Translating the Adenoma Detection Rate as a Quality Measure for Endoscopists to a Public Health Approach to Screening Underserved Patients for Colorectal Cancer

Abstract

See “Adenoma detection for 45- to 49-year-old screening population,” by Shaukat A, Rex DK, Shyne M, et al, on page 957. See “Adenoma detection for 45- to 49-year-old screening population,” by Shaukat A, Rex DK, Shyne M, et al, on page 957. In this issue of Gastroenterology, Shaukat et al present data characterizing the adenoma detection rate (ADR) for a 5-year cohort (2015–2019) of 159,817 patients with normal or average risk for developing colorectal cancer (CRC), including 4841 patients 45–49 years of age who had colonoscopies performed by 99 endoscopists in metropolitan Minnesota.1Shaukat A. Rex D.K. Shyne M. et al.Adenoma detection for 45- to 49-year-old screening population.Gastroenterology. 2022; 162: 957-959Abstract Full Text Full Text PDF Scopus (2) Google Scholar The authors aimed to establish endoscopic standards for ADR when scoping normal-risk younger patients. ADR is a validated endoscopy quality measure with 25% overall ADR (30% for men and 20% for women) the accepted benchmark for all endoscopists doing colonoscopies on normal-risk patients 50–75 years of age.2Rex D.K. Schoenfeld P.S. Cohen J. et al.Quality indicators for colonoscopy.Gastrointest Endosc. 2015; 81: 31-53Abstract Full Text Full Text PDF PubMed Scopus (568) Google Scholar When possible, colonoscopy exams with an indication of family history of CRC or advanced polyps were excluded. The authors suggest that if an endoscopist’s patient cohort is trending to patients younger than 50 years, in accordance with the new USPSTF guidelines,3US Preventive Services Task ForceScreening for colorectal cancer: US Preventive Services Task Force recommendation statement.JAMA. 2021; 325: 1965-1977Crossref PubMed Scopus (137) Google Scholar a 1%–3% drop in ADR can be anticipated if 10%–25% of all colonoscopies performed are on patients 45–49 years of age.1Shaukat A. Rex D.K. Shyne M. et al.Adenoma detection for 45- to 49-year-old screening population.Gastroenterology. 2022; 162: 957-959Abstract Full Text Full Text PDF Scopus (2) Google Scholar However missing cohort data on family cancer history and racial/ethnic characteristics raises concerns that individuals younger than 50 years in this cohort represent a group at higher risk of CRC than the older age groups. This editorial suggests how data from Shaukat et al1Shaukat A. Rex D.K. Shyne M. et al.Adenoma detection for 45- to 49-year-old screening population.Gastroenterology. 2022; 162: 957-959Abstract Full Text Full Text PDF Scopus (2) Google Scholar can be used to improve underserved patients of both normal and increased risk for CRC cared for by Federally Qualified Health Centers (FQHCs). The question arises whether these data can be used to improve CRC risk stratification and provision of care, taking into account the need for better cohort characterization, paired with ADR benchmarks for endoscopists completing colonoscopies through outsourced specialty referrals. FQHCs have screening programs in place to comply with UDS reporting requirements aligned with US Preventive Services Task Force (USPSTF) screening guidelines.3US Preventive Services Task ForceScreening for colorectal cancer: US Preventive Services Task Force recommendation statement.JAMA. 2021; 325: 1965-1977Crossref PubMed Scopus (137) Google Scholar,4Health Resources & Services AdministrationNational Health Center Program Uniform Data System (UDS) Awardee Data.https://data.hrsa.gov/tools/data-reporting/program-data/nationalDate accessed: December 1, 2020Google Scholar As clinics adapt to the new age guidelines, the question remains as to whether FQHC staff correctly identify patients at increased risk needing direct referrals to high-quality endoscopists rather than including them in their normal risk screening programs.5Allison J.E. Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the Fecal Immunochemical Test for Hemoglobin (FIT).. 2014; 8: 117-130Google Scholar FQHCs need to standardize risk assessment and document the results before making screening recommendations to their eligible patients. We know that many cohort studies incompletely exclude patients with known genetic mutations, such as Lynch syndrome (LS), because the number of patients excluded does not approach the expected proportion based on the known LS mutation frequency in the general population (1 in 279).6Wieszczy P. Waldmann E. Løberg M. et al.Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies.Gastroenterology. 2021; 160 (1067–74.e6)Google Scholar Encouraging better use of CRC risk assessment tools in FQHC patients will help to increase applicability for racial/ethnic groups currently under-represented in those tools, and allow for more accurate analysis of care delivered to patients, in both integrated and fragmented care delivery systems. The USPSTF guidelines lowering the screening to 45 years of age for normal-risk patients3US Preventive Services Task ForceScreening for colorectal cancer: US Preventive Services Task Force recommendation statement.JAMA. 2021; 325: 1965-1977Crossref PubMed Scopus (137) Google Scholar put additional pressure on resource-limited FQHCs. Specifically, FQHCs provide care for patients of which 91% are of low income and 63% are racial or ethnic minorities, with frequent movement of patients between FQHC systems not connected via electronic health records complicating the tracking of preventive services. This is further compounded by the Covid-19 pandemic, which caused significant changes to clinic operations, clinicians, and staff with added practice demands.7Friedberg M.W. Reid R.O. Timbie J.W. et al.Federally qualified health center clinicians and staff increasingly dissatisfied with workplace conditions.Health Aff (Millwood). 2017; 36: 1469-1475Crossref PubMed Scopus (25) Google Scholar In 2020, almost 28.6 million patients were cared for by FQHCs.4Health Resources & Services AdministrationNational Health Center Program Uniform Data System (UDS) Awardee Data.https://data.hrsa.gov/tools/data-reporting/program-data/nationalDate accessed: December 1, 2020Google Scholar Many of these systems have campaigns for mail-out fecal immunochemical testing (FIT) CRC screening to meet the 80% in Every Community8National Colorectal Cancer Roundtable. 80% in every community.https://nccrt.org/80-in-every-community/Date accessed: October 22, 2021Google Scholar national goal, but patients are triaged to FIT screening primarily based on age in accordance with USPSTF guidelines. For colonoscopy screening needs, FQHC experience fragmented specialty care as many outsource their colonoscopies and struggle to migrate results of those colonoscopies back into structured data fields that can be readily queried for quality improvement purposes. The NCI-funded consortium, Accelerating CRC Screening and Follow-Up Through Implementation Program has a framework in place to address improved risk assessment and triage to the appropriate CRC screening modality at FQHC.9Kim K. Polite B. Hedeker D. et al.Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol.Implement Sci. 2020; 15: 96Google Scholar As these implementation strategies become generalizable, FQHC can commit to documenting risk assessment and colonoscopy results in structured data fields in their electronic health records, including a flag if high-risk patients are triaged inappropriately to FIT rather than colonoscopy. The next step in the process is to hone the referral process of FQHC patients to endoscopists depending on patient risk and ADR quality measures of individual endoscopists. Pairing the Shaukat et al1Shaukat A. Rex D.K. Shyne M. et al.Adenoma detection for 45- to 49-year-old screening population.Gastroenterology. 2022; 162: 957-959Abstract Full Text Full Text PDF Scopus (2) Google Scholar study with one by Wieszczy et al6Wieszczy P. Waldmann E. Løberg M. et al.Colonoscopist performance and colorectal cancer risk after adenoma removal to stratify surveillance: two nationwide observational studies.Gastroenterology. 