Powell AA (Minneapolis VAMC), Ordin DL
(VA Office of Quality and Performance), Schlosser JE
(Bedford VAMC), Partin MR
In light of previous research indicating that many VA facilities may have substantial delays in follow up of positive colorectal cancer (CRC) screening tests, a FY2007 VA monitor was introduced requiring that all facilities track the proportion of positive FOBT patients who receive timely follow-up (colonoscopy within 60 days). In order to assess current performance on this measure and identify potential drivers of improvement, the National CRC Diagnosis Improvement Project, with the assistance of the VISN Chief Medical Officers, conducted an online survey of all VA medical centers. We used data from this survey to estimate the levels and determinants of timely +FOBT follow-up in the VA.
A web survey link was sent to VA facilities requesting available tracking data from October 2006 - March 2007. Facilities were asked to provide data on time to colonoscopy and colonoscopy appropriateness for a sample of +FOBT patients. Facilities also indicated the degree to which they had implemented a variety of process, capacity, and general quality improvement strategies and listed barriers to improvement. We calculated summary statistics on all measures and identified predictors of timely follow up using hierarchical linear modeling.
132 facilities responded to the questionnaire, 110 of which provided +FOBT follow up tracking data. Across all facilities, 24.9% (3,154/12,676) of patients received timely follow-up, with facility rates ranging from 0% to over 84.1%. Colonoscopy inappropriateness data was collected by 80 sites on 8,182 patients. Within this sample, 30.6% (2,506) of +FOBT cases were considered inappropriate for colonoscopic follow up. Facilities that had implemented general quality improvement strategies such as developing tracking processes and forming quality improvement teams had significantly better rates of follow up. Sites reporting capacity issues as a key barrier had significantly lower follow up rates.
Overall rates of timely +FOBT follow-up are low in the VA, due in part to “false” demand for follow up created by the screening of veterans who are considered inappropriate to receive colonoscopies.
Low +FOBT follow-up rates may be improved by reducing inappropriate screening, implementing general quality improvement strategies, and increasing colonoscopy capacity.