Colorectal Cancer Screening at the VA: How Well Are We Doing?

Abstract

Purpose: Fecal occult blood testing (FOBT) is the primary screening modality for colorectal cancer in the VA healthcare system. The benefit of FOBT is reduced by inappropriate testing and lack of follow-up with a colonoscopy for positive results. We sought to determine factors associated with receipt of a complete colonoscopy after a positive FOBT, and rates of inappropriate FOBT use. Methods: We used all positive FOBT results at the Minneapolis VA between 2006-2007 to identify rates of inappropriate FOBT, and factors associated with receipt of colonoscopy after a positive FOBT. We used multivariate logistic regression for the final model. Results: There were 606 positive FOBT results, of which 583 (98%) were male and 385 (95%) were white. The average age at the time of FOBT was 66 years old (range 22-91 years old). Within 3 years of positive FOBT, colonoscopies were performed in 454 (76%) patients. In multivariable logistic regression, patients with primary care based at the Minneapolis VA were more likely to receive a colonoscopy after a positive FOBT than patients with community-based outreach clinic (CBOC) primary care [OR 2.46, 95% CI 1.64-3.66, p<0.01]. Age, race, gender, distance from patient's home to the Minneapolis VA, number of primary care visits and number of primary care visits to the same provider within the 12 months prior to the positive FOBT result were not associated with receipt of colonoscopy. Of the positive FOBTs, 233 (39%) were done in patients in whom FOBT was inappropriate for colorectal cancer screening (patient was <50 or ≥80 years old, had history of colon polyps or cancer, IBD, hematochezia, iron-deficiency anemia, or a normal colonoscopy within the past 10 years). Patients with CBOC-based primary care were more likely to be given a FOBT inappropriately than VA-based primary care patients (52% vs. 47%, p=0.005). Of those “inappropriates” with positive FOBT results, 64% received a colonoscopy. Of patients appropriately screened with FOBT, 84% received a colonoscopy. Conclusion: Rates of follow-up colonoscopy after positive FOBT at the VA are high. Patients with VA-based primary care were more likely to receive a colonoscopy after a positive FOBT. Interventions to limit use of FOBT for colorectal cancer screening to the appropriate population are needed.