Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) occurs in several types of healthcare settings. For example, more than 40% of Veterans with positive FOBT may not be receiving timely follow-up with colonoscopy. Inadequate FOBT follow-up may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Michael DeBakey VAMC in Houston implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. QI activities included improving primary care providers’ response to abnormal FOBTs, and tracking positive tests until colonoscopies were performed. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Because definitions of appropriate follow-up vary greatly for cancer screening tests such as FOBT, investigators used recommendations from a 2007 VA Directive that defines timely referral for colonoscopy to be within 14 days from an FOBT-positive report.
Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the multi-faceted QI activities (60.5% vs. 31.7%). In addition, there was a significant decrease in median times to colonoscopy referral (6 days vs. 19 days) and performance (96.5 days vs. 190 days). However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening. Prominent factors associated with not getting a colonoscopy when indicated included: performance of a non-colonoscopy procedure (i.e., barium enema, flexible sigmoidoscopy), patient non-adherence to scheduled colonoscopy appointments, and failure to re-request and reschedule canceled colonoscopy procedures.
Singh H, Kadiyala H, Bhagwath G, Shethia A, El-Serag H, Walder A, Velez M, and Petersen L. Using a multi-faceted approach to improve the follow-up of positive fecal occult blood test results. American Journal of Gastroenterology 2009 Apr;104(4):942-952.
This study was partly funded by HSR&D. Drs. Singh, El-Serag, and Petersen, Ms. Shethia, and Ms. Walder are part of HSR&D’s Houston Center for Quality of Care and Utilization Studies.