Despite this outreach, 27.5% of veterans did not have a diagnostic colonoscopy following a positive FIT. This suggests that there may be inadequate education and counseling of veterans at the time of the FIT order about the subsequent series of events and need for diagnostic colonoscopy following a positive FIT. If a patient refuses to undergo a colonoscopy under any circumstances (including after a positive FIT), the utility of placing a FIT order is questionable.
There is also a need for more education of ordering HCPs on appropriate indications for FITs. We found that 35% of FIT ordered after a recent colonoscopy were done for the purpose of CRC screening, despite clear guidelines recommending against this. In addition, another 50% of FIT ordered after recent colonoscopy was done either for evaluation of GI symptoms like diarrhea and rectal bleeding or in the evaluation of anemia, both of which are inappropriate uses for FIT. Since FIT is an antibody test against globin, the protein component of hemoglobin that degrades during passage through the small bowel, it is not a useful test for the evaluation of upper GI or small bowel bleeding. A relatively recent database study in the Netherlands looking at the diagnosis of upper GI malignancies within 3 years of a positive FIT found a < 1% rate.11
In our study, albeit limited by the small number of veterans undergoing a repeat colonoscopy following a prior colonoscopy and subsequent positive FIT, there were few significant findings. Only 1 veteran had an advanced adenoma detected, and this veteran had already been recommended a repeat colonoscopy in 1 year due to an inadequate bowel preparation on the last examination.
Lastly, we found that certain HCPs (based on ordering clinic location) systematically performed improper FIT compared with other HCPs. This presumably is due to a lack of education on appropriate FIT usage and suggests opportunity for educational and/or systems interventions.
Limitations
While our study strengths include a relatively large number of veterans and detailed review of individual patient data, it has multiple limitations. As a retrospective chart review-based study, incomplete or inaccurate data are a possibility. It is possible that patients underwent repeat FIT or underwent colonoscopy outside of the VA system and never recorded into the VA records. In addition, there is likely a sampling bias in this study as only veterans who underwent at least 1 FIT in the interval were included. These patients may be different from those who choose to undergo colonoscopy for CRC screening or from those who do not undergo screening at all.
Conclusions
A large percentage of patients underwent improper FIT at a tertiary referral academic VA medical center. Additional education and systems interventions are necessary to improve both provider and patient adherence to appropriate CRC screening. For example, one measure may include providing HCPs with a list of their patients not up-to-date with CRC screening that was shown to increase patient participation in FIT screening compared with patients who received usual care in a 2017 study.12 In addition, a 2018 study showed that a digital health intervention that allows patients to self-order tests (eg, on an iPad) can increase CRC screening rates.13
Author Contributions
Adam Gluskin: Study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript. Jeffrey Dueker: Study concept and design; analysis and interpretation of data; statistical analysis; critical revision of the manuscript for important intellectual content. Asif Khalid: Study concept and design; analysis and interpretation of data; drafting of the manuscripts; critical revision of the manuscript for important intellectual content; study supervision.