Reports From the Field

Use of Fecal Immunochemical Testing in Acute Patient Care in a Safety Net Hospital System

Journal of Clinical Outcomes Management. 2021 March;28(2):82-89 | 10.12788/jcom.0042

Author(s):

Nathaniel J. Spezia-Lindner, MD

Jane R. Montealegre, PhD

Maria Daheri, RN

Shanna L. Harris, MT (ASCP)

Kenneth L. Muldrew, MD, MPH

Milena Gould Suarez, MD

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References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. 10.1CA Cancer 10.1J Clin. 2020;70(1):7-30.

2. Howlader NN, Noone AM, Krapcho M, et al. SEER cancer statistics review, 1975-2014. National Cancer Institute; 2017:1-2.

3. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974–2013. 10.1J Natl Cancer Inst. 2017;109(8):djw322.

4. Bailey CE, Hu CY, You YN, et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010. 10.25JAMA Surg. 2015;150(1):17-22.

5. Lin JS, Piper MA, Perdue LA, et al. Screening for colorectal cancer: updated evidence report and systematic review for the US Preventive Services Task Force. 10.25JAMA. 2016;315(23):2576-2594.

6. Centers for Disease Control and Prevention (CDC). Use of colorectal cancer screening tests. Behavioral Risk Factor Surveillance System. October 22, 2019. Accessed February 10, 2021. https://www.cdc.gov/cancer/colorectal/statistics/use-screening-tests-BRFSS.htm

7. Hewitson P, Glasziou PP, Irwig L, et al. Screening for colorectal cancer using the fecal occult blood test, Hemoccult. 10.25Cochrane Database Syst Rev. 2007;2007(1):CD001216.

8. Bujanda L, Lanas Á, Quintero E, et al. Effect of aspirin and antiplatelet drugs on the outcome of the fecal immunochemical test. 10.25Mayo Clin Proc. 2013;88(7):683-689.

9. Allison JE, Sakoda LC, Levin TR, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. 10.25J Natl Cancer Inst. 2007;99(19):1462-1470.

10. Dancourt V, Lejeune C, Lepage C, et al. Immunochemical faecal occult blood tests are superior to guaiac-based tests for the detection of colorectal neoplasms. 10.25Eur J Cancer. 2008;44(15):2254-2258.

11. Hol L, Wilschut JA, van Ballegooijen M, et al. Screening for colorectal cancer: random comparison of guaiac and immunochemical faecal occult blood testing at different cut-off levels. 10.25Br J Cancer. 2009;100(7):1103-1110.

12. Levi Z, Birkenfeld S, Vilkin A, et al. A higher detection rate for colorectal cancer and advanced adenomatous polyp for screening with immunochemical fecal occult blood test than guaiac fecal occult blood test, despite lower compliance rate. A prospective, controlled, feasibility study. Int J Cancer. 2011;128(10):2415-2424.

13. Friedman A, Chan A, Chin LC, et al. Use and abuse of faecal occult blood tests in an acute hospital inpatient setting. Intern Med J. 2010;40(2):107-111.

14. Narula N, Ulic D, Al-Dabbagh R, et al. Fecal occult blood testing as a diagnostic test in symptomatic patients is not useful: a retrospective chart review. Can J Gastroenterol Hepatol. 2014;28(8):421-426.

15. Ip S, Sokoro AA, Kaita L, et al. Use of fecal occult blood testing in hospitalized patients: results of an audit. Can J Gastroenterol Hepatol. 2014;28(9):489-494.

16. Mosadeghi S, Ren H, Catungal J, et al. Utilization of fecal occult blood test in the acute hospital setting and its impact on clinical management and outcomes. J Postgrad Med. 2016;62(2):91-95.

17. van Rijn AF, Stroobants AK, Deutekom M, et al. Inappropriate use of the faecal occult blood test in a university hospital in the Netherlands. Eur J Gastroenterol Hepatol. 2012;24(11):1266-1269.

18. Sharma VK, Komanduri S, Nayyar S, et al. An audit of the utility of in-patient fecal occult blood testing. Am J Gastroenterol. 2001;96(4):1256-1260.

19. Chiang TH, Lee YC, Tu CH, et al. Performance of the immunochemical fecal occult blood test in predicting lesions in the lower gastrointestinal tract. CMAJ. 2011;183(13):1474-1481.

