title: Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results.
abstract: OBJECTIVE
  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%, P<0.0001 and 11.4% vs. 3.4%, P=0.0005). 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.
authors.affiliation: Health Policy and Quality Program, Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA. hardeeps@bcm.tmc.edu
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
authors.forename: Himabindu
authors.initials: H
authors.lastname: Kadiyala
authors.forename: Gayathri
authors.initials: G
authors.lastname: Bhagwath
authors.forename: Anila
authors.initials: A
authors.lastname: Shethia
authors.forename: Hashem
authors.initials: H
authors.lastname: El-Serag
authors.forename: Annette
authors.initials: A
authors.lastname: Walder
authors.forename: Maria E
authors.initials: ME
authors.lastname: Velez
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
mesh_terms: D000554:Ambulatory Care Facilities; D003113:Colonoscopy / Q000592:standards*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D009780:Occult Blood; D015203:Reproducibility of Results; D012189:Retrospective Studies