We have shown that a simple electronic intervention that involves an automatic GI consult for patients with FOBT+ results improves follow-up and reduces the time between a FOBT+ result and GI evaluation, as well as CDE. Our findings are similar in both intervention sites and are clinically relevant. We do not have data on anatomic or distal health outcomes such as CRC death rates, but believe that our data show a practice change that could only improve the outcomes of CRC screening programs involving FOBTs, given the well-established benefit of FOBT-based CRC screening programs in reducing CRC mortality. The focus groups conducted at each intervention site showed that all providers were uniformly positive about this intervention.
The results achieved in this study compare favorably with results from prior studies evaluating interventions to improve FOBT+ follow-up.11–13
These studies all evaluated multifaceted interventions involving provider education, tracking systems and reminders, and none involved directly notifying GI of FOBT+ results. Our study results suggest that a simple modification of the electronic medical record system that involves directly notifying GI of FOBT+ results can lead to increases in FOBT+ follow-up comparable to those observed in prior studies. This intervention may also be less resource dependent than other interventions to improve follow-up. It is important to note, however, that factors other than referral play a role in patients obtaining appropriate and timely follow-up of FOBT screening tests, including institutional access and patient adherence.
The problem of inadequate follow-up of FOBT+ findings is important and not well recognized. Nationally, only one in three individuals with positive FOBT results undergoes colonoscopy.8
Data from a 120-site study showed that only 59% of patients with a positive FOBT result had any sort of evaluation within 6 months and that the average time until colonoscopy was 252 days after a FOBT+ result.14
Similar results have been shown with Medicare populations.8
Results from our control sites suggest similarly low rates of follow-up in spite of a major national effort in the VA to improve CRC screening and colonoscopy rates. A recent study evaluating 531 patients with newly diagnosed CRC identified 161 patients with at least one missed opportunity to diagnose CRC (or polyps) earlier.12
In addition, they found that FOBT+ results were missed 128 times in 64 patients who waited a median of 146 days after a FOBT+ finding before GI referral. Thus, a program that improves test follow-up has the potential to improve quality of care at the individual as well as the population level.
Failure to follow-up abnormal tests is a major patient safety issue and a source of anxiety for patients and physicians.15,16
One study showed that up to one-third of physicians do not notify patients of abnormal test results.17
Another study showed that only 32% of physicians have a reliable system of test follow-up.17
The Agency for Health Care Research and Quality advises patients that “no news is not good news” and recommends that patients ensure their physicians review laboratory results with them.18
In addition, PCPs are inundated with results. One survey showed that each week, full-time PCPs review 800 laboratory data points, 40 radiology reports and 12 pathology reports.19
This is in the midst of providing ongoing clinical care, including patient phone calls and e-mails. Similar findings were documented in a recent study as well.20
Thus, the opportunity for important test results to be missed is great. Notably, failure to follow up abnormal tests is an important area of medical malpractice and the source of 25% of all malpractice cases.21
The clear advantage of the electronic intervention we are reporting here is in directly notifying the appropriate specialist of a patient’s positive screening results. Effectively, the automatic FOBT+ consult created a redundant system so that positive tests were not missed.
Our study has important limitations. First, half of the sites initially randomized to the study could not be included in the final study because of the logistics of extracting data from the VA record system and limited programming resources. This barrier made the original data analysis plan unusable and limited the possible statistical tests to within site comparisons. This barrier was unexpected and will be important to other investigators who attempt to use the rich data base contained in the electronic medical records of the VA. Second, for unclear reasons, GI referral rates should have been nearly 100%, yet were not. A complicating factor in our study involved the movement of programming and IT supervision from individual VAs to the national VA office in the middle of our study, which decreased local programming flexibility and reduced our ability to interact with programmers at each of the sites. In our pilot test of the intervention in Portland, GI referral rates were above 90% after the intervention was implemented. Third, because of programming limitations, we were not able to evaluate exactly what sort of diagnostic evaluation our patients received, although we were able to date such procedures. We made an assumption that once the patient’s consult was reviewed by a gastroenterologist, the patient’s care would be appropriate for that patient. Finally, in the VA, there is great emphasis on screening patients for CRC, and much of the screening is done at clinic check-in or at a nursing or medical assistant level without careful review of patients’ records. This means that some patients will be screened inappropriately. Thus, even though referred to a gastroenterologist, these patients may be determined by the gastroenterologist or their PCP to be unlikely to benefit from follow-up of a FOBT+ result, which then results in a consult without further colon evaluation. Since the method of identifying patients for FOBT screening varies among VAs and practice settings, the number of inappropriate FOBT screens will vary as well. Such variations may explain differences in rates of follow-up of FOBT+ results at baseline and at follow-up. Because of differences in screening practices at each of the VAs, it was important that PCPs remain “in the loop” and could direct the care of their patients.
We recognize that instituting this intervention in VA medical centers may be more feasible than in non-veteran’s institutions because of our linked medical records and because it is essentially a closed system. However, we believe that other integrated systems and large group practices could create such an intervention. In addition, in these settings, this type of intervention might be more feasible as smaller size might allow more nimble manipulation of the electronic medical record. We also believe that as Accountable Care Organizations are developed, this sort of intervention will be feasible and effective.
In summary, we have shown that an electronic intervention that creates test notification redundancy improves the follow-up of patients with FOBT+ results. We believe that our study provides a model for improving the follow-up of important laboratory tests that is generalizable to many health care systems, as well as to many types of tests. In general, in medical care settings, physicians have relied on creating their own systems of follow-up that typically have relied on diligence and memory, and less often on systematic processes. The process we have created emulates systems in other fields such as the airline industry and anesthesiology, where creation of redundant, “fail-safe” systems improves over-all safety for travelers and patients. It is our belief that as physicians become more inundated with data that might include e-mails, written correspondence and phone calls, as well as results from laboratories, procedures, consultants and imaging, creation of system changes that assure patient safety will become increasingly important “due to man’s limitations as a data processor,” as noted by Clement McDonald in 1976.22