Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results

Hardeep Singh, Himabindu Kadiyala, Gayathri Bhagwath, Anila Shethia, Hashem El-Serag, Annette Walder, Maria E. Velez, Laura A. Petersen

Research output: Contribution to journalArticle

44 Citations (Scopus)

Abstract

Objectives: Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance.Methods: Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities.Results: In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5% vs. 31.7%, P0.0001 and 11.4% vs. 3.4%, P0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P < 0.0001 and 96.5 vs. 190 days, P < 0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3% vs. 35.9%, P = 0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR = 16.9; 95% CI, 1.9-145.1), patient non-adherence (OR = 33.9; 95% CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR = 17.9; 95% CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR= 11.0; 95% CI, 5.1-23.7).Conclusions: Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.

Original languageEnglish (US)
Pages (from-to)942-952
Number of pages11
JournalAmerican Journal of Gastroenterology
Volume104
Issue number4
DOIs
StatePublished - Jan 1 2009

Fingerprint

Occult Blood
Hematologic Tests
Colonoscopy
Quality Improvement
Referral and Consultation
Electronic Health Records
Sigmoidoscopy
Veterans
Gastroenterology
Tertiary Healthcare
Patient Compliance
Early Detection of Cancer
Colonic Neoplasms
Communication
Education

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

Cite this

Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results. / Singh, Hardeep; Kadiyala, Himabindu; Bhagwath, Gayathri; Shethia, Anila; El-Serag, Hashem; Walder, Annette; Velez, Maria E.; Petersen, Laura A.

In: American Journal of Gastroenterology, Vol. 104, No. 4, 01.01.2009, p. 942-952.

Research output: Contribution to journalArticle

Singh, H, Kadiyala, H, Bhagwath, G, Shethia, A, El-Serag, H, Walder, A, Velez, ME & Petersen, LA 2009, 'Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results', American Journal of Gastroenterology, vol. 104, no. 4, pp. 942-952. https://doi.org/10.1038/ajg.2009.55
Singh, Hardeep ; Kadiyala, Himabindu ; Bhagwath, Gayathri ; Shethia, Anila ; El-Serag, Hashem ; Walder, Annette ; Velez, Maria E. ; Petersen, Laura A. / Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results. In: American Journal of Gastroenterology. 2009 ; Vol. 104, No. 4. pp. 942-952.
@article{4c69b2f4e88c48f7807df7c487cbff5a,
title = "Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results",
abstract = "Objectives: Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance.Methods: Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities.Results: In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5{\%} vs. 31.7{\%}, P0.0001 and 11.4{\%} vs. 3.4{\%}, P0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P < 0.0001 and 96.5 vs. 190 days, P < 0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3{\%} vs. 35.9{\%}, P = 0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR = 16.9; 95{\%} CI, 1.9-145.1), patient non-adherence (OR = 33.9; 95{\%} CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR = 17.9; 95{\%} CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR= 11.0; 95{\%} CI, 5.1-23.7).Conclusions: Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.",
author = "Hardeep Singh and Himabindu Kadiyala and Gayathri Bhagwath and Anila Shethia and Hashem El-Serag and Annette Walder and Velez, {Maria E.} and Petersen, {Laura A.}",
year = "2009",
month = "1",
day = "1",
doi = "10.1038/ajg.2009.55",
language = "English (US)",
volume = "104",
pages = "942--952",
journal = "American Journal of Gastroenterology",
issn = "0002-9270",
publisher = "Nature Publishing Group",
number = "4",

}

TY - JOUR

T1 - Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results

AU - Singh, Hardeep

AU - Kadiyala, Himabindu

AU - Bhagwath, Gayathri

AU - Shethia, Anila

AU - El-Serag, Hashem

AU - Walder, Annette

AU - Velez, Maria E.

AU - Petersen, Laura A.

PY - 2009/1/1

Y1 - 2009/1/1

N2 - Objectives: Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance.Methods: Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities.Results: In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5% vs. 31.7%, P0.0001 and 11.4% vs. 3.4%, P0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P < 0.0001 and 96.5 vs. 190 days, P < 0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3% vs. 35.9%, P = 0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR = 16.9; 95% CI, 1.9-145.1), patient non-adherence (OR = 33.9; 95% CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR = 17.9; 95% CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR= 11.0; 95% CI, 5.1-23.7).Conclusions: Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.

AB - Objectives: Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance.Methods: Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities.Results: In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5% vs. 31.7%, P0.0001 and 11.4% vs. 3.4%, P0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P < 0.0001 and 96.5 vs. 190 days, P < 0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3% vs. 35.9%, P = 0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR = 16.9; 95% CI, 1.9-145.1), patient non-adherence (OR = 33.9; 95% CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR = 17.9; 95% CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR= 11.0; 95% CI, 5.1-23.7).Conclusions: Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.

UR - http://www.scopus.com/inward/record.url?scp=65449164284&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=65449164284&partnerID=8YFLogxK

U2 - 10.1038/ajg.2009.55

DO - 10.1038/ajg.2009.55

M3 - Article

C2 - 19293786

AN - SCOPUS:65449164284

VL - 104

SP - 942

EP - 952

JO - American Journal of Gastroenterology

JF - American Journal of Gastroenterology

SN - 0002-9270

IS - 4

ER -