Gluskin Adam B, Dueker Jeffrey M, Khalid Asif
is a Gastroenterology Fellow and and are Gastroenterologists at Veterans Affairs Pittsburgh Health Care System and the University of Pittsburgh Medical Center in Pennsylvania.
Fed Pract. 2021 Jun;38(6):270-275. doi: 10.12788/fp.0142.
Colonoscopies and fecal immunochemical tests (FITs) are the preferred modalities for colorectal cancer (CRC) screening. In addition to proper patient selection, appropriate fecal immunochemical testing requires that negative tests be repeated annually, positive tests lead to a diagnostic colonoscopy, and FIT not be performed within 5 years of a colonoscopy with adequate bowel preparation. We sought to study the frequency of inappropriate FITs at the Veterans Affairs Pittsburgh Health Care System in Pennsylvania.
A retrospective quality assurance study was undertaken of veterans undergoing FIT in a 3-year period (2015-2017). We calculated the rate of a negative initial FIT in 2015/2016 followed by a second FIT in 2016/2017 in a random selection of veterans (3% SE, 95% CI). Demographics were compared in an equal random number of veterans that did and did not have a follow-up FIT (5% SE, 95% CI of all negative FIT). We also calculated the rate of completing colonoscopy following a positive FIT in a random selection of veterans (3% SE, 95% CI). Finally, we investigated use of FIT following a colonoscopy for all veterans in the study period.
A total of 6,766 FITs were performed; 4,391 unique veterans had at least 1 negative FIT, and 709 unique veterans had a positive FIT. Of 1,742 veterans with at least 1 negative FIT, 870 were eligible for repeat testing during the study period, and only 543 (62.4%) underwent at least 2 FITs. There was no significant demographic difference in veterans that had only 1 or at least 2 FITs. Of 410 veterans with a positive FIT, 113 (27.5%) did not undergo a subsequent colonoscopy within 1 year due to patient refusal, or failure to schedule or keep a colonoscopy appointment. Of 832 veterans who had both a FIT and colonoscopy in the interval, 108 veterans underwent colonoscopy with a subsequent FIT (1.6% of total FITs performed). Of these, 95 (88%) were judged to be inappropriate. Thirteen instances of FIT following colonoscopy were appropriate based on patient preference to undergo fecal immunochemical testing for CRC screening modality after undergoing colonoscopy with an inadequate bowel preparation.
Veterans underwent inappropriate testing due to failure to undergo serial FIT after a negative result (37.6%), failure to complete colonoscopy following a positive FIT (27.5%), and undergoing inappropriate FIT following a recent colonoscopy (88%). Efforts are still required to improve both patient and provider education and adherence to appropriate fecal immunochemical testing and CRC screening guidelines.
结肠镜检查和粪便免疫化学检测（FIT）是结直肠癌（CRC）筛查的首选方式。除了正确选择患者外，适当的粪便免疫化学检测要求阴性检测结果需每年重复进行，阳性检测结果需进行诊断性结肠镜检查，且在进行了充分肠道准备的结肠镜检查后5年内不得进行FIT。我们试图研究宾夕法尼亚州匹兹堡退伍军人事务医疗系统中不适当FIT检测的频率。
对在3年期间（2015 - 2017年）接受FIT检测的退伍军人进行回顾性质量保证研究。我们计算了2015/2016年首次FIT检测为阴性，随后在2016/2017年进行第二次FIT检测的退伍军人的比例（3%标准误，95%置信区间）。对随机选择的有和没有进行后续FIT检测的相同数量退伍军人的人口统计学特征进行了比较（所有阴性FIT检测的5%标准误，95%置信区间）。我们还计算了随机选择的退伍军人中FIT检测呈阳性后完成结肠镜检查的比例（3%标准误，95%置信区间）。最后，我们调查了研究期间所有退伍军人在结肠镜检查后FIT检测的使用情况。
共进行了6766次FIT检测；4391名不同的退伍军人至少有1次FIT检测结果为阴性，709名不同的退伍军人FIT检测结果为阳性。在1742名至少有1次FIT检测结果为阴性的退伍军人中，870名在研究期间符合重复检测条件，但只有543名（62.4%）进行了至少2次FIT检测。仅进行1次或至少进行2次FIT检测的退伍军人在人口统计学特征上没有显著差异。在410名FIT检测结果为阳性的退伍军人中，113名（27.5%）由于患者拒绝、未能安排或未遵守结肠镜检查预约，在1年内未进行后续结肠镜检查。在该时间段内同时进行了FIT检测和结肠镜检查的832名退伍军人中，108名退伍军人在结肠镜检查后进行了FIT检测（占总FIT检测次数的1.6%）。其中，95名（88%）被判定为不适当。基于患者在结肠镜检查肠道准备不充分后更倾向于采用粪便免疫化学检测作为CRC筛查方式，有13例结肠镜检查后的FIT检测是适当的。
退伍军人由于FIT检测结果为阴性后未进行系列检测（37.6%）、FIT检测结果为阳性后未完成结肠镜检查（27.5%）以及近期结肠镜检查后进行了不适当的FIT检测（88%）而接受了不适当的检测。仍需努力提高患者和医疗服务提供者的教育水平，并使其遵守适当的粪便免疫化学检测和CRC筛查指南。
