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Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study

BMJ 2014; 348 doi: (Published 26 February 2014) Cite this as: BMJ 2014;348:g1247
  1. Sameer D Saini, research scientist12,
  2. Sandeep Vijan, research scientist12,
  3. Philip Schoenfeld, research scientist12,
  4. Adam A Powell, research scientist34,
  5. Stephanie Moser, data analyst1,
  6. Eve A Kerr, director and research scientist12
  1. 1Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
  2. 2Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
  3. 3Veterans Affairs Center for Chronic Disease Outcomes Research, Building 9, VA Minneapolis Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA
  4. 4Department of Medicine, University of Minnesota, Minneapolis, MN, USA
  1. Correspondence to: S D Saini Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA sdsaini{at}
  • Accepted 24 January 2014


Objective To examine whether the age based quality measure for screening for colorectal cancer is associated with overuse of screening in patients aged 70-75 in poor health and underuse in those aged over age 75 in good health.

Design Retrospective cohort study utilizing electronic data from the Veterans Affairs (VA) Health Care System, the largest integrated healthcare system in the United States.

Setting VA Health Care System.

Participants Veterans aged ≥50 due for repeat average risk colorectal cancer screening at a primary care visit in fiscal year 2010.

Main outcome measures Completion of colonoscopy, sigmoidoscopy, or fecal occult blood testing within 24 months of the 2010 visit.

Results 399 067 veterans met inclusion/exclusion criteria (mean age 67, 97% men). Of these, 38% had electronically documented screening within 24 months. In multivariable log binomial regression adjusted for Charlson comorbidity index, sex, and number of primary care visits, screening decreased markedly after the age of 75 (the age cut off used by the quality measure) (adjusted relative risk 0.35, 95% confidence interval 0.30 to 0.40). A veteran who was aged 75 and unhealthy (in whom life expectancy might be limited and screening more likely to result in net burden or harm) was significantly more likely to undergo screening than a veteran aged 76 and healthy (unadjusted relative risk 1.64, 1.36 to 1.97).

Conclusions Specification of a quality measure can have important implications for clinical care. Future quality measures should focus on individual risk/benefit to ensure that patients who are likely to benefit from a service receive it (regardless of age), and that those who are likely to incur harm are spared unnecessary and costly care.


  • We thank the following individuals for their valuable input on earlier drafts of this manuscript: Joseph Francis (VA Clinical Analytics and Reporting); Linda Kinsinger and Kathleen Pittman (VA National Center for Health Promotion and Disease Prevention); Jason A Dominitz, (VA Puget Sound Health Care System and the University of Washington School of Medicine); and Deborah Fisher (Durham VA Center for Health Services Research in Primary Care and Duke University Medical Center).

  • Contributors: SDS was involved in all aspects of this study, including study conception, study design, data analysis, and manuscript writing and revisions. EAK and SV contributed to study design and manuscript writing and revisions. SM contributed to study design, data analysis, and manuscript writing and revisions. AAP and PS contributed to manuscript revisions. SDS is guarantor.

  • Funding: This study was funded by the Veterans Health Administration. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or final approval of the manuscript. The opinions expressed in this paper are of the authors and do not necessarily reflect those of the Department of Veterans Affairs.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: SDS had financial support from the Department of Veterans Affairs for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the Institutional Review Board of the VA Ann Arbor Healthcare System (RO: 2011-100615) on 28 March 2012.

  • Transparency: SDS affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. All authors had full access to study data and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Data sharing: Statistical code is available on request from the corresponding author.

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