WCHQ Ambulatory Measure Specification

Colorectal Cancer Screening Performance Measure

Measurement Period 01/01/2015-12/31/2015

Submission Period: 03/07/16 - 03/18/16

Measure Description

The percentage of adults age 50 through 75 who had a minimum of one colorectal cancer screeningtest during the one year measurement period. (Refer to Table CCS-3 for qualifying tests and timeframes)

Disclaimer: Measures reported by WCHQ healthcare organizations represent a specific aspect of care in relation to an evidence-based standard, but are not clinical guidelines and do not establish standards of care.All providers should have an individual care plan established with their patient.

General Information/Rationale

The United States Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen men and women, at age 50 and older for colorectal cancer. The USPSTF concluded that the benefits from screening for colorectal cancer substantially outweigh potential harms, and that regardless of screening strategy chosen, it is likely to be cost-effective1.

The optimal interval for screening depends on the test. Annual fecal occult blood testing or fecal immunoassay testoffers greater reductions in mortality rates than biennial screening. A 10-year interval has been recommended for colonoscopy, but a 5-year interval is recommended for flexible sigmoidoscopies because of their lower sensitivity. Fecal DNA Screening (Cologuard test) has been added as a new option for screening in 2015 (recommended interval every three years) 2.

In persons identified as being at high-risk by their health care providers, initiating screening at an earlier age and at more frequent intervals is reasonable. It is recommended that all adults speak with their health care providers to determine, on an individual basis, the age at which to begin and end screenings, the best type of screening for individual circumstances, and the frequency of these screenings.

References:

  1. The Guide to Clinical Preventive Service 2007-Recommendations and rationale: Screening For Colorectal Cancer U.S. Preventive Services Task Force (USPSTF). Retrieved December 17, 2007 from

2.CMS Decision Memo for Screening for Colorectal Cancer - Stool DNA Testing, October 9, 2014

Definitions

12 Months: Measurement Period

24 Months: Measurement Period plus Prior Year

36 Months: Measurement Period plus Prior Two Years

Primary Care Office Visit: Office visit in an outpatient, non-urgent care setting

PCP: For WCHQ measure purposes, a primary care provider is defined as any General Practice, Internal Medicine, Family Practice, Pediatrics provider with the following degree types (MD, DO, PA, NP), and any other practitioners identified by the healthcare system as primary care practitioners. The rationale for the additional practitioner(s) must be documented and must be applied consistently across all measures by the organization.

Age Range 50-75: Patients born between 01/01/1940and 01/01/1965

Denominator Description

Adults, whose age at the beginning of the one year measurement period is at least 50 and whose age at the end of the one year measurement period is less than 76 and who are alive as of the last day of the Measurement Period. Expired patients for whom a specific date of expiration cannot be found are excluded from the denominator population.

The rationale for the denominator population is built from the following criteria:

[Question 1] – Is this a patient whose care is managed within the physician group?

[Question 2] – Is this a patient currently managed in our system?

[Question 3] – Is this a patient that is eligible for colorectal cancer screening?

MINIMUM POPULATION SIZE

Organization Level Reporting:

For every WCHQ Ambulatory Measure, each organization must calculate total denominator population for this measure, not a sample (see Encounter Data section). If the Denominator for any given measure is less than 50 patients, the organization does not have to report the Numerator for the measure to WCHQ. To allow for appropriate comparisons of performance across organizations, a minimum population of 50 patients ensures a maximum of a 2% incremental scale on proportional measures.

Publication on the Website: If the Denominator is less than 50, only the Physician Group Name, Population Size (N), and the following statement will display on

  • The patient population is too small (N<50) for purposes of reliably predicting Physician Group performance.

Historical Trend for Low Population Sizes: The historical trend display of Physician Group performance will not include measurement periods with population sizes less than 50. For each measurement period with insufficient data, there will be no display for that period.

Site Level Reporting:

Denominator Minimum: For site level reporting there must be a minimum of 100 patients per clinic in the denominator for each measure. If the clinic denominator for any given measure is less than 100 patients the organization does not publicly report the results for the measure. The results will still be included in the organization level data.

Provider Minimum per Clinic: For site level reporting there are two options as follows:

  • A minimum of 3 providers per clinic who have patients in the measure denominator. There could be a provider or providers in a given clinic who do not get counted because they have no patients in the measure denominator.
  • If an organization desires, they can report site level data for a clinic with fewer than 3 providers as long as the clinic meets the 100 patient threshold. If your organization is planning to report results publicly for clinics with less than 3 providers, all clinics that meet this criteria will need to be reported.

Publication on the Website: Clinics who do not have enough providers or patients to be publicly reported for a given measure or measures will still display on the website by name but without results and with a caveat indicating that data was reported but did not meet the minimum provider or population size.

Provider and /or Clinic Attrition Recommendation:

  1. If a provider or clinic has left the organization prior to the end of the measurement period and if the organization can track the provider termination date, the provider will not be included in the site level reporting results. The provider or clinic is still included in the group level results.
  2. If a clinic closes or is no longer affiliated with a health care system after the end of the measurement period and prior to next year’s data being published a terminationdate and verbiage will be added next to that clinic’s name on the website. This will require website updating throughout the year.

