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.
