UCLA/VA study: Many patients not receiving follow-up tests after positive screening for colon cancerA UCLA/Veteran's Affairs study showed that more than 40 percent of patients who initially had received a positive result on a fecal occult blood test (FOBT) -- an initial screening tool for colon cancer -- did not receive appropriate diagnostic follow-up tests such as a colonoscopy or barium enema in 2002. According to the authors, the study may even underestimate this problem in the United States, since previous studies have shown the VA's level of preventive care and follow-up traditionally has been higher than at most other health care settings.
Published in May in the journal Diseases of the Colon & Rectum, the UCLA/VA study is one of the largest reviews of colorectal screening and follow-up patient data to date. The study used data from the VA, the nation's largest integrated health care system. The study was performed as a prelude to a national VA effort, now underway, to improve colorectal cancer screening and suggested the need for better medical follow-through for patients with potential colon cancer.
Study authors took advantage of the VA's ongoing quality improvement program to analyze 39,870 patient records. Overall, 61 percent of eligible VA patients had been screened for colorectal cancer, a rate significantly higher than the national average. Of the screened population, 313 patients had an abnormal FOBT result. Only 59 percent, or 185 patients, of this group received follow-up diagnostic tests such as a colonoscopy or a barium enema. Forty-one percent, or 128 patients, received no follow-up at all in the six months following the FOBT.
"As a nation, we are getting better in providing colorectal cancer screening, but we need to do a much better job in following-up with diagnostic tests for those patients who have abnormal screening results," said Dr. David A. Etzioni, principal investigator and a Robert Wood Johnson Clinical Scholar in the Division of General Surgery at the David Geffen School of Medicine at UCLA.
The authors believe that the study has implications for how health care systems monitor their own quality. "Any healthcare system that provides cancer screening programs needs to track each step in the screening process," Etzioni said. "Many patients were not offered any kind of total colon examination after having a positive screening for colon cancer. Traditionally, quality-of-care assessments just look at initial screening rates for colon cancer, but this study reveals that efforts should focus on the entire diagnostic process to help ensure that patients don't slip through cracks in the system."
In the study, researchers identified several possible factors why patients didn't receive follow-up tests. Fifteen percent of the patients who did not receive follow-up did not have a primary care visit in the six months after the positive FOBT screening. The remaining patients in this group saw a primary care physician but were not referred for a follow-up colonoscopy. For those who did receive follow-up tests, there was a long period between having a positive FOBT to receiving a colonoscopy (250 days) or barium enema (120 days).
"These findings have helped the VA identify key issues to spur more timely follow-up testing, and other systems around the country might do the same" Etzioni said.
Potential solutions include educating patients to advocate for screening and follow-up, and putting electronic systems in place to track follow-up.
The study was funded by the Robert Wood Johnson Foundation Clinical Scholars Program; the Department of Veterans Affairs, Health Services Research and Development; and the National Cancer Institute Colorectal Cancer Quality Enhancement Research Initiative, Service Directed Project.
Other study authors include: Elizabeth M. Yano, Dr. Lisa V. Rubenstein, Martin L. Lee, Dr. Clifford Y. Ko, Robert H. Brook, Patricia H. Parkerton and Dr. Steven M. Asch, all from UCLA.
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