Preoperative Testing for Fecal Occult Blood: A Questionable Practice

The benefit of fecal occult blood testing (FOBT) in patients without gastrointestinal symptoms who are hospitalized for an elective surgical procedure is uncertain. To resolve this issue, we analyzed the costs and benefits of preoperative FOBT by the model of a decision tree. In 2- and 3-way sensitivity analyses, the costs of diagnostic and therapeutic procedures and the probabilities of their various outcomes are varied simultaneously so that we might study their joint influence on the outcome of the decision analysis. The decision analysis shows that preoperative FOBT is associated with a smaller benefit than would be its omission. The higher cost and lower net benefit of preoperative FOBT reflect the impact of false-positive tests for occult blood. False-positive FOBT leads to expenditures for negative gastrointestinal work-ups, increased procedural costs, and a diminished rate of success for the elective surgical procedure, by delaying it. This outcome of the analysis is insensitive to large variations in the costs and probabilities built into the model. We conclude that screening for fecal occult blood provides no benefit if done routinely in patients who are hospitalized for any major surgical procedure.     

Colorectal Cancer Testing in the National Veterans Health Administration

Background  

Colorectal cancer (CRC) screening is a priority for the Veteran’s Health Administration (VHA). Optimizing fecal occult blood testing (FOBT) is integral to CRC screening in health care systems.     

Colocare Self-Test versus Hemoccult II Sensa for Fecal Occult Blood Testing

Objective: To compare the efficacy of ColoCARE Self-Test pads against Hemoccult II SENSA, a traditional guaiac-based card test, in the screening for colorectal neopiasia.
Methods: Prospective crossover analysis of 102 high-risk patients for screening of colorectal neoplasia with fecal occult blood testing, using ColoCARE Self-Test pads and Hemoccult II SENSA cards.
Results: Sixty-eight of the 102 patients (67%) had colorectal lesions diagnosed at colonoscopy. Of this group, 55 patients (81%) had either a polyp or cancer diagnosed at colonoscopy, with 13 of these 55 patients having polyps ≥ 1 cm. ColoCARE detected 21% of all lesions, compared with 72% for Hemoccult II SENSA. ColoCARE detected only 16% of cases involving either a cancer or a polyp, and 24% of cases involving either a cancer or polyp ≥ 1 cm in size. This compares with 75% and 95%, respectively, for Hemoccult II SENSA. Significantly more patients preferred ColoCARE (84%) to Hemoccult II SENSA (5%) ( p < 0.00001), and patients found it easier to use ColoCARE ( p < 0.01). However, 33% of patients did not feel comfortable interpreting the ColoCARE results, and 29% found it difficult to interpret the color change.
Conclusion: These results indicate that patients may prefer the simplicity and convenience of ColoCARE; however, the test is not sensitive for the detection of colorectal neoplasia. Furthermore, patients do not feel comfortable interpreting ColoCARE results and prefer to have fecal occult blood testing interpreted by medical personnel.     

Improving Fecal Occult Blood Testing Compliance Using a Mailed Educational Reminder

BACKGROUND  

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low.     

Immunological Determination of Fecal Hemoglobin and Transferrin Levels: A Comparison with Other Fecal Occult Blood Tests

Immunological determination of fecal hemoglobin and transferrin levels was performed in inpatients on an unrestricted diet, including patients with colon cancer or polyps and a control group. When hemoglobin levels of 5.1 micrograms/g feces and transferrin levels of 0.4 microgram/g feces were designated as positive, 48 of the 60 fecal specimens from colon cancer patients were positive. This result was significantly superior to that for another fecal occult blood immunological test (FECA-EIA) (p less than 0.005), and similar to the results of two chemical tests (guaiac and Hemoccult). Twenty-eight of the 78 fecal specimens from patients with colonic polyps were positive, again a result superior to the FECA-EIA (p less than 0.005) and similar to the chemical tests. Three of the 99 control fecal specimens were positive, which was a similar result to that obtained with the FECA-EIA and significantly superior to the chemical tests (both p less than 0.005). Thus, combined detection of fecal hemoglobin and transferrin levels can be used as a fecal occult blood test in patients without dietary restriction.     

Novel Approach to Fecal Occult Blood Testing by Assay of Erythrocyte-Specific microRNA Markers

Digestive Diseases and Sciences - Fecal occult blood testing (FOBT) has historically relied on methods to detect hemoglobin with no fundamental innovations in decades. To examine microRNA (miRNA)...     

Effect of Verification Bias on the Sensitivity of Fecal Occult Blood Testing: a Meta-Analysis

OBJECTIVES  

There is controversy regarding the sensitivity of fecal occult blood tests (FOBT) for detecting colorectal cancer. Many of the published studies failed to correct for verification bias which may have increased the sensitivity.     

A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration

Background  Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing. Objective  To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing. Design  Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program. Patients  Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection Measurements  Pre- to post-changes in the rates of HIV testing at the intervention and control facilities Results  At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities. Conclusions  Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention’s goal of having every American know their HIV status as a matter of routine clinical practice.     

