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Challenges in the management of positive fecal occult blood tests
Sandhya K Rao1, Thad F Schilling, Thomas D Sequist
1Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
Insights
Many patients with positive fecal occult blood tests (FOBT) do not complete recommended follow-up colonoscopies. Factors like the reason for the test and insurance status influence colonoscopy completion rates, highlighting areas for improved patient care.
Area of Science:
- Gastroenterology
- Public Health
- Health Services Research
Background:
- A significant number of patients with positive fecal occult blood tests (FOBT) do not proceed with recommended follow-up evaluations.
- This gap in care can lead to delayed diagnosis and treatment of colorectal conditions.
Purpose of the Study:
- To determine the rate of follow-up colonoscopy after a positive FOBT.
- To identify the key factors contributing to the lack of follow-up colonoscopies.
Main Methods:
- A retrospective chart review was conducted.
- Data from 1,041 adults with positive FOBTs between 2004 and 2006 were analyzed.
- Multivariable logistic regression identified predictors of follow-up colonoscopy completion.
Main Results:
- Colonoscopy follow-up was completed in 62% of cases with positive FOBTs.
- Positive FOBTs were most commonly ordered for colorectal cancer screening (76%).
- Factors associated with higher follow-up rates included FOBT for screening and gastroenterology consultation; lower rates were seen in older/younger patients, uninsured individuals, and those with recent prior colonoscopies.
Conclusions:
- Clinical decisions and patient characteristics at the time of FOBT significantly influence whether a follow-up colonoscopy is performed.
- Improving physician understanding of FOBT utilization may enhance follow-up rates and reduce inappropriate testing.
Background:
Many patients with a positive fecal occult blood test (FOBT) do not undergo follow-up evaluations.
Objective:
To identify the rate of follow-up colonoscopy following a positive FOBT and determine underlying reasons for lack of follow-up.
Design:
It is a retrospective chart review.
Participants:
The subject group consisted of 1,041 adults with positive FOBTs within a large physician group practice from 2004 to 2006.
Measurements:
We collected data on reasons for ordering FOBT, presence of prior colonoscopy, completed evaluations, and results of follow-up tests. We fit a multivariable logistic regression model to identify predictors of undergoing follow-up colonoscopy.
Results:
Most positive FOBTs were ordered for routine colorectal cancer screening (76%), or evaluation of anemia (13%) or rectal bleeding (7%). Colonoscopy was completed in 62% of cases, with one-third of these procedures identifying a colorectal adenoma (29%) or cancer (4%). Factors associated with higher rates of follow-up colonoscopy included obtaining the FOBT for routine colorectal screening (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.11-2.29) and consultation with gastroenterology (OR 1.99, 95% CI 1.46-2.72). Patients were less likely to undergo colonoscopy if they were older than 80 years old (OR 0.54, 95% CI 0.31-0.92), younger than 50 years old (OR 0.44, 95% CI 0.28-0.70), uninsured (OR 0.50, 95% CI 0.27-0.93), or had undergone colonoscopy within the prior five years (OR 0.32, 95% CI 0.23-0.44).
Conclusions:
Clinical decisions and patient factors available at the time of ordering an FOBT impact performance of colonoscopy. Targeting physicians' understanding of the use of this test may improve follow-up and reduce inappropriate use of this test.
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