Patient navigators, clinician reminders may improve follow-up after positive fecal blood test

Patient navigators and clinician reminders may improve follow-up colonoscopy rates after a positive fecal blood test in asymptomatic adults, according to a systematic review, and there may be promising systemic interventions as well.

Researchers reviewed studies (7 randomized and 16 nonrandomized) to identify interventions for improving rates of follow-up colonoscopy after positive fecal test results. The study was published Oct. 17 by Annals of Internal Medicine.

Eleven studies described patient-level interventions (e.g., changes to the screening invitation strategy, provision of results or follow-up appointments, and patient navigators), five studies described clinician-level interventions (e.g., reminders or performance data), and seven studies described system-level interventions (e.g., automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). While most of the research was low-quality, especially for system-level interventions, researchers found moderate evidence to support patient- and clinician-level interventions. Six studies either had no control group or reported only coefficients of change in colonoscopy completion rates. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy versus a control population; absolute differences ranged from −7.4 percentage points (95% CI, −19 to 4.3 percentage points) to 25 percentage points (95% CI, 14 to 35 percentage points).

The evidence suggests that the use of patient navigators can increase rates of follow-up colonoscopy, the authors wrote, but cost may be a limiting factor. Patient navigation for the follow-up of abnormal results on cancer screening tests costs an additional $275 per patient (95% CI, $260 to $290 per patient).

The authors noted that two promising, low-cost interventions for integrated systems include implementing clinician reminder systems in the EHR and directly notifying endoscopists of positive fecal test results. “Nearly all patients with positive results will require colonoscopy, and comprehensive EHRs can allow automatic transfer of patient information,” they wrote. “However, direct notification requires accountability and patient-tracking capabilities by gastroenterology offices.”

The authors wrote that novel strategies could include increasing colonoscopy capacity in health systems by gastroenterologists, surgeons, or nonphysician staff; developing incentives for gastroenterology practices to encourage patient tracking and high completion rates; better engaging patients with access to their own medical records and low-cost reminder systems; and stratifying patient populations to target more intensive interventions to appropriate patients.

“Although the relatively small number of positive test results at any 1 clinic may limit research, making trials difficult outside of large integrated health systems like the VA, the widespread use of EHRs should allow better measurement of the effect of future interventions,” they wrote.