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Age-based criteria led to colorectal cancer screening misuse
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Age-based quality measures resulted in overuse of colorectal cancer screening in unhealthy patients aged 75 years or younger and underuse of screening in healthy patients older than 75 years, according to results of a retrospective cohort study.
“Despite the use of well-established age-based quality measures, experts recommend that the decision to screen be informed by estimated life expectancy rather than age alone,” Sameer D. Saini, MD, MS, a research scientist at the Veterans Affairs Center for Clinical Management Research and an assistant professor of internal medicine at the University of Michigan Health System, and colleagues wrote. “Age is a reliable proxy for life expectancy in young patients (long life expectancy) and very elderly patients (short life expectancy). But in most elderly patients eligible for screening, life expectancy varies considerably according not only to age but also health status.”
Sameer D. Saini
The US Preventive Services Task Force recommends routine colorectal cancer screening in average-risk patients aged 50 to 75 years. The researchers conducted the study to determine whether the age-based quality measure led to underuse of screening in patients older than 75 who were in good health, or overuse of screening in patients who met the age criteria but were in poor health.
Saini and colleagues collected data from 399,067 patients (mean age, 67.2 years) seen at the Veterans Affairs health care system. All eligible participants were at average risk for colorectal cancer and were due for colorectal cancer screening at a primary care visit in 2010.
The completion of colonoscopy, sigmoidoscopy or fecal occult blood testing within 24 months after the 2010 appointment served as the primary outcome measure.
Thirty-eight percent of patients were screened within that 24-month period. On multivariable analysis adjusted for Charlson comorbidity index, sex and number of primary care visits, researchers observed a notable decrease in screening for those older than 75 years (adjusted RR=0.35; 95% CI, 0.3-0.4).
Consistent with this finding, an unhealthy veteran aged 75 years — with the possibility of limited life expectancy, and greater potential for screening-related burden or adverse effects — was significantly more likely to be screened than a healthy veteran aged 76 years (unadjusted RR=1.64; 95% CI, 1.36-1.97).
The findings show current quality measures are not optimized for individual patient benefit, according to researchers.
“The way quality measures are defined has important implications for how care is delivered,” Saini said in a press release. “By focusing on age alone, we’re not screening everyone who’s likely to benefit and some people who are not likely to benefit are being screened unnecessarily. If quality measures focused on age and health status, rather than age alone, we’d have better outcomes.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Sheetal Sharma, MBBS
For many years, guideline committees have recommended routine colon cancer screening in patients starting at the age of 50 and continuing to the age of 75. These guidelines have subsequently been translated into "quality measures" and utilized in quality improvement efforts, to promote appropriate care. Saini and colleagues propose that encouraging strict adherence to age-based guidelines may lead to more harm than good in certain patient subsets. Specifically, their retrospective data suggests that screening is likely overused in sick patients aged 75 and younger, and underused in healthy patients over age 75. His group provides yet another example of the need for medical decision-making to be personalized. Unfortunately, much to the chagrin of policymakers, simply "checking the box" does not translate into high-quality medicine. To this day, medicine remains an art and a science.
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