2021; 160 (1067–74.e6)Google Scholar linking ADR to subsequent post-colonoscopy CRC suggests some additional improvements in the CRC risk stratification process may better identify those patients at increased risk who need a referral for colonoscopy, vs normal-risk FQHC patients who should be offered FIT with follow-up colonoscopy for abnormal results as the primary screening modality. As Toyoshima et al10Toyoshima O. Nishizawa T. Yoshida S. et al.Expert endoscopists with high adenoma detection rates frequently detect diminutive adenomas in proximal colon.Endosc Int Open. 2020; 8: E775-E782Google Scholar indicate, referring higher risk patients to endoscopists meeting high ADR quality benchmarks may improve cancer outcomes for these patients. In addition, several national organizations have set colonoscopy reporting standards linked to patient risk assessment and potential integration with data systems.2Rex D.K. Schoenfeld P.S. Cohen J. et al.Quality indicators for colonoscopy.Gastrointest Endosc. 2015; 81: 31-53Abstract Full Text Full Text PDF PubMed Scopus (568) Google Scholar,11Lieberman D. Nadel M. Smith R.A. et al.Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable.Gastrointest Endosc. 2007; 65: 757-766Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar However, the integration of results within FQHCs from outsourced colonoscopies is less clear. Although integrated health systems have internal tracking that can link colonoscopy reports to the ADR of individual endoscopists, FQHCs without direct EHR linkages to the outsourced endoscopy service may not be able to document the equivalent standard of care. To ameliorate this, some incremental steps are suggested to help promote more health equity for those receiving care at FQHCs, including: 1) tasking the endoscopy service doing the outsourced colonoscopies to be proactive in assigning patients identified as higher risk to endoscopists meeting higher ADR standards10Toyoshima O. Nishizawa T. Yoshida S. et al.Expert endoscopists with high adenoma detection rates frequently detect diminutive adenomas in proximal colon.Endosc Int Open. 2020; 8: E775-E782Google Scholar within their endoscopy practice, which is feasible if the clinics improve their risk-stratification process by identifying patients at higher risk for developing CRC before the colonoscopy referrals; 2) gaining commitment by the endoscopy practice to offer the same standard of care of an ADR of 25% for endoscopists performing colonoscopies for patients at normal risk for developing CRC but being referred because of abnormal FIT results, with adjustments made for those scoping a larger percentage of younger patients as Shaukat et al suggest1Shaukat A. Rex D.K. Shyne M. et al.Adenoma detection for 45- to 49-year-old screening population.Gastroenterology. 2022; 162: 957-959Abstract Full Text Full Text PDF Scopus (2) Google Scholar; and 3) commitment by the endoscopy service to report the ADR of the person completing the colonoscopy with the information transmitted back to the referring FQHC. According to the National Cancer Institute, their CRC risk assessment tool is less accurate for Blacks/African Americans, Asian Americans/Pacific Islanders, and Hispanic/Latinos owing to missing data.12National Cancer InstituteColorectal Cancer Risk Assessment Tool.https://www.cancer.gov/ccrisktoolDate accessed: October 20, 2021Google Scholar Given the higher percentage of racial/ethnic minorities served by FQHCs, FQHCs that consistently include valid risk assessments using a standardized tool may also help increase representation by racial/ethnic groups currently under-represented in those tools. With risk stratification that is more inclusive of all people receiving colonoscopies, cohorts may then be more clearly defined as normal or high risk and then linked to colonoscopy outcomes that also consider ADR quality measures of the endoscopists.12National Cancer InstituteColorectal Cancer Risk Assessment Tool.https://www.cancer.gov/ccrisktoolDate accessed: October 20, 2021Google Scholar Ultimately, this may help reduce structural barriers for more racial/ethnic groups,13American Medical AssociationOrganizational strategic plan to embed racial justice and advance health equity, 2021–2023.https://www.ama-assn.org/system/files/2021-05/ama-equity-strategic-plan.pdfGoogle Scholar and may improve care delivered throughout the screening continuum for all patients14Bonner C. Fajardo M.A. Doust J. et al.Implementing cardiovascular disease prevention guidelines to translate evidence-based medicine and shared decision making into general practice: theory-based intervention development, qualitative piloting and quantitative feasibility.Implement Sci IS. 2019; 14: 86Crossref PubMed Scopus (15) Google Scholar independently from where they receive care.