329 Quality Assessment of Appropriate Follow-Up for Positive Fecal Immunochemical Tests at a Large Federal Healthcare Facility

Abstract

INTRODUCTION: Annual fecal immunochemical testing (FIT)—a first tier screening test for colorectal cancer—has the potential to help achieve wider compliance with screening recommendations, including in vulnerable populations. The impact of FIT is dependent on the ability to follow up a positive test with a colonoscopy. National guidelines provide recommendations regarding targets for appropriate follow up. We sought to study practice patterns and performance of FIT follow up at our multi-level care medical center (which includes an on-site patient centered medical home). METHODS: The study was performed at the Department of Defenses’ largest military treatment facility with primary care and gastroenterological (GI) services located on the same campus. All FIT orders between January 2013 and December 2017 were identified through electronic test identification codes. Retrospective chart review was performed to evaluate the indication for testing, patient notification of a positive test, GI referral, and completion of colonoscopy. RESULTS: A total of 979 tests were ordered with 246 positive tests. The majority of patients (169, 70.2%) had appropriate follow up or an alternative explanation of a positive test (e.g. infectious colitis). 77 patients (29.8%) had inadequate follow up. 33 of 83 patients (39.7%) ages 50-75 and 69 of 198 patients ages 18-75 did not receive adequate follow. Patients without adequate follow up were offered expedited evaluation in GI. CONCLUSION: We found that despite being on the same campus and sharing an electronic record, patients seen in primary care clinics utilizing an opportunistic screening strategy had appropriate follow up just over 60% of the time in the screening age cohort (50/83), falling below the 80% threshold recommended by national guidelines. Due to our findings, we embarked on plans to alter the way patients with positive FIT are routed between primary care providers and GI clinic. Interventions to improve follow-up of positive FIT include expedited colonoscopy scheduling and automatic patient notification of FIT results. We have adjusted our electronic ordering system to require providers to specify an indication when ordering FIT so that patients with positive screening tests are automatically referred in a highly reliable fashion. These findings support the use of a programmatic screening program when utilizing a FIT test as a screening modality; systems must allocate resources to ensure patients with positive tests successfully navigate the medical system.