Challenges in the Management of Positive Fecal Occult Blood Tests

BACKGROUND  Many patients with a positive fecal occult blood test (FOBT) do not undergo follow-up evaluations. OBJECTIVE  To identify the rate of follow-up colonoscopy following a positive FOBT and determine underlying reasons for lack of follow-up. DESIGN  It is a retrospective chart review. PARTICIPANTS  The subject group consisted of 1,041 adults with positive FOBTs within a large physician group practice from 2004 to 2006. MEASUREMENTS  We collected data on reasons for ordering FOBT, presence of prior colonoscopy, completed evaluations, and results of follow-up tests. We fit a multivariable logistic regression model to identify predictors of undergoing follow-up colonoscopy. RESULTS  Most positive FOBTs were ordered for routine colorectal cancer screening (76%), or evaluation of anemia (13%) or rectal bleeding (7%). Colonoscopy was completed in 62% of cases, with one-third of these procedures identifying a colorectal adenoma (29%) or cancer (4%). Factors associated with higher rates of follow-up colonoscopy included obtaining the FOBT for routine colorectal screening (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.11–2.29) and consultation with gastroenterology (OR 1.99, 95% CI 1.46–2.72). Patients were less likely to undergo colonoscopy if they were older than 80 years old (OR 0.54, 95% CI 0.31–0.92), younger than 50 years old (OR 0.44, 95% CI 0.28–0.70), uninsured (OR 0.50, 95% CI 0.27–0.93), or had undergone colonoscopy within the prior five years (OR 0.32, 95% CI 0.23–0.44). CONCLUSIONS  Clinical decisions and patient factors available at the time of ordering an FOBT impact performance of colonoscopy. Targeting physicians’ understanding of the use of this test may improve follow-up and reduce inappropriate use of this test. This project was supported by a grant from the Harvard Risk Management Foundation and has not been previously published or presented in any form.     

Intensive care services in the Veterans Health Administration

OBJECTIVE: We describe the national organization and distribution of intensive care services within the Veterans Health Administration (VHA), the largest single integrated health-care system in the United States. DATA SOURCES: Data come primarily from the 2004 Survey of Intensive Care Units in VHA, an electronically distributed survey of all ICUs in the VHA. Medical directors and nurse managers from all 213 ICUs in the VHA responded to the survey. In addition, we extracted data on the number of ICU admissions and unique veterans served from national VHA databases. RESULTS: The VHA has a geographically dispersed, multilevel system of care with variation in geographic access for eligible veterans (varying from 3.1 to 3.5 ICU beds per 1,000 patient discharges) and variation in service provision (from 10 to 19 level 1 ICUs across four regions). Level 1 ICUs are the highest tertiary-level ICUs, with the full range of subspecialty care. The proportion of beds associated with VHA-developed ICU levels of care ranges from 55% level 1 beds in the Northeast to 73% in the South, while level 4 beds represent 4% of all ICU beds in the South and 10% in the Midwest. CONCLUSIONS: Overall, the VHA system has a fair amount of regional variation, but level 1 ICUs are available in all geographic regions, and there are regional clusters of all levels. Adopting a four-level system for rating ICUs may assist in monitoring and assessing the quality of care provided in the smallest, most rural facilities.     

Infertility Services for Veterans Enrolled in Veterans Health Administration Care

BackgroundInfertility care is provided to Veterans through the Veterans Health Administration (VHA) medical benefits package and includes infertility evaluation and many infertility treatments.ObjectiveOur objective was to examine the incidence and prevalence of infertility diagnoses and the receipt of infertility healthcare among Veterans using Veterans Health Administration (VHA) healthcare from 2018 to 2020.MethodsVeterans using the VHA and diagnosed with infertility during October 2017–September 2020 (FY18–20) were identified in VHA administrative data and through VA-purchased care (i.e., community care) claims. Infertility was categorized among men as azoospermia, oligospermia, and other and unspecified male infertility, and among women as anovulation, infertility of tubal origin, infertility of uterine origin, and other and unspecified female infertility using diagnosis and procedure codes (ICD-10, CPT).Key ResultsA total of 17,216 Veterans had at least one VHA infertility diagnosis in FY18, FY19, or FY20, including 8766 male Veterans and 8450 female Veterans. Incident diagnoses of infertility were observed in 7192 male Veterans (10.8/10,000 person (p)-years) and 5563 female Veterans (93.6/10,000 p-years). A large proportion of Veterans who were diagnosed with infertility received an infertility-related procedure in the year of their incident diagnosis (males: 74.7, 75.3, 65.0%, FY18–20 respectively; females: 80.9, 80.8, 72.9%, FY18–20 respectively).ConclusionsIn comparison to a recent study of active duty servicemembers, we found a lower rate of infertility among Veteran men and a higher rate among Veteran women. Further work is needed to investigate military exposures and circumstances that may lead to infertility. Given the rates of infertility among Veterans and active duty servicemembers, enhancing communications between Department of Defense and VHA systems regarding sources of and treatment for infertility is essential to help more men and women benefit from infertility care during military service or as Veterans.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-023-08080-z.     

Utilization of drug-eluting stents in the Veterans Health Administration

Little is known about how drug-eluting stents (DESs) are used and perform in everyday clinical practice. This report identifies factors associated with the use of DESs in the Veterans Health Administration and compares mortality and the need for coronary artery bypass graft surgery in patients who received DESs or bare metal stents. There was rapid adoption of DESs from the end of 2002 to September 2004, when 52% of percutaneous coronary interventions used DESs. Ten-day death rates in DES and bare metal stent groups were similar (0.8% vs 1.1%), as were 10-day bypass surgery rates (0.2% vs 0.4%). In summary, in a large health care system, DESs were used widely with low rates of death and bypass surgery.     

Obesity Diagnosis and Care Practices in the Veterans Health Administration

BACKGROUND  

In response to dramatic increases in obesity prevalence, clinical guidelines urge health care providers to prevent and treat obesity more aggressively.