Assignment of Provider to Clinic:

Organizations can use their current internal site level reporting methodology to assign a provider to a clinic. A provider must be assigned to a “home” clinic. Organizations who are not already doing internal site level reporting can work with WCHQ for assistance.

Assignment of Patient to Provider:

For purposes of WCHQ site level reporting a patient must be attributed to one provider. Organizations can use their own internal algorithm to assign a patient to a provider. Those who are not already doing this can work with WCHQ for assistance.

ENCOUNTER DATA

Patients eligible for inclusion in the denominator include: (See Figure CCS-1)

[Question 1] –Is this a patient whose care is managed within the physician group?

Patients who had at least two Primary Care office visits (Table CCS-1), regardless of diagnosis code, on different dates of service, to a PCP in the past 36 months (Measurement Period plus Prior Two Years).

[Question 2] –Is this a patient currently managed in our system?

Patients who had at least one Primary Care office visit (Table CCS-1) regardless of diagnosis code, with a PCP in the most recent 24 months (Measurement Period plus Prior Year)

[Question 3] – Is this a patient that is eligible for Colorectal Cancer Screening?

  • Exclude those who have had a total colectomy (Table CCS-2). The organizations may look for exclusions as far back as possible in the patient’s history, through administrative data and/or medical record review. The exclusion can be identified through an ICD-9 diagnosis-based problem list. The problem must be ACTIVE. There is no limit on the look back date, but the date of documentation or onset date must occur prior to the end of the measurement period.

NUMERATOR DESCRIPTION

The number of eligible adults who had one or more screenings for colorectal cancer as defined by the following criteria:

  • Fecal Immunoassay Test (FIT) / Fecal Occult Blood Test (FOBT): One test during the measurement period (12 months)
  • DNA Stool Test (Cologuard): One test during the measurement period or the two years prior to the measurement period
  • Flexible Sigmoidoscopy: During the measurement period or the four years prior to the measurement period.
  • CT Colonography (virtual colonoscopy): During the measurement period or the four years prior to the measurement period.
  • Colonoscopy: During the measurement period or the nine years prior to the measurement period.

This may be demonstrated through any of the following:

  • Administrative data, which can include:
  • Table CCS-3
  • Internal, external and/or patient reported screenings extracted electronically from an Electronic Medical Record (EMR), requiring one of the following:

Year test was performed

Date range test was performed, providing the entire range is within the measurement period.

NOTE: This does not include results with a date of documentation only; the actual year or date range of the test must be present and be within the numerator description timeframes for inclusion in the numerator.

  • Medical Record Review (Refer to Medical Record Review for Numerator Inclusion/Denominator Exclusion section)

AST he Measurement Period during the Measurement Period – 12 monthsor the four years prior to the Measurement Period)

Period – 12 monthsor the four years prior to the Measurement SIGMOIDOSCOPY)

Colorectal Cancer Screening Annual Review –Draft 2016_Spring

This specification is updated annually; refer to previous versions for coding and other changes

1

WCHQ Ambulatory Measure Specification

Colorectal Cancer Screening Performance Measure

Measurement Period 01/01/2015-12/31/2015

Submission Period: 03/07/16 - 03/18/16

Colorectal Cancer Screening Annual Review –Draft 2016_Spring

This specification is updated annually; refer to previous versions for coding and other changes

1

WCHQ Ambulatory Measure Specification

Colorectal Cancer Screening Performance Measure

Measurement Period 01/01/2015-12/31/2015

Submission Period: 03/07/16 - 03/18/16

sampling methodology

Organizations unable to collect numerator databy electronic means can do so by using the following criteria for chart review;

The Sample size for chart review is determined based in the following criteria:

  • c = 95% Confidence Interval
  • E = 5% Margin of Error
  • N = Total number of patients in the denominator pool
  • Use the “Sample Size Generator” at the Wisconsin Collaborative for Healthcare Quality website and enter values to generate the sample size appropriate for your organization
  • A 10% over sample is recommended beyond the generated sample size.

Internally Developed Codes – Data Translation/Mapping Requirements

If a medical group utilizes internally generated codes to identify specific services or events required for a given WCHQ performance measure, the group may translate or map the information to the WCHQ performance measurement specifications. The medical group must assure that the internally generated code matches the clinical specificity of the standard (ICD-9, CPT) codes included in the WCHQ performance measurement specifications.

In order to use internally developed codes for WCHQ performance measure reporting, the medical group needs to document the translation/mapping to the codes in the specifications. This documentation should include the internally generated code, a description of the internally developed code, any additional clinical information for the internally developed code, and the equivalent standard code with description from the WCHQ performance measurement specifications. Once the translation/ mapping documentation is established, the medical group’s WCHQ performance measurement team must review the mapping on a yearly basis and document that internally developed codes have not changed and are being used in the manner described in the translation/ mapping document.

The medical group must have documented processes in place for adding codes to the medical group’s administrative data system and procedures to implement the internally developed codes.

