Improving Compliance With CMS Colonoscopy Core Measures: A Quality Improvement Intervention 1668
Colorectal Cancer (CRC) is the unchecked division of abnormal cells in the colon and rectum. It is the second leading cause of cancer death and the third most common cancer in men and women in the US. It is curable if diagnosed early; removing polyps can reduce the incidence of CRC up to 90%. The Am...
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| Published in: | The American journal of gastroenterology Vol. 113; no. Supplement; p. S961 |
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| Main Authors: | , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
New York
Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
01-10-2018
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| Subjects: | |
| Online Access: | Get full text |
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| Summary: | Colorectal Cancer (CRC) is the unchecked division of abnormal cells in the colon and rectum. It is the second leading cause of cancer death and the third most common cancer in men and women in the US. It is curable if diagnosed early; removing polyps can reduce the incidence of CRC up to 90%. The American College of Gastroenterology recommends CRC screening on everyone ages 50 to 75. Documentation of a screening interval is paramount for adequate follow up. The purpose of this study is to ensure compliance with the Centers for Medicare & Medicaid Services (CMS) mandated screening interval documentation in an urban community hospital setting. A pre-intervention chart review assessed the frequency of correct documentation. A lecture was then given to 12 Gastroenterology faculty and fellows regarding documentation of screening intervals. A post-intervention chart review was done to analyze a change in documentation. Inclusion criteria: any screening colonoscopy done on patients between 50 and 75 years old. Multiple Plan Do Study Act (PDSA) cycles were completed. Statistical analysis was done using a standard test of difference in proportions. 30 days prior to the lecture, 68 patients met inclusion criteria, 7 of which did not have appropriate documentation. 30 days after the first lecture, out of 73 patients, 2 did not have appropriate documentation. A refresher lecture was then given; 30 days after that, all 72 patients had appropriate documentation. While we observed improvement after the first lecture, it was not statistically significant. After the second lecture, the improvement became statistically significant (Table 1). Appropriate documentation for CRC screening intervals is important for patient safety as well as for meeting CMS measures, which can have a financial impact. In our urban, community hospital, a fellow-driven quality improvement study succeeded in addressing this issue. The first PDSA cycle identified and addressed the issue with a lecture. While we noted improvement, it was not statistically significant. A repeat PDSA cycle noted deficient charts had "pending pathology" documented instead of a tangible time period. We realized there was an incomplete understanding of the CMS requirement. After a reminder lecture, we noted a perfect documentation rate. This highlights the importance of occasional refreshers in addition to set lectures in achieving change and compliance to colonoscopy core measures. |
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| ISSN: | 0002-9270 1572-0241 |
| DOI: | 10.14309/00000434-201810001-01668 |