We studied the effect of several QI activities to improve the follow-up of positive FOBT results with a timely colonoscopy. Activities included improving the response of primary care providers to abnormal FOBTs and tracking positive tests till colonoscopy performance,. While the timeliness of colonoscopy referral and performance was not optimal according to recent VA policy recommendations, we found a significant increase in the proportion of patients who received a timely colonoscopy referral and a timely colonoscopy performance after implementation of these activities. The QI activities were also accompanied by a significant decrease in the median times for colonoscopy referral and performance and a significant decrease in the proportion of FOBT test results that were never followed-up. Prominent factors associated with a lack of performance of an indicated colonoscopy included patient non-adherence to scheduled colonoscopy appointments, and failure to re-request and reschedule cancelled colonoscopy procedures. Because colonoscopy was not indicated in approximately one third of patients with positive FOBT (267/800), our study raises concerns about current screening practices and the appropriate denominator used for performance measurement standards related to CRC screening.32
Our study also has implications beyond the VA to many other health care systems that rely mostly on FOBT testing, rather than screening colonoscopies, due to limited colonoscopy capacity.
Previous studies of activities to increase follow-up of abnormal cancer screens have mostly focused on patient-level factors and tests such as Papanicolaou smears.6,33–36
Relatively few studies have addressed systems-based practice and focused on providers, especially for FOBT follow-up.1,6,37
For instance, a study by Myers et al. provided physicians with reminders for abnormal FOBTs, accompanied by feedback on follow-up completion, educational visits, a tailored letter and a follow-up reminder call.37
A study by Manfredi 33
used procedures such as standardized communication from the exit nurse, a form that patients returned after compliance, and written and telephone reminders to improve compliance with referrals for several abnormal screening tests including FOBT. However, none of these studies were conducted in systems with integrated electronic medical records (EMRs), which potentially overcome test result notification barriers and facilitate tracking procedures.
While we did not measure the impact of the individual components of the QI activities, we believe that provider notification (both through alerts and mailbox) followed by monitoring performed by the preventive medicine coordinator likely provided the greatest benefit in improving the FOBT follow-up. Despite the use of an integrated EMR and tracking patients until colonoscopy completion, the timely referral and performance rates for eligible patients improved to only about 60% and 11% respectively. This inability to ensure subsequent follow-up in many cases is consistent with results of previous interventions that have used tracking procedures.12
Further performance improvement may result from activities not addressed by our initiatives, such as increasing capacity for colonoscopy procedures, improving care coordination processes that contribute to post-colonoscopy referral delays and patient education. Overall timeliness of follow-up of positive FOBT tests remained far less than those recommended by recent VA policy recommendations (median duration of 96.5 days to colonoscopy performance post implementation). These recommendations were released in early 2007, at the end of our study period, so their true impact on performance remains to be seen. Such QI activities highlight and accentuate the issue of limited endoscopic capacity, which is likely to worsen with further improvement in timely handling of positive FOBT results and clearing pending gastroenterology consults. Hence, these QI activities may paradoxically increase delays due to more referrals for colonoscopy and higher demand for this service. Despite these limitations, our activities resulted in improvement in provider to response to abnormal test results; moreover, these initiatives are feasible and relatively easy to implement within systems that use integrated EMRs.
Although a recommendation or referral for colonoscopy was made in about 80% of indicated cases, we found several inappropriate follow-up actions such as repeating the FOBT test and ordering a barium enema or flexible sigmoidoscopy. The frequency of these actions was much lower than that reported by Nadel et al. in 2005, an effect that could be partly explained by guideline diffusion over time.38
Despite provider notification, about 15% of positive FOBT cases lacked a documented follow-up plan at the time of chart review. Moreover, several opportunities to follow up the test result occurred subsequent to the date of the FOBT when providers could have “caught” the abnormality in a readily accessible EMR system. Many of these missed opportunities involved visits during which a comprehensive patient assessment, including a review of test results, was indicated.
