FOBT for colorectal cancer detection
In this Audit 
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:
- Identify all patients who have had a FOBT in the previous 12 months
- 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 credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.