Process Improvement:
Adherence (Rescreen & Compliance)
WHY FOCUS ON RESCREEN FOR COLORECTAL CANCER?
GUIDELINES SUPPORT AND QUALITY MEASURE IMPLICATIONS
For all screening modalities, the effectiveness decreases substantially as adherence to the regimen declines. At the individual level, adherence to a screening regimen will be more important in life-years gained than will the particular regimen selected.7
- USPSTF
It is persistent adherence, rather than once-off adherence to a CRC screening modality, that is key to program efficacy and screening effectiveness, particularly for fecal-based screening tests where repeated testing improves performance.8
- KEW GS, KOH CJ, GUT LIVER
Footnotes:
HEDIS = Healthcare Effectiveness Data and Information Set. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
NQF = National Quality Forum.
CAHPS = Consumer Assessment of Healthcare Providers and Systems program. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). †NQF does not: develop performance measures, require the reporting of performance measures or provide technical assistance to practices or health systems as they use performance measures to guide improvement efforts
*MIPS = Merit-Based Incentive Payment System.
References: 1. NCQA. 2020 HEDIS Summary table of Measures, Product Lines and Changes. Accessed October 23, 2023. https://www.ncqa.org/wp-content/uploads/2019/07/20190701_HEDIS_2020_Measures_Summary_of_Changes.pdf. 2. Centers for Medicare and Medicaid Services. Fact Sheet - 2020 Part C and D Star Ratings. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/downloads/2020-star-ratings-fact-sheet-.pdf. Accessed October 23, 2023. 3. Centers for Medicare and Medicated Services. Medicare Shared Savings Program. Quality Measurement Methodology and Resources. Accessed October 23, 2023. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/quality-measurement-methodology-and-resources.pdf. Published May 2019. 4. Center for Medicare and Medicaid Services Quality Payment Program. MIPS Explore Measures. Accessed October 23, 2023. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_113_MIPSCQM.pdf 5. HRSA Health Center Program. 2021 Uniform Data System (UDS) Program Assistance Letter. October 21, 2020. Accessed October 23, 2023. https://bphc.hrsa.gov/compliance/policy-information-notices-pins-program-assistance-letters-pals/pal-2020-07. 6. National Quality Partners Action Brief. Shared decision making: a standard of care for all patients. National Quality Forum. October 2017. https://www.qualityforum.org/Publications/2017/10/NQP_Shared_Decision_Making_Action_Brief.aspx 7. Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi: 10.1001/jama.2021.6238 8. Kew GS, Koh CJ. Strategies to Improve Persistent Adherence in Colorectal Cancer Screening. Gut Liver. 2020;14(5):546-552. doi:10.5009/gnl19306
EARLY DETECTION OF COLORECTAL CANCER CAN LEAD TO INCREASED SURVIVAL AND DECREASED TREATMENT COSTS
OF PATIENTS DIAGNOSED IN STAGES I OR II*
9/10 SURVIVE 5 YEARS1†
$57,901
OF PATIENTS DIAGNOSED IN STAGE IV
~1/10 SURVIVE 5 YEARS1†
$108,599
*Based on people diagnosed with CRC in stage I stage IIa, or stage IIb between 2011 and 2017.
†Per American Joint Committee on Cancer's (AJCC) staging system: Localized = Stage I, IIa, IIb. Regional = stage IIc and III. Distant = stage IV.3
References: 1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33. CA Cancer J Clin. 2022;72:7-33. 2. California Healthcare Foundation. Cancer care spending in California: what Medicare data say. www.chcf.org/wp-content/uploads/2017/12/PDF-CancerCareSpendingMedicare.pdf. Published August 2015. Accessed October 23, 2023. J Natl Cancer Inst. 2011;103(2):117-128. doi:10.1093/jnci/djq495. 3. American Cancer Society. Survival Rates for Colorectal Cancer, by Stage. Accessed October 23, 2023. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/survival-rates.html
GUIDELINES DESIGNATE RESCREENING INTERVALS AND IMPACT QUALITY METRICS
STOOL-BASED TESTS
Outpatient
(hs)-gFOBT
EVERY YEAR
FIT
EVERY YEAR
mt-sDNA†
EVERY 3 YEARS‡
STRUCTURAL EXAMINATIONS
Inpatient
FLEXIBLE SIGMOIDOSCOPY
EVERY 5-10 YEARS§
CT COLONOGRAPHY
EVERY 5 YEARS
COLONOSCOPY
EVERY 10 YEARS
Guidelines have found no head-to-head studies demonstrating that any of these screening strategies are more effective than others, and no specific test is recommended for CRC screening. Screening intervals are recommended per ACS Guidelines1
“Discussion with patients may help better identify screening tests that are more likely to be completed by given individual”
–United States Preventive Services Task Force, 20211
*All recommendations are category 2A unless otherwise indicated. NCCN makes no representation or warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way.
†Guidelines may refer to mt-sDNA by different names, including FIT-Fecal DNA, FIT-DNA, and sDNA.
‡Exact Sciences does not have programmatic data for 1-year or 3-year screening intervals.
§USPSTF also recommends flexible sigmoidoscopy every 10 years + FIT annually.
FIT = fecal immunochemical test; (hs)-gFOBT = high-sensitivity fecal occult blood test; mt-sDNA = multitarget stool DNA.
References: 1. Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi: 10.1001/jama.2021.6238. 2. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colorectal Cancer Screening V.2.2021. © National Comprehensive Cancer Network, Inc. 2021. All rights reserved. Accessed October 23, 2023. 3. Centers for Medicare & Medicaid Services. Medicare Shared Savings Program. Accountable Care Organization (ACO) 2018 Quality Measures. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-reporting-year-narrative-specifications.pdf. Published January 20, 2018. Accessed October 23, 2023. 4. NCQA. Colorectal cancer screening (COL). Accessed October 23, 2023. https://www.ncqa.org/hedis/measures/colorectal-cancer-screening/. 5. CMS. Quality measure specifications. Quality ID#113 (NQF 0034). November 2019. Accessed October 23, 2023. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2020_Measure_113_MedicarePartBClaims.pdf.
STUDY OUTCOMES DISPLAY GAPS IN ADHERENCE TO RESCREENING INTERVALS*
A 3-year randomized trial measured FOBT compliance for
344 PATIENTS1†
14%
Compliant with annual FOBT screening year over year for 3 years
*Adherence to screening was defined as completion of three FOBT cards in each of 3 years, with colonoscopy if FOBT was positive, or one colonoscopy during the first year of enrollment.
References: 1. Liang PS, Wheat CL, Abhat A, et al. Adherence to competing strategies for colorectal cancer screening over 3 years. Am J Gastroenterol. 2016;111(1):105-114.
RESCREEN CONSIDERATIONS FOR YOUR SYSTEM
What efforts does your system undertake to identify patients that are in need of rescreening for CRC?
How do you ensure patients are compliant with rescreening needs?
From a quality perspective, what impact do gaps in care for up-to-date screening have on your metrics attainment?
What type of patient outreach efforts do you employ to identify patients eligible for rescreening for CRC?