title: 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-positive (FOBT(+))].
  
  
  METHODS
  We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, 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 six months using hierarchical logistic regression models.
  
  
  RESULTS
  Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six 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 six-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 six-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).
  
  
  CONCLUSIONS
  Directly notifying gastroenterology providers about FOBT(+) results, using 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.
  
  
  CONCLUSIONS
  These findings may inform organizational-level interventions to improve FOBT(+) follow-up.
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota. Melissa.partin@va.gov.
authors.forename: Melissa R
authors.initials: MR
authors.lastname: Partin
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Diana J
authors.initials: DJ
authors.lastname: Burgess
authors.affiliation: Center for Healthcare Organization and Implementation Research, Boston Veterans Affairs Health Care System, Boston, Massachusetts. Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts.
authors.forename: James F
authors.initials: JF
authors.lastname: Burgess
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.
authors.forename: Amy
authors.initials: A
authors.lastname: Gravely
authors.affiliation: VA Health Services Research and Development Center for Health Information and Communication, Roudebush VAMC, Indianapolis, Indiana. Division of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: David
authors.initials: D
authors.lastname: Haggstrom
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Lillie
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.
authors.forename: Sean
authors.initials: S
authors.lastname: Nugent
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.
authors.forename: Adam A
authors.initials: AA
authors.lastname: Powell
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Aasma
authors.initials: A
authors.lastname: Shaukat
authors.affiliation: Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California.
authors.forename: Louise C
authors.initials: LC
authors.lastname: Walter
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota. Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
authors.forename: David B
authors.initials: DB
authors.lastname: Nelson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000175:diagnosis* / Q000517:prevention & control; D003113:Colonoscopy / Q000706:statistics & numerical data*; D055088:Early Detection of Cancer / Q000379:methods*; D006787:Hospitals, Veterans; D006801:Humans; D008875:Middle Aged; D009780:Occult Blood; D014728:Veterans; D058014:Veterans Health; D055815:Young Adult