Navigators, Reminders May Improve Follow-Up After Positive Fecal Blood Test

Follow-up intervention by patient navigators or provider reminders may help to improve the number of patients who undergo colonoscopy after positive fecal blood test results, according to the results of a review published in Annals of Internal Medicine.

“Timely diagnostic colonoscopy after a positive fecal test result is a critical step on the colorectal cancer screening continuum,” wrote Kevin Selby, MD, of Kaiser Permanente Division of Research in Oakland, California, and colleagues. “Although research has primarily focused on screening completion, fecal testing will not be effective if positive results are not followed.”

With this review, Selby and colleagues evaluated interventions that could improve follow-up rates after positive fecal blood tests. They reviewed 23 studies that reported data from an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. The studies included seven randomized and 16 nonrandomized studies.

Much of the research was of low-quality, the researchers noted, particularly with regard to system-level interventions, such as automated referral, patient registries, and quality improvement efforts. However, the study did reveal moderate evidence that supported the implementation of patient- and provider-level interventions.

The evidence suggested that the use of patient navigators, or individuals who work with patients to counsel and guide them through the barriers associated with cancer care, can increase rates of follow-up colonoscopy. The review included five studies of patient navigation interventions. One study compared usual care with or without the addition of a registered nurse patients navigator. Use of a navigator to help with logistic barriers and to conduct motivational interview resulted in a non-significant but clinically relevant increase in the number of patients completing colonoscopies.

“Patient navigators can provide one-on-one education and individualized reduction of structural barriers,” the researchers wrote. “Cost may be a limiting factor, however: An economic evaluation concluded that patient navigation for the follow-up of abnormal results on cancer screening tests costs an additional $275 per patient (CI, $260 to $290).”

Provider-level interventions that utilize electronic reminders to alert physicians of patients who have not taken adequate action after a positive test result were shown to improve colonoscopy completion from 9 to 25 percentage points.

Based on these results, the researchers concluded that “more research is needed given the critical role of the diagnostic resolution of positive test results in fecal blood-based screening.”