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Doshi P, Sievers C. Understanding the Utility of Fecal Occult Blood Testing in Hospitalized Patients With Suspected GI Bleeding. Cureus 2024; 16:e57406. [PMID: 38694647 PMCID: PMC11062598 DOI: 10.7759/cureus.57406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 05/04/2024] Open
Abstract
Colorectal cancer (CRC) is one of the leading causes of cancer-related mortality worldwide. There have been increasing efforts to reduce its incidence and mortality. Screening plays a crucial role, with various tests such as the fecal occult blood test (FOBT), colonoscopy, and flexible sigmoidoscopy commonly used for investigation. FOBT is a Food and Drug Administration (FDA) approved screening tool commonly used in acute healthcare settings for early detection of CRC. We report a 50-year-old man presenting with shortness of breath, chills, and malaise with findings positive for pneumonia. Laboratory tests revealed anemia as an incidental finding. A subsequent FOBT came back positive, and the patient was admitted for further gastrointestinal testing. Esophagogastroduodenoscopy (EGD) and colonoscopy were performed, but no significant findings were observed. This case report focuses on the overuse of FOBT testing during hospital admission, despite its limited impact on patient care in acute settings. Key takeaways include being aware of the potential for false positive and false negative results from a FOBT. Using the test carefully can help reduce both direct and indirect healthcare costs for hospitalized patients, as well as minimize the use of hospital resources. The test should primarily be used for CRC screening in the outpatient setting.
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Affiliation(s)
- Priyam Doshi
- Internal Medicine, Western Reserve Hospital, Cuyahoga Falls, USA
| | - Corey Sievers
- Gastroenterology, Western Reserve Hospital, Cuyahoga Falls, USA
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2
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Toth JF, Trivedi M, Gupta S. Screening for Colorectal Cancer: The Role of Clinical Laboratories. Clin Chem 2024; 70:150-164. [PMID: 38175599 PMCID: PMC10952004 DOI: 10.1093/clinchem/hvad198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/06/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer incidence and mortality. Screening can result in reductions in incidence and mortality, but there are many challenges to uptake and follow-up. CONTENT Here, we will review the changing epidemiology of CRC, including increasing trends for early and later onset CRC; evidence to support current and emerging screening strategies, including noninvasive stool and blood-based tests; key challenges to ensuring uptake and high-quality screening; and the critical role that clinical laboratories can have in supporting health system and public health efforts to reduce the burden of CRC on the population. SUMMARY Clinical laboratories have the opportunity to play a seminal role in optimizing early detection and prevention of CRC.
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Affiliation(s)
- Joseph F Toth
- Department of Internal Medicine, University of California San Diego Health, La Jolla, CA, United States
| | - Mehul Trivedi
- Department of Internal Medicine, University of California San Diego Health, La Jolla, CA, United States
| | - Samir Gupta
- Department of Internal Medicine, University of California San Diego Health, La Jolla, CA, United States
- Department of Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
- Division of Gastroenterology and Hepatology, University of California San Diego Health, La Jolla, CA, United States
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3
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Bhatti U, Jansson-Knodell C, Saito A, Han A, Krajicek E, Han Y, Imperiale TF, Fayad N. Not FIT for Use: Fecal Immunochemical Testing in the Inpatient and Emergency Settings. Am J Med 2022; 135:76-81. [PMID: 34508698 DOI: 10.1016/j.amjmed.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Fecal immunochemical testing (FIT) is widely used for colorectal cancer screening, its only indication. Its effect on clinical decision-making beyond screening is unknown. We studied the use of FIT in emergency and inpatient settings and its impact on patient care. METHODS Using electronic medical records, we reviewed all non-ambulatory FITs performed from November 2017 to October 2019 at a tertiary care community hospital. We collected data on demographics, indications, gastroenterology consultations, and endoscopic procedures. Multivariate logistic regression was performed to determine the effect of FIT on gastroenterology consultation and endoscopy. RESULTS We identified 550 patients with at least 1 FIT test. Only 3 FITs (0.5%) were performed for colorectal cancer screening. FITs were primarily ordered from the emergency department (45.3%) or inpatient hospital floor (42.2%). Anemia (44.0%), followed by gastrointestinal bleeding (40.9%), were the most common indications. FIT was positive in 253 patients (46.0%), and gastroenterology consultation was obtained for 47.4% (n = 120), compared with 14.5% (n = 43) of the 297 FIT-negative patients (odds ratio 3.28; 95% confidence interval, 2.23-4.82, P < .0001). A potential bleeding source was identified in 80% of patients with reported or witnessed overt gastrointestinal bleeding, a similar proportion (80.7%; P = .92) to patients who were FIT positive with overt gastrointestinal bleeding. Multivariate analysis showed that melena, hematemesis, and a positive FIT were associated with gastroenterology consultation (all P < .05), while only melena (odds ratio 3.34; 95% confidence interval, 1.48-7.54) was associated with endoscopy. CONCLUSIONS Nearly all emergency department and inpatient FIT use was inappropriate. FIT resulted in more gastroenterology consultation but was not independently associated with inpatient endoscopy.
