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The U.S. Veterans Affairs (VA) Health System has an age-based quality measure for colorectal cancer screening: 75 is the upper age cutoff. In this retrospective study, investigators determined whether this age-based quality measure for colorectal cancer screening is associated with overuse of screening in 70- to 75-year-old veterans with poor health and short life expectancy and underuse of screening in older veterans (age, ≥76) with good health and long life expectancy.
The study included 400,000 veterans (mean age, 67) who were seen in VA primary care clinics in 2010 and were due for routine colorectal cancer screening. Screening rates were about 45% throughout the age range of 50 to 75. However, among older veterans, screening rates were much lower (about 16%), independent of comorbidity status and patient characteristics (relative risk, 0.4). In fact, an unhealthy 75-year-old with limited life expectancy was significantly more likely to undergo screening than a healthy 76-year-old with long life expectancy (unadjusted RR, 1.6).
Saini SD et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: Retrospective cohort study. BMJ 2014 Feb 26; 348:g1247. (http://dx.doi.org/10.1136/bmj.g1247)
Comment
In this study, a VA age-based quality measure promoted overuse of colorectal cancer screening in unhealthy elders and underuse in healthy elders. Notably, U.S. Preventive Services Task Force guidelines recommend screening average-risk adults between ages 50 and 75, but allow for tailoring of cancer screening in older patients (age range, 76–85) based on health status and other factors (NEJM JW Gen Med Oct 28 2008).Unlike guidelines, quality measures tend to be rigid, simplistic, and mandatory (JAMA 2004; 291:2466) and — as this study suggests — might unintentionally result in poorer quality of care.