There are a number of theories as to how performance feedback can improve the quality of health-care practice. These include changing awareness about current practices, changing social norms, enabling self-efficacy, and facilitating goal setting [9]. The evidence suggests that “audit and feedback” approaches generally result in improvement in practice, and the degree of improvement depends on an individual’s performance at baseline and the type of feedback provided [9]. For example, feedback has been shown to be more effective when it is provided by a supervisor or a colleague, when it is provided more than once, when it is provided in both verbal and written form, and when it provides unambiguous targets for action.

At the population level, the rate of CRC screening uptake is a key measure used in performance feedback systems. Studies have shown that assessment and feedback of provider performance in CRC screening leads to improved performance [10, 11]. As it relates to colonoscopy quality, a number of studies have examined the impact of performance feedback on quality measures, and the majority have shown no impact on polyp detection rates [12]. However, three studies deserve mention. The first described an intervention that combined audible withdrawal timer with improved inspection technique [13]. This feedback intervention resulted in a significant increase in the detection of polyps as well as an overall population-level increase in the detection of advanced adenomas. In a recent study in the Veterans Health Administration, a quarterly report card resulted in a significant increase in adenoma detection and cecal intubation rates [14]. In a third study, an educational intervention combined with monthly feedback of adenoma detection rates resulted in marked improvement in detection rates during the course of the intervention [15]. Of note, none of these studies found a significant increase in advanced adenoma detection among physicians. More importantly, none have been able to assess the impact on the truly meaningful outcome, namely CRC incidence.

Tying financial incentives to performance feedback is one potential mechanism to augment the impact of physician feedback programs . Pay-for-performance (P4P) programs are in place for traditional Medicare inpatient and Medicare advantage plans, where withholds for nonparticipation will be implemented for individual physicians beginning in 2015. The individual physician program is based on the physician quality reporting system (PQRS) which has been in place since 2007 [16]. The physician value-based payment modifier (VBPM) will initially encourage participation but will quickly expand to incentivize performance on a defined set of measures [17].

Evidence on the impact of P4P programs is mixed [16]. Robust assessments of the impact of these interventions are lacking, and it is difficult to draw definitive conclusions from the existing literature [18]. The lack of impact of P4P programs may be related to inadequate incentive size, incentive structures, and even the choice of metrics themselves [19].

Dedicated studies evaluating the impact of P4P in CRC screening are not available although the American College of Gastroenterology (ACG) has identified a set of principles for the development and evaluation of these programs [20]. Furthermore, others have outlined recommendations for the use of payment reform to improve colonoscopy quality [21]. Several CRC screening quality measures are included in the government’s P4P program and will be further described below .

The belief that public reporting will result in improved quality is based on the notion that, in a competitive marketplace, information disclosure will cause self-regulation of the health-care system through actions on purchasers, consumers, policymakers, providers, and the public [22]. There are success stories in the general medical literature [23, 24], but the quality of the data is insufficient to make any broad conclusions on the impact of public reporting on consumer behavior, provider behavior, or clinical outcomes in health care [25, 26]. Furthermore, physicians are wary of public reporting programs because of concerns that these programs will distract the public from paying attention to the unmeasured components of health-care quality and will cause providers to avoid high-risk patients or perhaps even lower the quality of care through unintended consequences [27, 28].

In CRC screening, there are a few studies examining the impact of public reporting on the quality of care. Sarfaty and Myers found that the addition of a CRC screening rate to the HEDIS measures resulted in a number of changes by Pennsylvania health plans to increase screening rates in their populations [29]. This is notable because very few health plans had comprehensive management of CRC screening programs before that time [30]. The impact of public reporting of other quality measures in CRC screening is yet to be determined as many of these measures are still in their developmental stages.

One particular method of public reporting is the use of “physician designation” programs. These are programs that rate, rank, or tier health-care providers based on measures of quality and cost with the hopes of directing patients to the preferred providers . One of the earliest attempts at physician designation was the creation of preferred provider organizations (PPO), where physicians were either in or out of the network [31]. These networks surged in popularity in the late 1990s to early 2000s and remain as the predominant option for commercial payers, but have failed to deliver substantive cost or quality improvements [32].

More recent attempts at physician designation have relied on more sophisticated criteria of quality and cost, balancing performance feedback with elements of public reporting. Key to the success of these programs is the accuracy of information provided to the public, and accuracy has been one of the concerns prompting legal action around physician designation. One early example is action taken by the Attorney General of New York in 2007 [33]. In response to attempts by insurers to tier physicians on quality and cost-efficiency, the NY Attorney General initiated an investigation that lead to a wide-reaching agreement with a number of insurers to create a core set of principles for the accuracy and transparency of data used for physician tiering .

In 2008, Colorado enacted legislation-requiring standards and procedures for health insurers that are initiating physician-rating systems [31]. The Physician Designation Disclosure Act has a number of key requirements: first, the law requires that any public reporting or ranking of a physician’s performance must include quality of care data; second, performance measures used in the ranking must be endorsed by the National Quality Forum , a national physician-specialty group or the Colorado Clinical Guidelines Collaborative and be measured in a statistically sound fashion; third, the rating must include a disclaimer advising patients not to rely solely on the ranking in choosing a physician; finally, the law gives physicians right to review the data on which his/her ranking is based and to take action should they feel the data misrepresent their practice. Similar legislation has been considered in a number of other states, including Oklahoma, Maryland, and Texas .

The impact of these programs on quality and cost of CRC screening remains unknown. In part, it is unclear to what extent differentiation of providers using existing performance metrics will impact the quality of care. Furthermore, physician cost profiling has been shown to be unreliable [34], and it remains to be seen how cost transparency will influence patient and physician behavior .

Using performance feedback, P4P, public reporting, and physician designation as the levers of action, a number of entities in the USA use CRC screening quality measures for physician evaluation. In this section, we will review a number of these programs with a specific focus on government, commercial, and regional programs as well as those of integrated delivery systems.