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Affiliation(s)
- Umer Bhatti
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Claire Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Andrew Han
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Edward Krajicek
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Yan Han
- Division of Biostatistics & Health Data Science, Indiana University-Purdue University, Indianapolis
| | - Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis; Division of Gastroenterology and Hepatology, Department of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Ind; Regenstrief Institute, Inc. Indianapolis, Ind
| | - Nabil Fayad
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis; Division of Gastroenterology and Hepatology, Department of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Ind.
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Aby E, Olson APJ, Lim N. Serum ammonia use: unnecessary, frequent and costly. Frontline Gastroenterol 2021; 13:275-279. [PMID: 35722602 PMCID: PMC9186040 DOI: 10.1136/flgastro-2021-101837] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/03/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE While ammonia plays a role in the complex pathophysiology of hepatic encephalopathy (HE), serum ammonia is unreliable for both diagnosis of, and correlation with, neurological symptoms in patients with cirrhosis. We aimed to quantify ordering, cost and appropriate use of serum ammonia in a major Midwestern healthcare system. DESIGN/METHOD Serum ammonia ordering in adult patients presenting to a large Midwestern health system was evaluated from 1 January 2015 to 31 December 2019. RESULTS Serum ammonia ordering was prevalent, with 20 338 tests ordered over 5 years. There were no differences in the number of inappropriate serum ammonia tests per 100 000 admissions for chronic liver disease over time (Pearson's correlation coefficient=-0.24, p=0.70). As a proportion of total ammonia tests ordered, inappropriate tests increased over time (Pearson's correlation coefficient=0.91, p=0.03). Inappropriate ordering was more common at community hospitals compared with the academic medical centre (99.3% vs 87.6%, p<0.001). CONCLUSION Despite evidence that serum ammonia levels are unreliable for the diagnosis of HE and are not associated with severity of HE in individuals with cirrhosis, ordering remains prevalent, contributing to waste and potential harm.
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Affiliation(s)
- Elizabeth Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Burton CR, Williams L, Bucknall T, Fisher D, Hall B, Harris G, Jones P, Makin M, Mcbride A, Meacock R, Parkinson J, Rycroft-Malone J, Waring J. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background
Health-care systems across the globe are facing increased pressures to balance the efficient use of resources and at the same time provide high-quality care. There is greater requirement for services to be evidence based, but practices that are of limited clinical effectiveness or cost-effectiveness still occur.
Objectives
Our objectives included completing a concept analysis of de-implementation, surfacing decision-making processes associated with de-implementing through stakeholder engagement, and generating an evidence-based realist programme theory of ‘what works’ in de-implementation.
Design
A realist synthesis was conducted using an iterative stakeholder-driven four-stage approach. Phase 1 involved scoping the literature and conducting stakeholder interviews to develop the concept analysis and an initial programme theory. In Phase 2, systematic searches of the evidence were conducted to test and develop this theory, expressed in the form of contingent relationships. These are expressed as context–mechanism–outcomes to show how particular contexts or conditions trigger mechanisms to generate outcomes. Phase 3 consisted of validation and refinement of programme theories through stakeholder interviews. The final phase (i.e. Phase 4) formulated actionable recommendations for service leaders.
Participants
In total, 31 stakeholders (i.e. user/patient representatives, clinical managers, commissioners) took part in focus groups and telephone interviews.
Data sources
Using keywords identified during the scoping work and concept analysis, searches of bibliographic databases were conducted in May 2018. The databases searched were the Cochrane Library, Campbell Collaboration, MEDLINE (via EBSCOhost), the Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), the National Institute for Health Research Journals Library and the following databases via the ProQuest platform: Applied Social Sciences Index and Abstracts, Social Services Abstracts, International Bibliography of the Social Sciences, Social Sciences Database and Sociological Abstracts. Alerts were set up for the MEDLINE database from May 2018 to December 2018. Online sources were searched for grey literature and snowballing techniques were used to identify clusters of evidence.
