Organizational Predictors of Colonoscopy Follow-up for Positive Fecal Occult Blood Test Results: An Observational Study

Abstract

Background This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive Fecal Occult Blood Tests (FOBT+). Methods We identified 74,104 patients with FOBT+ results from 98 Veterans Health Administration (VHA) facilities between 8/16/09-3/20/11 and followed them until 9/30/11 for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by Primary Care and Gastroenterology Chiefs. We estimated predictors of colonoscopy completion within 60 days and 6 months using hierarchical logistic regression models. Results 30% of patients with FOBT+ results received colonoscopy within 60 days and 49% within 6 months. Having Gastroenterology or Laboratory staff notify Gastroenterology providers directly about FOBT+ cases was a significant predictor of 60-day (odds ratio (OR)=1.85, p=0.01) and 6-month follow-up (OR 1.25, p=0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR 1.43, p=0.01) and frequent individual feedback to Primary Care providers about FOBT+ referral timeliness (OR 1.79, p=0.04). Additional predictors of 6-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR 1.57, p=0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR 1.48, p=0.0001). Conclusion Directly notifying Gastroenterology providers about FOBT+ results, employing guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60-days may require increased colonoscopy capacity and feedback to Primary Care providers. Impact These findings may inform organizational-level interventions to improve FOBT+ follow-up.

Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems

“…The system with the longest follow-up time was a county-wide public, safety net health system with limited colonoscopy capacity whose patients may face greater personal and system-level barriers to successfully completing follow-up colonoscopy. Like other studies (23), we observed some variation in follow-up time across clinics within healthcare systems, which may reflect differences in patient populations or local practices.…”

“…A VA study of 98 facilities found that 60-day colonoscopy follow-up rates were associated with direct notification of gastroenterology providers by gastroenterology staff and with colonoscopy appointment availability not being identified as a barrier (23). Follow-up rates were also related to the how instructions for bowel preparation were delivered.…”

“…The percentages of patients followed-up by two months (range across healthcare systems:17–62%) and six months (range across healthcare systems: 50–81%) in our study were similar to but slightly higher than those from Partin et al’s study of VA hospitals during a similar time period. Partin et al reported that 30% of positive fecal blood tests were followed up by 60 days (range across facilities: 10–57%) and 49% by six months (range across facilities: 30–70%) (23). VA studies from earlier time periods reported lower 60-day (24.5%, interquartile range: 13.8% to 40.7%) (31) and one year follow-up rates (around 40%) (9, 14) compared to our study.…”

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests

“…Nearly all test-positive patients will require colonoscopy, and comprehensive EHRs can allow the automatic transfer of patient information. A recent study found an association between VA clinics using direct gastroenterology notification and higher rates of colonoscopy completion at 6 months (odds ratio, 1.25 [CI, 1.06 to 1.47]) (60). However, direct notification requires accountability and patient-tracking capabilities by gastroenterology offices (61).…”

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial (Preprint)

“…Barriers to follow-up after a positive FOBT have been identified in the literature [17][18][19][20][21][22] and are divided into four general groups based on whether they are related to patients, physicians, providers, or information technology [23][24][25]. Intervention programs have been developed to target each of these groups [26].…”