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Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment

  • Arjun Gupta
    Affiliations
    Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas

    Parkland Hospital, Dallas, Tex
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  • Zhouwen Tang
    Affiliations
    Parkland Hospital, Dallas, Tex

    Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas

    Digestive & Liver Specialists of Houston, Tex
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  • Deepak Agrawal
    Correspondence
    Requests for reprints should be addressed to Deepak Agrawal, MD, University of Texas Southwestern Medical Center, Division of Gastroenterology, 5323 Harry Hines Boulevard, Dallas, TX 75390-8852.
    Affiliations
    Department of Internal Medicine, University Texas Southwestern Medical Center, Dallas

    Parkland Hospital, Dallas, Tex

    Division of Gastroenterology, University Texas Southwestern Medical Center, Dallas
    Search for articles by this author
      The fecal occult blood test has an unimpeachable role in population-wide colorectal cancer screening. More than 5 decades ago, soon after commercial availability of the test, its use was extended for workup of altered stool color (example, melena) or anemia. Although this practice was debatable even then, current imaging and endoscopic tools have revolutionized our approach, rendering the fecal occult blood test irrelevant to modern hospital practice.
      • Levin B.
      • Lieberman D.A.
      • McFarland B.
      • et al.
      Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.
      • US Preventive Services Task Force
      Final Recommendations Statement Colorectal Cancer: Screening.
      • Mathews B.
      • Ratcliffe T.
      • Sehgal R.
      • Abraham J.
      • Monash B.
      Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding.
      Yet the routine use of fecal occult blood tests in hospitalized patients has persisted, sometimes reflexively with rectal examinations. Fecal occult blood tests are of 2 types: guaiac-based tests measuring heme, and immunochemical tests measuring globin.
      • Mathews B.
      • Ratcliffe T.
      • Sehgal R.
      • Abraham J.
      • Monash B.
      Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding.
      They are used to detect the microscopic presence of hemoglobin in stool but are plagued by poor accuracy. False-positive results can occur with nongastrointestinal bleeding sources (epistaxis, swallowed hemoptysis), mucosal inflammation without bleeding (inflammatory bowel disease), certain foods (vegetables containing peroxidase, and meats), toxins (such as alcohol), or clinically insignificant bleeding caused by anti-inflammatory drugs.
      • Mathews B.
      • Ratcliffe T.
      • Sehgal R.
      • Abraham J.
      • Monash B.
      Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding.
      False-negative results, such as those caused by slow or intermittent bleeding, ingestion of antioxidants such as vitamin C, or upper gastrointestinal bleeding in which globin is denatured, preclude their ability to convincingly rule out important pathology.
      • Mathews B.
      • Ratcliffe T.
      • Sehgal R.
      • Abraham J.
      • Monash B.
      Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding.
      Multiple samples need to be sent for increased sensitivity, and visual misinterpretation of results can occur.
      • Mathews B.
      • Ratcliffe T.
      • Sehgal R.
      • Abraham J.
      • Monash B.
      Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding.
      Inappropriate testing and interpretation not only leads to increased costs of testing but can lead to patient harm through incorrect downstream management decisions and unnecessary interventions. Studies have questioned the utility of having fecal occult blood tests available as an orderable test in the inpatient setting.
      • Sharma V.K.
      • Komanduri S.
      • Nayyar S.
      • et al.
      An audit of the utility of in-patient fecal occult blood testing.
      • Friedman A.
      • Chan A.
      • Chin L.C.
      • et al.
      Use and abuse of faecal occult blood tests in an acute hospital inpatient setting.
      • Duggan A.
      When inexpensive tests have expensive outcomes: faecal occult blood tests as an example.
      • Peacock O.
      • Watts E.S.
      • Hanna N.
      • Kerr K.
      • Goddard A.F.
      • Lund J.N.
      Inappropriate use of the faecal occult blood test outside of the National Health Service colorectal cancer screening programme.
      • Ip S.
      • Sokoro A.A.
      • Kaita L.
      • Ruiz C.
      • Elaine M.
      • Singh H.
      Use of fecal occult blood testing in hospitalized patients: results of an audit.
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