screening rates.
- Of note, VA recently modified quality measure specifications to permit CRC screening exceptions for Veterans aged ≤ 75 with shortened life expectancies or serious comorbid medical conditions.
- Future patient-centered quality measures should focus on clinical benefit rather than chronological age to ensure that patients who are likely to benefit from screening receive it (regardless of age), and that those who are are likely to incur harm are spared uncessary and costly care.
This study was funded by VA/HSR&D's Quality Enhancement Research Initiative, and Dr. Saini is supported by an HSR&D Career Development Award. Drs. Saini, Vijan, Schoenfeld, and Kerr (Director) are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI. Dr. Powell is part of HSR&D's Center for Chronic Disease Outcomes Research, Minneapolis, MN.
Saini S, Vijan S, Schoenfeld P, Powell A, Moser S, and Kerr E. The Role of Quality Measurement in Inappropriate Use of Colorectal Cancer Screening: A Retrospective Cohort Study. BMJ February 26, 2014;348;