title: Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits.
abstract: OBJECTIVE
  Colonoscopy is a common procedure, yet little is known about variations in colonoscopy quality among outpatient facilities. We developed an outcome measure to profile outpatient facilities by estimating risk-standardized rates of unplanned hospital visits within 7 days of colonoscopy.
  
  
  METHODS
  We used a 20% sample of 2010 Medicare outpatient colonoscopy claims (331,880 colonoscopies performed at 8140 facilities) from patients ≥65 years or older, and developed a patient-level logistic regression model to estimate the risk of unplanned hospital visits (ie, emergency department visits, observation stays, and inpatient admissions) within 7 days of colonoscopy. We then used the patient-level risk model variables and hierarchical logistic regression to estimate facility rates of risk-standardized unplanned hospital visits using data from the Healthcare Cost and Utilization Project (325,811 colonoscopies at 992 facilities), from 4 states containing 100% of colonoscopies per facility.
  
  
  RESULTS
  Outpatient colonoscopies were followed by 5412 unplanned hospital visits within 7 days (16.3/1000 colonoscopies). Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits. Fifteen variables were independently associated with unplanned hospital visits (c = 0.67). A history of fluid and electrolyte imbalance (odds ratio [OR] = 1.43; 95% confidence interval [CI]: 1.29-1.58), psychiatric disorders (OR = 1.34; 95% CI: 1.22-1.46), and, in the absence of prior arrhythmia, increasing age past 65 years (aged >85 years vs 65-69 years: OR = 1.87; 95% CI: 1.54-2.28) were most strongly associated. The facility risk-standardized unplanned hospital visits calculated using Healthcare Cost and Utilization Project data showed significant variation (median 12.3/1000; 5th-95th percentile, 10.5-14.6/1000). Median risk-standardized unplanned hospital visits were comparable between ambulatory surgery centers and hospital outpatient departments (each was 10.2/1000), and ranged from 16.1/1000 in the Northeast to 17.2/1000 in the Midwest.
  
  
  CONCLUSIONS
  We calculated a risk-adjusted measure of outpatient colonoscopy quality, which shows important variation in quality among outpatient facilities. This measure can make transparent the extent to which patients require follow-up hospital care, help inform patient choices, and assist in quality-improvement efforts.
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Isuru
authors.initials: I
authors.lastname: Ranasinghe
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Craig S
authors.initials: CS
authors.lastname: Parzynski
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Rana
authors.initials: R
authors.lastname: Searfoss
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Julia
authors.initials: J
authors.lastname: Montague
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Zhenqiu
authors.initials: Z
authors.lastname: Lin
authors.affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: John
authors.initials: J
authors.lastname: Allen
authors.affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Ronald
authors.initials: R
authors.lastname: Vender
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Kanchana
authors.initials: K
authors.lastname: Bhat
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut; Section of General Internal Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut; Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut; Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University, New Haven, Connecticut; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut; Section of General Internal Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut; Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University, New Haven, Connecticut.
authors.forename: Susannah
authors.initials: S
authors.lastname: Bernheim
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut; Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University, New Haven, Connecticut; Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.affiliation: Center for Outcomes Research and Evaluation (CORE), Yale-New Haven Hospital, New Haven, Connecticut; Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut. Electronic address: Elizabeth.drye@yale.edu.
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Drye
mesh_terms: D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000379:methods / Q000592:standards; D000554:Ambulatory Care Facilities / Q000592:standards* / Q000639:trends; D015331:Cohort Studies; D003113:Colonoscopy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D006278:Medicare; D016017:Odds Ratio; D010045:Outpatients / Q000706:statistics & numerical data; D061214:Patient Safety; D010360:Patient Transfer / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care / Q000592:standards*; D020379:Risk Adjustment; D017678:Sex Distribution; D014481:United States
keywords: Admission; Endoscopy; Health Policy; Outcomes