Overutilization of Fecal Occult Blood Test in the Acute Hospital Setting and its Impact on Clinical Management and Outcomes

Abstract

Fecal occult blood test (FOBT) was traditionally used as a non-invasive screening tool for colorectal cancer (CRC) screening, however it is increasingly used in the inpatient setting despite the controversy for indications other than CRC screening. Moreover, FOBT has a high false positive rate which may lead to an increased in unnecessary investigations and health care cost. In phase I of this 2 phase study, we aim to identify and evaluate practice trends in utilizing FOBT in the inpatient setting and its impact on clinical management and patient outcomes. METHODS: We performed a retrospective chart review of patients admitted to an urban-community teaching hospital who underwent FOBT from January 1, 2019 to June 31, 2019. Patient demographics, admission details, indications for FOBT, and the impact of FOBT results on endoscopic procedures performed and clinical outcomes were assessed. Statistical analysis was performed using SPSS version 25 (IBM, USA). RESULTS: A total of 752 patients were identified, out of which 455 (60.5%) had a resulted FOBT. The mean and median ages were 65 and 66 respectively. African Americans represented 81.7% of the study population (p¼0.0001). Female representation (53.6%) was slightly higher than males (p¼0.02). Medical specialties requested significantly more FOBT (85.1%) compared to surgical specialties (p¼0.0001). The most common indication for FOBT was anemia (53.4%) followed by GI bleeding (GIB) (32%). FOBT was positive in a total of 107 cases (23.5%). The likelihood of a positive FOBT in patients with GIB (60/146) was higher than those admitted for anemia (41/243) (p¼0.0001). FOBT was negative in 83% of patients undergoing testing for anemia. Among patients with a positive FOBT, 34 underwent endoscopic evaluation (7.5%). Patients with positive FOBT presenting with GIB were more likely to undergo inpatient endoscopic evaluation than those presenting with anemia and positive FOBT (p¼0.0036). The most common endoscopic findings were gastric ulcer/gastritis, both representing 55.9% of cases. The overall odds ratio of having endoscopic evaluation for positive FOBT was 6.02 (CI 3.39 -10.7, P<0.05). There was no significant difference in positive endoscopic findings explaining the indication of the endoscopic procedure between patients who underwent endoscopy with a positive or negative FOBT (p¼0.2). There were no statistically significant effect of using Aspirin/NSAIDs, Iron supplement or anticoagulation or vitamin C on the results of FOBT. CONCLUSION: Inappropriate and overutilization of FOBT in the inpatient setting is common, and its use is associated with increased cost but no change in clinical management or patient outcomes. We propose limiting inpatient use of FOBT in the setting of acute illness. Phase II of our study will be aimed towards education of providers regarding the indications of FOBT use, and a 6