Improving the effectiveness of fecal occult blood testing in a primary care clinic by direct colonoscopy referral for positive tests

Nurse's Roles in Colorectal Cancer Prevention: A Narrative Review

The objective of this paper is to investigate the different roles of nurses as members of healthcare teams at the primary, secondary, and tertiary levels of colorectal cancer prevention. The research team conducted a narrative review of studies involving the role of nurses at different levels of colorectal cancer prevention, which included a variety of quantitative, qualitative, and mixed-method studies. We searched PubMed, Scopus, Web of Science, Cochrane Reviews, Magiran, the Scientific Information Database (SID), Noormags, and the Islamic Science Citation (ISC) databases from ab initio until 2021. A total of 117 studies were reviewed. Nurses' roles were classified into three levels of prevention. At the primary level, the most important role related to educating people to prevent cancer and reduce risk factors. At the secondary level, the roles consisted of genetic counseling, stool testing, sigmoidoscopy and colonoscopy, biopsy and screening test follow-ups, and chemotherapy intervention, while at the tertiary level, their roles were made up of pre-and post-operative care to prevent further complications, rehabilitation, and palliative care. Nurses at various levels of prevention care also act as educators, coordinators, performers of screening tests, follow-up, and provision of palliative and end-of-life care. If these roles are not fulfilled at some levels of colorectal cancer, it is generally due to the lack of knowledge and competence of nurses or the lack of instruction and legal support for them. Nurses need sufficient clinical knowledge and experience to perform these roles at all levels.

Bridging the Gap: Patient Navigation Increases Colonoscopy Follow-up After Abnormal FIT

INTRODUCTION

Recent studies indicate low rates of follow-up colonoscopy after abnormal fecal immunochemical testing (FIT) within safety net health systems. A patient navigation (PN) program is an evidence-based strategy that has been shown to improve colonoscopy completion in private and public healthcare settings. The aim of this study was to evaluate the effectiveness of a PN program to encourage follow-up colonoscopy after abnormal FIT within a large safety net hospital system.

METHODS

We established an enterprisewide PN program at 5 tertiary care hospitals within the Los Angeles County Department of Health Services system in 2018. The PN assisted adult patients aged 50-75 years with an abnormal FIT to a follow-up colonoscopy within 6 months. PN activities included initiating referral for and scheduling of colonoscopy, performing reminder phone calls to patient for their upcoming colonoscopy, and following up with patients who did not attend their colonoscopy. We assess the effectiveness of the PN intervention by comparing follow-up colonoscopy rates with a period before the intervention.

RESULTS

There were 2,531 patients with abnormal FIT results (n = 1,214 in 2017 and n = 1,317 in 2018). A majority were women (55% in 2017 vs 52% in 2018) with a mean age of 60 ± 6.2 years. From a previous mean of 163 days without PN in 2017, the mean time from abnormal FIT to colonoscopy with PN improved to 113 days in 2018. The frequency of colonoscopy completion with PN increased from 40.6% (n = 493) in 2017 to 46% (n = 600) in 2018.

DISCUSSION

After the introduction of the PN program, there was a significant increase in patients undergoing follow-up colonoscopy after abnormal FIT and patients were more likely to undergo colonoscopy within the recommended 6 months.

Strategies to Improve Follow-up After Positive Fecal Immunochemical Tests in a Community-Based Setting: A Mixed-Methods Study

OBJECTIVES

The effectiveness of fecal immunochemical test (FIT) screening for colorectal cancer depends on timely colonoscopy follow-up of positive tests, although limited data exist regarding effective system-level strategies for improving follow-up rates.

METHODS

Using a mixed-methods design (qualitative and quantitative), we first identified system-level strategies that were implemented for improving timely follow-up after a positive FIT test in a large community-based setting between 2006 and 2016. We then evaluated changes in time to colonoscopy among FIT-positive patients across 3 periods during the study interval, controlling for screening participant age, sex, race/ethnicity, comorbidity, FIT date, and previous screening history.

RESULTS

Implemented strategies over the study period included setting a goal of colonoscopy follow-up within 30 days of a positive FIT, tracking FIT-positive patients, early telephone contact to directly schedule follow-up colonoscopies, assigning the responsibility for follow-up tracking and scheduling to gastroenterology departments (vs primary care), and increasing colonoscopy capacity. Among 160,051 patients who had a positive FIT between 2006 and 2016, 126,420 (79%) had a follow-up colonoscopy within 180 days, including 67% in 2006-2008, 79% in 2009-2012, and 83% in 2013-2016 (P < 0.001). Follow-up within 180 days in 2016 varied moderately across service areas, between 72% (95% CI 70-75) and 88% (95% CI 86-91), but there were no obvious differences in the pattern of strategies implemented in higher- vs lower-performing service areas.