20. Chokshi DA, Chang JE, Wilson RM. Health reform and the changing safety net in the United States. N Engl J Med. 2016;375(18):1790-1796.

21. Nguyen OK, Makam AN, Halm EA. National use of safety net clinics for primary care among adults with non-Medicaid insurance in the United States. PLoS One. 2016;11(3):e0151610.

22. United States Census Bureau. American Community Survey. Selected Economic Characteristics. 2019. Accessed February 20, 2021. https://data.census.gov/cedsci/table?q=ACSDP1Y2019.DP03%20Texas&g=0400000US48&tid=ACSDP1Y2019.DP03&hidePreview=true

23. McNutt LA, Wu C, Xue X, et al. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003;157(10):940-943.

24. Rockey DC. Occult gastrointestinal bleeding. Gastroenterol Clin North Am. 2005;34(4):699-718.

25. Macrae FA, St John DJ. Relationship between patterns of bleeding and Hemoccult sensitivity in patients with colorectal cancers or adenomas. Gastroenterology. 1982;82(5 pt 1):891-898.

26. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study. Gastroenterology. 1990;98(2):380-386.

27. Fleming JL, Ahlquist DA, McGill DB, et al. Influence of aspirin and ethanol on fecal blood levels as determined by using the HemoQuant assay. Mayo Clin Proc. 1987;62(3):159-163.

28. Gupta A, Tang Z, Agrawal D. Eliminating in-hospital fecal occult blood testing: our experience with disinvestment. Am J Med. 2018;131(7):760-763.

From Baylor College of Medicine, Houston, TX (Drs. Spezia-Lindner, Montealegre, Muldrew, and Suarez) and Harris Health System, Houston, TX (Shanna L. Harris, Maria Daheri, and Drs. Muldrew and Suarez).

Abstract

Objective: To characterize and analyze the prevalence, indications for, and outcomes of fecal immunochemical testing (FIT) in acute patient care within a safety net health care system’s emergency departments (EDs) and inpatient settings.

Design: Retrospective cohort study derived from administrative data.

Setting: A large, urban, safety net health care delivery system in Texas. The data gathered were from the health care system’s 2 primary hospitals and their associated EDs. This health care system utilizes FIT exclusively for fecal occult blood testing.

Participants: Adults ≥18 years who underwent FIT in the ED or inpatient setting between August 2016 and March 2017. Chart review abstractions were performed on a sample (n = 382) from the larger subset.

Measurements: Primary data points included total FITs performed in acute patient care during the study period, basic demographic data, FIT indications, FIT result, receipt of invasive diagnostic follow-up, and result of invasive diagnostic follow-up. Multivariable log-binomial regression was used to calculate risk ratios (RRs) to assess the association between FIT result and receipt of diagnostic follow-up. Chi-square analysis was used to compare the proportion of abnormal findings on diagnostic follow-up by FIT result.

Results: During the 8-month study period, 2718 FITs were performed in the ED and inpatient setting, comprising 5.7% of system-wide FITs. Of the 382 patients included in the chart review who underwent acute care FIT, a majority had their test performed in the ED (304, 79.6%), 133 of which were positive (34.8%). The most common indication for FIT was evidence of overt gastrointestinal (GI) bleed (207, 54.2%), followed by anemia (84, 22.0%). While a positive FIT result was significantly associated with obtaining a diagnostic exam in multivariate analysis (RR, 1.72; P < 0.001), having signs of overt GI bleeding was a stronger predictor of diagnostic follow-up (RR, 2.00; P = 0.003). Of patients who underwent FIT and received diagnostic follow-up (n = 110), 48.2% were FIT negative. These patients were just as likely to have an abnormal finding as FIT-positive patients (90.6% vs 91.2%; P = 0.86). Of the 382 patients in the study, 4 (1.0%) were subsequently diagnosed with colorectal cancer (CRC). Of those 4 patients, 1 (25%) was FIT positive.

Conclusion: FIT is being utilized in acute patient care outside of its established indication for CRC screening in asymptomatic, average-risk adults. Our study demonstrates that FIT is not useful in acute patient care.

Keywords: FOBT; FIT; fecal immunochemical testing; inpatient.