Our study findings have implications for current and future policies and guidelines that address the timeliness or appropriateness of CRC screening. First, policy recommendations on timeliness, such as those released by the VA, must adopt benchmarks with explicit numerators and denominators in far more detail than currently done.31
Currently, outcomes for positive FOBT tests in situations when colonoscopy is not indicated are not well accounted for and could result in significant underestimations of timeliness. Such situations could occur because of a procedure performed elsewhere previously, patient refusal, or request for procedure performance elsewhere, and were found in over 10% of positive FOBT cases in our sample. Additionally, guidelines indicate that CRC screening is not required for up to 10 years following a negative colonoscopy but are silent on how to handle positive FOBTs in patients who have had a recent colonoscopy. 25,39
When we recalculated our outcome measures after including the 31 patients with recent negative colonoscopy in the denominator, the rates were slightly lower because none of them had received a timely colonoscopy. Of 216 patients where we found colonoscopy inappropriate or not warranted, only 17 (7.8%) eventually had a colonoscopy at chart review. Hence, our findings are conservative estimates of underutilization of colonoscopy. Anecdotally, we have noticed a low yield for tests with recent negative colonoscopy. Currently in our system, most PCPs do not obtain FOBTs on patients who have had a recent negative colonoscopy. Given that the median time from FOBT result to colonoscopy performance was 96.5 days, our findings also suggest a need for numerators that reflect achievable evidence based practice goals; the 60-day colonoscopy performance recommendation may not be easily achievable currently without increased endoscopic capacity. When we used a 90-day time frame, the proportion of patients with timely performance was slightly better (post-implementation 27.3% versus pre-implementation 10.3%). Using a 120 day window, timely performance increased to 36.5% post-QI versus 16% pre-QI. In a previous study, we found no difference in outcomes (stage/survival) of patients with CRC diagnosed within 30, 60 or 90 days of positive FOBT. 40
Second, during both pre- and post- implementation periods we found a large proportion of FOBTs (~17%) were performed on patients when the test was likely not indicated. This problem has received heightened attention in recent literature,28,30,41
however, recently released guidelines do not adequately address who should not
be screened for CRC.39
These FOBTs further strain an already limited endoscopic capacity. While only a small percentage of these patients (12.3%) ultimately underwent a colonoscopy in our study, the findings call for more explicit appropriateness criteria to prevent the diversion of resources to patients who may not necessarily need them. Such defined exclusion parameters could link to electronic FOBT reminders in the medical record to guide providers and their patients to make informed choices. Notably, many of our exclusionary criteria were facility-specific and not currently used in a standardized fashion nationwide to calculate VA performance measures.
Our study has implications not just for the VA but also other health care institutions that use FOBT for screening due to limited colonoscopy capacity. These institutions should consider implementing sophisticated EMR systems for improving follow-up of abnormal screen findings.42
In addition to improving electronic communication related to test results and consultations, further reduction in diagnostic delays43
will also be possible with advent of systems that are able to track colonoscopy completion post-referral. We believe that use of information technology and case managers with dedicated time could facilitate tracking procedures.44
Consistent with previous studies, 16,45
we found that patient adherence to colonoscopy was a significant barrier in getting a full colon evaluation. Previous interventions have focused on improving patient adherence to methods of cancer screening.46–48
However, interventions to improve patient adherence to follow-up procedures related to abnormal cancer screens are also warranted.19,33,37,49–51
Also needed are better systems of arranging follow-up procedures after cancellations, a common scenario in ambulatory care practice. Whether the primary care provider re-requests a procedure or the gastroenterologist reschedules it on their own may depend on institutional practices, but this problem may be improved by better tracking systems20,52–54
using either reminders built into the EMR or navigation programs for patients with suspected cancer.19,55–57
Our study has several strengths. Access and follow-up in the VA system is less affected by financial factors. In addition, the VA EMR allows for a comprehensive review of available data. Many previous studies6,11,18,38,58,59
have used either administrative data or patient self-reports to measure follow-up, but standardized medical chart review overcomes some of the limitations of these methods.60
Our results should be interpreted with several limitations. This was a single institution study and the findings may not be generalizable to the study population of other VA facilities or to non-VA settings. Due to our retrospective chart review design we were not able to determine precisely why providers did not follow-up on the FOBT results data, nor could we comprehensively examine the many other factors that may affect timely colonoscopy performance. Although we were able to able to capture and account for many dual users of both VA and non-VA services through detailed chart review61
, we may have missed some instances where information about colonoscopies in non-VA settings was not documented in the EMR. Additionally, due to resource limitations, our QI activities did not involve patient contact.