FOBT for colorectal cancer detection

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Background

Each year approximately 1200 people in New Zealand die of colorectal cancer, a mortality rate similar to breast and prostate cancers combined.1 Faecal occult blood testing (FOBT) detects the presence of haemoglobin in faeces, which may indicate colorectal adenomas or cancers. Therefore the primary use of FOBT is in screening for colorectal cancer. New Zealand does not currently have a national screening programme for colorectal cancer, but the use of FOBT for screening is currently being studied in a pilot programme in Waitamata DHB.

Routine use of FOBT is not recommended, until such a time that a screening programme is established. The decision to request FOBT may be considered on a case-by-case basis, in people aged over 50 years, whose risk does not indicate referral for colonoscopy.

New Zealand colorectal cancer surveillance guidelines recommend that people at increased risk of colorectal cancer, should be monitored using colonoscopy.2

This includes people who have:

  • A family history of colorectal cancer or an inherited colorectal syndrome
  • A history of colorectal polyps
  • Inflammatory bowel disease

People with bowel symptoms suggestive of colorectal cancer, such as blood mixed with the stool, persistent change in bowel habit, abdominal pain or bloating and weight loss, should have an abdominal and rectal examination to rule out benign causes, followed by referral to a gastroenterologist if the symptoms are unexplained. FOBT is of little value, as a negative result does not exclude colorectal cancer.

FOBT is not recommended as a surveillance tool for people with a previous history of colorectal cancer.

The purpose of this audit is for General Practitioners to review their use of FOBT, and assess whether it has been requested appropriately.

Recommendations

FOBT is not currently recommended as a population screening tool for colorectal cancer and the test’s use in primary care is limited by several factors.

FOBT should not be used to assess the presence of colorectal cancer in patients:

  • Aged less than 50 years (the false-positive rate in younger people is increased)
  • With a prior history of colorectal cancer (surveillance colonoscopy is indicated)
  • Who have symptoms of colorectal cancer (unexplained symptoms would indicate referral to a gastroenterologist for further investigation for colorectal cancer)
  • Who are in a moderate or high risk group for colorectal cancer (colorectal cancer guidelines recommend referral for surveillance colonoscopy)

A moderate or high risk group is defined as anyone who has a family history of inherited colorectal cancer, who has had a first-degree relative diagnosed under age 55 years, or more than one second-degree relative, diagnosed with colorectal cancer or has any relative who has been diagnosed with colorectal cancer and also had multiple bowel polyps. In addition, this group also includes anyone with a personal history of colorectal polyps or inflammatory bowel disease.

For further information on risk-groups for colorectal cancer see: “Surveillance of people at increased risk of colorectal cancer”, BPJ 44 (May, 2012).

For further information on the appropriate use of FOBT see: “Appropriate use of the faecal occult blood test for colorectal cancer”, Best Tests (June, 2012).

Audit plan

The recommended steps for completing the audit and for best practice are:

  1. Identify all patients who have had a FOBT in the previous 12 months
  2. Determine whether the use of FOBT was appropriate

Criteria for a positive result

Any patient who has had a FOBT requested in the previous 12 months should have the following recorded in their notes:

  • They are aged over 50 years
  • They are asymptomatic for colorectal cancer
  • There is no prior history of colorectal cancer
  • They do not have any factors which would infer a moderate or high risk of colorectal cancer

Audit standards

Ideally all patients who have received a FOBT within the previous 12 months will have met the above criteria; however, an acceptable standard for this audit is that 90% of patients will meet the above criteria.

Data

Eligible people

An eligible person is anyone who has had a FOBT requested for them in the previous 12 months.

Identifying patients

You will need to have a system for identifying patients who have had a FOBT.

Many practices will be able to identify patients by running a ‘query’ through their patient management system (PMS) for people who have had a FOBT requested and the result recorded.

If searching medicines via the PMS is problematic, examining consultation notes should help in identifying patients, however, more patients are likely to be missed with this method due to differing consultation notation practices.

Sample size

The number of eligible patients will vary according to your practice demographic. If you identify a large number of patients, take a random sample of 20 patients whose notes you will audit.

Data analysis

Use the data sheet to record your data and calculate percentages.

Identifying opportunities

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Decide on a set of priorities for change and develop an action plan to implement any changes.

It may be useful to consider the following points when developing a plan for action.

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan develop previously against the timeline at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet.

Undertaking a second cycle

In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practitioners complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).