A quality measure in CMS's 2015 Outpatient Prospective Payment System proposed rule would count instances of Medicare beneficiaries seeking hospital treatment for adverse events related to outpatient colonoscopies.
For the first time, hospital outpatient centers would be evaluated on the safety of their practitioners' skill in performing colonoscopies if language in a proposed rule from the Centers for Medicare & Medicaid Services becomes final.
Specifically, the new quality measure would count the number of times Medicare beneficiaries had to seek hospital care to treat a complication, such as perforation of the colon, gastrointestinal bleeding, or a cardiopulmonary event, within seven days of an outpatient colonoscopy.
Complications captured would include those occurring during preparation, the procedure itself, and follow-up care.
"We expect the measure would promote improvement in patient care over time because transparency in publicly reporting measure scores will make patient unplanned hospital visits (emergency department visits, observation stays, and inpatient admissions) following colonoscopies more visible to providers and patients," CMS said in the proposed rule.
2015 OPPS Proposed Rule Detailed
It would "encourage providers to incorporate quality improvement activities in order to reduce these visits." Too often there is a disconnect between adverse events from colonoscopies and feedback to the practitioners who performed them, CMS said.
Reporting of these events by facility would enable consumers to make informed choices about where to get cancer prevention screening exams, and physicians and facilities with performance issues could take corrective action, CMS said.
"Providers are often unaware of complications following colonoscopy for which patients visit the hospital," CMS said in its 2015 Outpatient Prospective Payment System proposed rule. "This will encourage providers to achieve the outcome rates of the best performers." There is a wide variation in complication rates among colonoscopy centers nationally.
Complications can occur because of physician error, and can include blunt trauma from the endoscope, unintended resection or dissection of tissue or injuries during polyp snare.
More than 14 million colonoscopies are performed each year, making it a common screening procedure, recommended every 10 years or less for people starting at age 50.
The proposed measure, OP-32, or "Facility 7-Day Risk-Standardized Hospital Visit Rate After Outpatient Colonoscopy," would be added to the hospital outpatient quality reporting program starting in 2017, and would be publicly reported.
Hospital returns after colonoscopy are unexpected, but the majority that do occur happen within the first seven days. Colonoscopy complications requiring hospital visits within 14 days of the procedure approach 1%.
A 2010 paper published in the Archives of Internal Medicine by researchers at Beth Israel Medical Center in Boston found that costs were $1,403 for each emergency department visit and $10,123 per hospitalization.
CMS has indicated it wants to add OP-32 to its hospital outpatient quality reporting or payment for reporting and ambulatory surgical center quality reporting programs.
In general, after a year or more of public reporting, such measures can be adopted for performance payment, in which facilities with higher risk-adjusted complications than other facilities may be financially penalized.
Patients with a prior diagnosis of inflammatory bowel disease or diverticulitis would be excluded from the count, as well as patients without continuous enrollment in Medicare Parts A and B in the month after the procedure.
OP-32 would apply to any hospital outpatient center or ambulatory surgical center that performs simple colonoscopies on Medicare fee-for-service beneficiaries.
The proposed measure has not yet been endorsed by the National Quality Forum, although the NQF's Measures Application Partnership conditionally recommended it for approval last year.
CMS said it expects the measure to be endorsed, as it is "well-defined and precisely specified for consistent implementation within and between organizations that will allow for comparability."
In a draft NQF report in June, the NQF said CMS was asked why it wanted to limit complications to just seven days after the procedure when some complications can occur within 30 days.
The agency "explained that while there is a range of side effects that could occur after a colonoscopy, the literature suggests that a majority of complications or adverse events occur within 7 days. The developers empirically tested this looking at the number of hospital visit per each day post procedure, and noticed the number of visits levels off to after about 7 days," according to the NQF report.
The Ambulatory Surgery Center Association and several professional societies of gastroenterologists and endoscopists declined to comment because they said they have not had a chance to thoroughly review the CMS recommendation.
CMS will issue its final rule this fall.