Reducing Inappropriate Fecal Immunochemistry Testing at a Veterans Affairs Healthcare System

Introduction: Colorectal cancer (CRC) is the second most deadly and the third most common cancer in the United States. Therefore, early detection of CRC is an important population health metric. Currently, the American College of Gastroenterology recommends colonoscopy or fecal immunochemistry test (FIT) as the primary CRC screening modalities for average risk patients. The US Department of Veterans Affairs (VA) also uses FIT for CRC screening. However, there have been several studies reporting inappropriate use of FIT such as FIT for indications other than CRC screening and FIT in patients who are not average risk for colorectal cancer. Thus, in this quality improvement project, we aimed to decrease the number of inappropriate FIT ordered at the Minneapolis VA Medical Center. Methods: Our outcome measure was the number of inappropriate FIT ordered per month. Inappropriate FIT was defined as FIT done within 10 years of a prior colonoscopy. Our intervention was modifying the FIT order set in the electronic medical record (EMR) to educate clinicians on the correct FIT indication and define average risk patients. Pre intervention data includes all patients with FIT test within 10 years of a prior colonoscopy from 1/12/2023 to 4/11/2023. Our intervention was implemented on 4/12/2023. Post intervention data period was from 4/13/2023 to 5/12/2023. The following data were collected: demographics, FIT indications, comorbidities, medications, distance from the hospital. Results: There were 125 patients and 30 patients in the pre- and post-intervention groups respectively. The number of inappropriate FITs per month decreased by 28% (42 to 30). The two groups were similar in demography and distance from the VA. The distribution of FIT indications was also similar with the most common indications being CRC screening and anemia (Table 1). Conclusion: In this QI project, our intervention resulted in a 28% reduction in the number of monthly inappropriate FIT even though the post intervention data was only for one month. This finding suggested that simple modifications to the FIT order set can be effective in reducing inappropriate FIT. Other potential changes for the order set include introducing a hard stop that requires clinicians to review the last colonoscopy before ordering FIT. After collecting 3 months of post intervention data, we plan to collect feedback for the next Plan-Do-Study-Act cycle. Table 1. - Pre- and Post-Intervention Patient Demographics and Number of Inappropriate FIT Pre-Intervention Post-Intervention Time Period 1/12/2023 - 4/12/2023 4/13/2023 - 5/12/2023 Number of Patients 125 30 Number of Inappropriate FIT per month 42 30 Age (average +/- SD) 62 (+/- 7) 62 (+/- 9) Smoker (n, %) 25 (2) 5 (17) Gender (n, %) Male 118 (94) 28 (93) Female 7 (6) 2 (7) Race (n, %) White 116 (93) 20 (67) Other 9 (7) 10 (33) FIT Indication (n, %) CRC Screening 107 (85) 28 (93) Anemia 13 (10) 1 (3) GI Bleed 5 (4) 1 (3) Others 0 (0) 0 (0) Comorbidities (n, %) IBD 1 (1) 0 (0) DM 38 (30) 11 (37) Anxiety 25 (20) 12 (40) Depression 38 (30) 12 (40) PTSD 13 (10) 5 (17) Medications (n, %) Aspirin 42 (34) 9 (30) Antiplatelet 4 (3) 2 (7) Anticoagulation 9 (7) 6 (20) Opioid 9 (7) 3 (10) Distance from the hospital (average +/- SD). 43 (+/- 7) 38 (+/- 6)