Results
The concept analysis showed that de-implementation is associated with five main components in context and over time: (1) what is being de-implemented, (2) the issues driving de-implementation, (3) the action characterising de-implementation, (4) the extent that de-implementation is planned or opportunistic and (5) the consequences of de-implementation. Forty-two papers were synthesised to identify six context–mechanism–outcome configurations, which focused on issues ranging from individual behaviours to organisational procedures. Current systems can perpetuate habitual decision-making practices that include low-value treatments. Electronic health records can be designed to hide or remove low-value treatments from choice options, foregrounding best evidence. Professionals can be made aware of their decision-making strategies through increasing their attention to low-value practice behaviours. Uncertainty about diagnosis or patients’ expectations for certain treatments provide opportunities for ‘watchful waiting’ as an active strategy to reduce inappropriate investigations and prescribing. The emotional component of clinician–patient relationships can limit opportunities for de-implementation, requiring professional support through multimodal educational interventions. Sufficient alignment between policy, public and professional perspectives is required for de-implementation success.
Limitations
Some specific clinical issues (e.g. de-prescribing) dominate the de-implementation evidence base, which may limit the transferability of the synthesis findings. Any realist inquiry generates findings that are essentially cumulative and should be developed through further investigation that extends the range of sources into, for example, clinical research and further empirical studies.
Conclusions
This review contributes to our understanding of how de-implementation of low-value procedures and services can be improved within health-care services, through interventions that make professional decision-making more accountable and the prominence of a whole-system approach to de-implementation. Given the whole-system context of de-implementation, a range of different dissemination strategies will be required to engage with different stakeholders, in different ways, to change practice and policy in a timely manner.
Study registration
This study is registered as PROSPERO CRD42017081030.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher R Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Lynne Williams
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Melbourne, VIC, Australia
| | - Denise Fisher
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- Library and Archives Services, Bangor University, Bangor, UK
| | - Gill Harris
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Peter Jones
- School of Health Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Matthew Makin
- North Manchester Care Organisation, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Anne Mcbride
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - John Parkinson
- School of Psychology, College of Human Sciences, Bangor University, Bangor, UK
| | | | - Justin Waring
- School of Social Policy, University of Birmingham, Birmingham, UK
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Brennan GT, Parsons AS. A Case for Abandoning Inpatient Fecal Occult Blood Testing. Cureus 2020; 12:e8807. [PMID: 32724753 PMCID: PMC7381841 DOI: 10.7759/cureus.8807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fecal occult blood testing (FOBT) is currently Food and Drug Administration (FDA) approved only for colorectal cancer (CRC) screening. There is now widespread off-label use of FOBT in the hospital setting as a diagnostic test. Here we present a brief case and a more detailed review of the literature arguing against inpatient FOBT. Inpatient use of FOBT is problematic for several reasons including failure to account for false positives or negatives, delays in appropriate consultations or endoscopy, increased costs, increase length of stays, unnecessary procedures, and test results that do not change management. Inappropriate use of FOBT can lead to both overuse and underuse of endoscopy. Many retrospective audit studies and more recently a meta-analysis have shown that FOBTs have poor test performance and are unable rule out the need for endoscopy in patients with iron deficiency anemia. For these reasons we argue that inpatient FOBT should be abandoned.
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Affiliation(s)
- Saroja Bangaru
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas
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Applying the 'COST' (Culture, Oversight, Systems Change, and Training) Framework to De-Adopt the Neutropenic Diet. Am J Med 2019; 132:42-47. [PMID: 30145223 DOI: 10.1016/j.amjmed.2018.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/03/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022]
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9
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Affiliation(s)
- Saroja Bangaru
- Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas
| | - David Tang
- Digestive and Liver Specialists of Houston, Houston, Texas
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University Texas Southwestern Medical Center, Dallas
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10
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Balancing Measures When Restricting Laboratory Testing. Am J Med 2018; 131:e429. [PMID: 30316406 DOI: 10.1016/j.amjmed.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
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11
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Selby K, Barnes GD. Learning to De-Adopt Ineffective Healthcare Practices. Am J Med 2018; 131:721-722. [PMID: 29649460 PMCID: PMC6201840 DOI: 10.1016/j.amjmed.2018.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/18/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Kevin Selby
- Kaiser Permanente Division of Research, Oakland, Calif; Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Mich.
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