The Wrong FITting: A Quality Improvement Project to Reduce Inpatient Fecal Immunochemical Test (FIT) Usage at the Veterans Affairs Medical Center (VAMC)

Introduction: Fecal immunochemical test (FIT) utilizes antibodies to detect the globin (protein) part of hemoglobin. Indications for FIT include screening for colorectal cancer (CRC) and in cases of anemia without any overt gastrointestinal (GI) bleeding. An abnormal FIT could suggest the presence of CRC, polyps, hemorrhoids, or ulcers and should be pursued with a colonoscopy for evaluation. Despite these indications for FIT, we realized there were numerous instances at the VAMC in which FIT was obtained inappropriately inpatient, such as in overt GI bleeding. This quality improvement (QI) project aimed to identify and reduce the situations of inpatient FIT usage, to educate on the proper indications for FIT, and to evaluate the impact on patient outcomes. Methods: A retrospective chart review was performed of 1 year of inpatient FIT usage. Subsequently, weekly pre-intervention questionaire surveys were distributed over 3 months to various VA healthcare providers to gauge baseline understanding of FIT. Then, teaching and educational handouts were provided (Figure 1). Data post intervention was collected over a 3 month period and analyzed. Results: A total of 400 FITs (on average 33/month) were ordered pre-intervention with 20% done on patients with active GI bleeds: abdominal pain and diarrhea were other reasons. Pre-intervention surveys were obtained from 74 individuals; 13% of respondents thought FIT was for GI bleeding while 7% were unsure of FIT indication. Post educational intervention, 89 FITs (on average 30/month) were collected, with the majority of ordering providers of medicine specialty. Anemia was the most common indication for FIT at 64% (Table 1). Of the +FITs, GI was only consulted on 76% of these cases post intervention in which colonoscopy was performed in 38% of these cases. 31% of inpatients with +FITs were critically ill with multiple comorbidities, had no overt GI bleeding, and thus colonoscopy was deferred. Among the FIT+ patients whom did not undergo endoscopic evaluation, about 40% had died from non GI related causes by completion of the study. Conclusion: FIT is overutilized in the hospital setting and it's inpatient role is limited. Despite the lack of difference in the number of FITs ordered pre and post educational intervention, our data suggests +FITs did not affect patient outcome or clinical management. We propose decreased usage of FIT in the acute inpatient setting with a plan for continued educational intervention and setting forth limitations to ordering providers.Figure 1.: Educational handouts on FIT usage were provided to healthcare providers.Table 1.: Reasons for Ordering FIT pre vs post intervention.