Medical Record Review for Numerator Inclusion/Denominator Exclusion

If appropriate, and/or when necessary, every organization may complement their electronic capture of patient medical history with electronic or manual record review. The following criteria apply only to data captured/reviewed during medical record review.

Numerator Inclusion

For WCHQ Preventive Screening Measures, which can include, internal, external, and/or patient reported test results, proof of numerator compliance requires one of the following:

Year test was performed

Date range test was performed, providing the entire range is within the measurement period.

NOTES:

  • This does not include results with a date of documentation only; the actual year or date range of the test must be present and be within the numerator description timeframes for inclusion in the numerator.
  • CPT Code 82272 - Blood, occult, by perioxidase activity (eg guaiac), qualitative, feces, single specimen is NOT numerator compliant.
  • A colon polyp pathology report with no colonoscopy procedure report can count towards a colonoscopy or flex sig as one of the two procedures would have to have been done to remove the polyp. This would be found during a chart review from reading a path report, not something that will have a code for electronic data collection. If it is not possible to tell the location of the polyp in the colon then default to flex sig because it is the shorter look back.

Denominator Exclusion

For all WCHQ Measures, proof of Denominator exclusion requires:

Existence of exclusion criteria.

These data may be retrieved, in whole or in part, from any of the following:

  • Notation in Progress Note
  • Notation in Medical History or Surgical History
  • Flag/Field in Electronic Medical Record
  • Documentation in patient chart

REQUIRED DATA SUBMISSION FIELDS

Fields required for data submission for this measure depend upon the methodology used. The fields are as follows:

Organization Level Reporting:

TOTAL POPULATION METHODOLOGY:

  • Population Denominator(N)(Patients Eligible for Colorectal Cancer Screening)
  • Numerator (Patients who had a minimum of one Colorectal Cancer Screen)

Upon entry of these numbers, the rate is automatically calculated

Random Sample Methodology:

  • Population Denominator (N) (Patients Eligible for Colorectal Cancer Screening)
  • Population Sample (n) (r) (Patients in Denominator Population whose records will be reviewed)
  • (n)=Population Sample and (r)=Patients Reviewed equal the same number
  • The Population Sample size must be determined using the WCHQ Sample Calculator
  • Numerator (Patients who had a minimum of one Colorectal Cancer Screen from Population Sample)

Upon entry of these numbers, the rate is automatically calculated

Hybrid Methodology:

  • Population Denominator (N) (Patients Eligible for Colorectal Cancer Screening)
  • Administrative Review Denominator(Patients in Total Denominator Population whose numerator information is obtained through administrative data)
  • Administrative Review Numerator(Patients who had a minimum of one Colorectal Cancer Screen found through administrative data)
  • Manual Review Denominator(Patients in Total Denominator Population whose numerator information cannot be obtained through administrative data)
  • Manual Review Sample Size(Patients in Manual Review Denominator Population whose records will be reviewed)
  • The Manual Review Sample size must be determined using the WCHQ Sample Calculator plus a 10% over sample
  • Manual Review Numerator (Patients who had a minimum of one Colorectal Cancer Screen found through Manual Review Sampling)

Upon entry of these numbers, the Rates, Weight Factors and Total Reviewed are automatically calculated. Total Reviewed equals Administrative Review Denominator + Manual Review Sample Size.

Site Level Reporting:

Non-RBS Organizations:

  1. Refer to the “Non-RBS Site Level Reporting Upload Template.xls” for specific instructions.

RBS Organizations:

  1. Refer to the “RBS Site Level Reporting Upload Template.xls” for specific instructions.

PAYER STRATIFICATION:

  1. Denominator data submission is requested by Payer Stratification for Medicare, Medicaid, Commercial and Uninsured.
  2. Numerator data submission can be entered by primary payer category only for total population methodology

Refer to Appendix A for definitions of the payer stratification categories

FIELDS REQUIRED FOR MEASURE VALIDATION

Validation of this measure will require patient level data files for Administrative Data and/or for Manual Review. The following indicates fields needed for validation, which may be helpful to consider when querying the measure:

Denominator Data File fields:

  • Patient Identifier (can be medical record number or other ID)
  • Primary Care Office Visit Dates
  • Provider Specialty
  • Patient Date of Birth
  • Exclusion codes used for Colectomy
  • Date of Colectomy documentation

Numerator Data File fields:

  • Patient Identifier (can be medical record number or other ID)
  • Colorectal Cancer Screening Code or Description
  • Colorectal Cancer Screening Test Date

Site Level Reporting fields:

  • Clinic Name
  • Period
  • Metric ID
  • Clinical Topic
  • Measure
  • Clinic ID
  • Clinic Name
  • Metric Level (for A1C and LDL Testing and Control measures)
  • Payer (optional)
  • Numerator
  • Denominator
  • Percentage
  • Provider Count
  • Provider Minimum Count Flag
  • Patient Minimum Count Flag

Appendix A

Primary Payer

In keeping with the changing atmosphere of quality measurement and reporting, WCHQ would like for participating organizations to include the primary payer source with their data submissions for the ambulatory care measures.