Age is not enough
Clinical benefit should be considered in colorectal cancer quality measures
issue 21 | Spring-Summer 2014
Current colorectal cancer screening quality measures use age to identify who should be tested, with the VA, Medicare and many private insurers encouraging screening among 50- to 75-year-olds. But use of simple age cut-offs in these quality measures may contribute to what researchers found was underuse of screening in healthy older people and overuse in unhealthy older people. The findings resulted from reviewing the patient records of nearly 400,000 VA enrollees.
An unhealthy 75-year-old — whose life expectancy is estimated at less than five years — was significantly more likely to undergo screening than a 76-year-old who's in good health.
BOTH UNDER AND OVERUTILIZATION
"The way quality measures are defined has important implications for how care is delivered," says lead study author Sameer Saini, M.D., a research scientist at VA-CCMR and assistant professor of Internal Medicine at the University of Michigan Health System. "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, like those with severe health problems."
"If quality measures focused on age and health status, rather than age alone, we'd have better outcomes," he adds.
Most people who are diagnosed with colon cancer are older than 50. But in elderly patients, life expectancy varies considerably according to health status. For instance, a 74-year-old man who is in excellent health has a life expectancy of almost 15 years. The study suggests the upper age cut-off could unintentionally discourage screening for these healthy older individuals, leading them to miss out on the colorectal screenings known to prevent cancer.
PREVENTION FOR THE RIGHT PEOPLE
Screening can often detect pre-cancerous growths, called polyps, in the colon and rectum. Although most polyps will not turn into cancer, removing them can prevent cancer from occurring. Colorectal screening — which includes colonoscopy, sigmoidoscopy and fecal occult blood testing — is credited with a 30 percent drop in colon cancer deaths in the past 10 years.
"Clinicians and patients should be aware of this potential unintended effect of quality measurement," Saini says. "When it comes to preventive care in older patients, clinicians should strive to make decisions that are clinically sensitive, taking the individual's overall health and preferences into account."
Future patient-centered quality measures should focus on clinical benefit rather than age to ensure that patients who are likely to benefit from screening receive it, regardless of age, and that those who are likely to incur harm are spared unnecessary and costly care.