CONCLUSIONS

The implementation of system-level strategies coincided with substantial improvements in timely colonoscopy follow-up after a positive FIT. Intervention studies are needed to identify the most effective strategies for promoting timely follow-up.

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review

BACKGROUND

Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results.

PURPOSE

To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical).

DATA SOURCES

English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017.

STUDY SELECTION

Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results.

DATA EXTRACTION

Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type.

DATA SYNTHESIS

Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points).

LIMITATION

More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis.

CONCLUSION

Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient.

PRIMARY FUNDING SOURCE

National Cancer Institute. (PROSPERO: CRD42016048286).

A centrally generated primary care physician audit report does not improve colonoscopy uptake after a positive result on a fecal occult blood test in Ontario's ColonCancerCheck program

BACKGROUND

Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. In the present study, we evaluated the effectiveness of centrally generated, physician-targeted audit and feedback to improve colonoscopy uptake after a positive fecal occult blood test (fobt) result within Ontario's population-wide ColonCancerCheck Program.

METHODS

This prospective cohort study used data sets from Ontario's ColonCancerCheck Program (2008-2011) that were linked to provincial administrative health databases. Cox proportional hazards regression was used to estimate the effect of centralized, physician-targeted audit and feedback on colonoscopy uptake in an Ontario-wide fobt-positive cohort.

RESULTS

A mailed physician audit and feedback report identifying individuals outstanding for colonoscopy for 3 or more months after a positive fobt result did not increase the likelihood of colonoscopy uptake (hazard ratio: 0.95; 95% confidence interval: 0.79 to 1.13). Duration of positive fobt status was strongly inversely associated with the hazard of follow-up colonoscopy (p for linear trend: <0.001).

CONCLUSIONS

In a large population-wide setting, centralized tracking in the form of physician-targeted mailed audit and feedback reports does not improve colonoscopy uptake for screening participants with a positive fobt result outstanding for 3 or more months. Mailed physician-targeted screening audit and feedback reports alone are unlikely to improve compliance with follow-up colonoscopy in Ontario. Other interventions such as physician audits or automatic referrals, demonstrated to be effective in other jurisdictions, might be warranted.

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

BACKGROUND

To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy.

METHODS

We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan-Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models.

RESULTS

Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P <0.001). Median days to colonoscopy ranged from 41 (95% CI, 40-41) to 174 (95% CI, 123-343); percent followed-up by 12 months ranged from 58.1% (95% CI, 51.6%-63.7%) to 83.8% (95% CI, 83.4%-84.3%) and differences across health care systems were also observed at 1, 2, 3, and 6 months. Increasing age and comorbidity score were associated with lower follow-up rates.

CONCLUSION

Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests.

IMPACT

Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up.

Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices

BACKGROUND

ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT.

METHODS

Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses.

RESULTS

There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period.

CONCLUSION

In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.

Mailed participant reminders are associated with improved colonoscopy uptake after a positive FOBT result in Ontario's ColonCancerCheck program

Background

Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. This study evaluates the effectiveness of two ongoing interventions designed to improve colonoscopy uptake after a positive fecal occult blood test (FOBT) result within Ontario’s population-wide ColonCancerCheck program. The first was a revision of mailed FOBT lab results to physicians to explicitly define a positive FOBT and to recommend colonoscopy. The second was a letter to participants informing them of the positive FOBT and urging them to seek appropriate follow-up.

Methods

Prospective cohort study using Ontario’s ColonCancerCheck program data sets (2008–2011), linked to provincial administrative health databases. Crude rate ratios were calculated to assess determinants of colonoscopy uptake among an Ontario-wide FOBT-positive cohort with rolling enrolment, followed from October 2008 through February 2011. Segmented time-series regression was used to assess the average additional change in colonoscopy uptake after FOBT-positive status following the introduction of two ongoing interventions among the same cohort.

Results

A notification mailed directly to FOBT-positive screening participants was observed to increase colonoscopy uptake, beyond the modest average underlying increase throughout the study period, by an average of 3% per month (multivariable-adjusted RR: 1.03, 95% CI: 1.00–1.06). However, revision of the existing FOBT result notification to physicians was observed to have no effect.

Conclusions

Direct participant notification of a positive FOBT result improved adherence with follow-up colonoscopy in Ontario’s population-wide ColonCancerCheck program. Further participant-directed interventions may be effective means of maximizing adherence in population-wide screening.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0226-0) contains supplementary material, which is available to authorized users.