GIQuIC: measuring endoscopy quality, streamlining CMS reporting

High-quality gastroenterology care has always been a priority among GI physicians. In recent years, quality metrics and documentation of high-quality GI care have become increasingly important measures of accountability and evaluation. For example, Medicare reimbursements and accreditation of endoscopy centers may depend on standardized evidence of high-quality GI care, and referring doctors may wish for information on a GI specialist’s adenoma detection rate.

Therefore, the ACG and the ASGE collaborated to develop the GI Quality Improvement Consortium (GIQuIC), a nonprofit clinical benchmarking tool introduced in 2010. The associations designed GIQuIC to evaluate quality metrics in endoscopy.

“Without knowing what your data is, you can’t be sure you’re performing high-quality procedures,” Glenn Eisen, MD, MPH, FASGE, current president and chair of the board of directors for GIQuIC told Healio Gastroenterology. “A lot of doctors presume they are doing this, but without knowledge of their own data, it doesn’t really hold water.”

Eisen spoke with Healio Gastroenterology about GIQuIC’s origins, its key objectives and its increasing growth as a valuable tool in gastroenterology.

Q: What prompted the development and introduction of GIQuIC?

Eisen: This has been developed over time, the idea of what we define as high-quality endoscopic performance. The best way to assess quality in a lot of endeavors, including ours, is to measure it. Doctors submit data on procedures they perform and the data is collated and analyzed by our staff. This is different than just doing an endoscopy report. This is actually pulling out the measures that we think represent a high-quality procedure.

GIQuIC began about 7 years ago. Irving Pike, MD, FACG, FASGE, came up with the idea of formally looking at quality metrics in colonoscopy, and partnered with a company where he was working in Tidewater, Va., in practice.

Initially the data registry only looked at colonoscopy. They did a pilot study with endoscopy centers that collected the data to see how often doctors detected precancerous polyps, how often they were able to do a complete exam, how often they had complications, among other data points.

This coincided with a movement for gastroenterologists to look at quality metrics in all kinds of endoscopy. Dr. Pike was one of the doctors who co-wrote guidelines that were published in GI Endoscopy and The American Journal of Gastroenterology. This put forth the measures that should be collected and why; their rationale and the evidence behind the measures. There have been studies that show that these measures have been validated.

Q: What are the metrics that have been established for GIQuIC?

Eisen: The primary metric for screening colonoscopy is what’s called adenoma detection rate, also known as ADR. ADR is essentially how often you find precancerous polyps in patients undergoing screening colonoscopies. The numerator is the number of patients you’ve screened who have at least one such polyp, and the denominator is all of your screening colonoscopies in patients aged 50 and over. If you have an ADR of 25%, it means that you are finding these precancerous polyps in one out of four patients you’re doing colonoscopies on. There was a study in The New England Journal of Medicine and another in JAMA that found a relationship between higher ADR and lower likelihood of an interval colon cancer; that is a cancer that develops between colonoscopy exams for a patient. This measure is a surrogate for preventing colon cancer, and now everyone should be assessing their ADR.

Q: How do es detecting precancerous polyps potentially prevent interval colon cancers ?

Eisen: We know that taking out precancerous polyps decreases the risk for getting subsequent colon cancer. But now we also know that if you take out polyps at a relatively high rate, it’s unlikely that the patient will develop colon cancer before their next colonoscopy, which is something you definitely want to avoid. There was a Polish study and a study from Kaiser that showed a stepwise inverse correlation; the higher an endoscopist’s ADR, the lower the risk of interval colon cancer.

The idea is, colonoscopy cannot prevent 100% of colon cancers, but it can prevent the large majority, and many people who get colon cancer in the U.S. never have colonoscopies. We know that over the last 10 years, the rate of colon cancer occurring in the U.S. is going down, and we think quite a bit of it is due to high-quality colonoscopy screening.

Now, even the government thinks this is an important measure. CMS, through the Merit-Based Incentive Payment System (MIPS), wants to know what our ADRs are.

Q: What other measures is the registry collecting?

Eisen: We measure something called cecal intubation rate, which evaluates how often an endoscopist does a full examination. Are you able to see the entire colon? Ideally, we should achieve this more than 90% of the time; in very high-quality centers, it’s more like 95% or more of the time. Other things we look for are individual endoscopist’s recommendations for screening and surveillance intervals. In other words, if I do a colonoscopy on you and it’s normal, when do I say you should come back for your next one? In general, if you have no risk factors, it should be 10 years, but we want to know what fraction of doctors are doing the correct interval recommendations. We want to evaluate whether doctors are over- or underdoing the frequency of colonoscopy.

The GI societies have national guidelines on when appropriate surveillance would be, and if you follow those guidelines 90% to 95% of the time, that’s appropriate. There are some doctors who are overdoing colonoscopies. They might be doing them every other year, for unclear reasons, and that’s expensive and has risks, and there’s no reason to do it.

Q: Based on data you’ve collected, how are physicians doing in these measures?

Eisen: One thing the data has shown is that doctors are getting better in a lot of these metrics. ... I can tell you just from my practice here in Oregon, we’ve been collecting ADR data for about 7 or 8 years. Every year, the rates of our entire practice go up. We’ve more than doubled what it used to be. We’ve been sharing the physicians’ data with each of them every quarter, and they’ve improved.

Q: Since its inception, what other progress has the registry made?

Eisen: It continues to grow monthly. Also, now that CMS requires us to collect and send them quality data, we are one of the major tools in GI for this, because Medicare/Medicaid has designated us as a qualified clinical data registry (QCDR). If you submit your data to the GIQuIC registry, we can give it to CMS, and that qualifies as doing quality data collection, which will actually affect your payments. This is a real impetus for people to join the registry, and this is one of the factors of the growth.

We now have over 4000 endoscopists contributing over 5 million colonoscopies, and we also collect data on upper endoscopies. We’re planning on expanding in the near future into GI areas not related to endoscopy. For example, we want to collect data on care of inflammatory bowel disease and hepatitis patients, because there are quality metrics that can and should be collected in any part of medical practice.

Q: What are some of the other goals for GIQuIC moving forward?

Eisen: We want to have a much larger percentage of gastroenterologists using GIQuIC. GIQuIC currently has approximately one-third of gastroenterologists participating in the registry, but there is growth still to be had to have a higher number of providers participate. We have now opened our registry so doctors can do research with the data; they can apply to do a research project to look at a specific question. Another goal is to align with doctors to look at things that don’t have to do with just endoscopy. Then, we want to also provide the tools so they can stay up to date as they need to with CMS and other payors, because it’s not easy to collect quality data.

We also want to set standards for the country as to what the metrics should be. We’re trying to do research to say, “Okay, doctors should be at X point as far as this, or they should be this good at doing that to be considered high quality.” The goal is not to be punitive, or to suggest that doctors aren’t good enough; the goal is to let doctors know where they stand in their practice, locally and nationally, and give them an opportunity to improve. – by Jennifer Byrne

References:

Corley DA. N Engl J Med. 2014;doi:10.1056/NEJMoa1309086.

Meester RG. JAMA. 2015;doi:10.1001/jama.2015.6251.

For More Information:

Glenn Eisen, MD, can be reached at 9701 SW Barnes Rd #300, Portland, OR 97225; email: Brian Davis at BDavis@gi.org.

Disclosure: Eisen reports no relevant financial disclosures.