Colorectal cancer is the second leading cause of cancer-related deaths in the United States. Four population based studies of screening for colon cancer with fecal occult blood testing (FOBT) have shown that mortality can be significantly reduced with early detection and treatment. However, outside the research setting, nearly half of all positive screening tests are not appropriately evaluated. Our study describes a trial of an electronic record intervention designed to improve the follow-up of positive FOBTs (FOBT+).
1. To improve the rate of follow-up of positive FOBT colon cancer screening tests.
2. To improve the timeliness of follow-up of positive FOBT colon cancer screening tests.
We conducted a cluster randomized trial involving four VA medical centers pair-matched by colonoscopy volume and randomized within the pair to receive the electronic intervention or usual care. The intervention involved directly notifying the gastroenterology (GI) clinic of a FOBT+ result, using an electronic consult template that imported relevant clinical information and could be easily reviewed by GI to plan further evaluation. Two medical centers continued with their usual process of directly notifying only primary care providers of FOBT+ results. Analysis was conducted to evaluate pre to post changes in site-specific follow-up of FOBT+s, as well as the time lag between a FOBT+ and follow-up.
Thirty, 90 and 180 day GI consult/follow-up rates improved significantly in both sites randomized to the intervention, and were either unchanged or worsened in the two sites continuing with usual care. In addition, 30, 90 and 180 day rates of GI consult plus an anatomic evaluation of the colon (defined as complete diagnostic evaluation or CDE) improved significantly in the intervention sites and did not change in the control sites. Finally, the post intervention time lag between a FOBT+ and either GI consult or CDE was significantly shorter at post- versus pre-intervention in the sites randomized to the electronic intervention, while no significant differences were observed in the clinics following their usual care.
Our study has shown that a relatively simple intervention can significantly improve the appropriate follow-up of FOBT+s. This finding is important given the generally poor follow-up of these tests reported in the literature as well as its potential generalizability to other tests or procedures. Primary care providers are overwhelmed with data and interventions such as this could improve patient care, as well as help providers feel more confident in their care of patients and less fearful of missing important results.
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