Physician-reported reasons for limited follow-up of patients with a positive fecal occult blood test screening result

Abstract

Objective Fecal occult blood testing (FOBT) screening can reduce colorectal cancer (CRC) mortality when patients with an abnormal result [FOBT(+)] undergo a complete diagnostic evaluation (colonoscopy or double-contrast barium enema with or without flexible sigmoidoscopy). The aim of this study was to determine common reasons for nonperformance of a complete diagnostic evaluation. Methods We identified 544 FOBT(+) patients, aged 50 yr or older, who had participated in a managed care organization–sponsored CRC screening program. The performance of a complete diagnostic evaluation was determined from a patient-specific follow-up form and managed care organization claims data. Physicians were asked to report whether patients submitted to a complete diagnostic evaluation. When an evaluation was not done, the physicians were also asked to state the reasons for nonperformance. Results A total of 248 (46%) patients did not undergo a complete diagnostic evaluation. Physicians provided reasons for nonperformance for 50% (123/248). Factors accounting for nonperformance of a complete diagnostic evaluation were classified as follows: primary care physician decision (50%); specialist decision (28%); patient decision (17%); and other (practice-related) (5%). Many failures to complete an appropriate diagnostic evaluation were due to providers deciding to repeat the FOBT, perform a sigmoidoscopy, or not to proceed with any further testing. Conclusion Many patients with a positive FOBT do not receive a complete diagnostic evaluation. The reasons for nonperformance most frequently have to do with physician decision making. Many physician-related explanations do not conform to expert recommendations for appropriate follow-up.