A Cost Containment Project Fecal Occult Blood Testing in Patients Admitted for GI Bleeding: A Cost Containment Project Nathan King M.D. An Update with original project by Kelvin Nguyen 5/10/2013 April 23, 2015

Current Clinical Context Patients admitted to UCI for GI bleeding Introduction Current Clinical Context Patients admitted to UCI for GI bleeding Most often admitted to IM or FM services Occasionally in MICU or on surgical services Regardless of true indication have at times received fecal occult blood testing

Background Current Guidelines[1] Cancer Screening & Prevention Ideally prevention test with colonoscopy the potential to image both cancer and polyps Cost or Pt. preference, cancer detection test annual fecal immunochemical test (FIT) Superior sensitivity and specificity to guaiac-based Hemoccult cards (gFOBT) 10-12% increased adherence in 2 RCTs ACG recommends abandonment of gFOBT Higher sensitivity detections tests: Hemoccult Sensa and HemoQuant – Less RCT data Fecal DNA testing – High cost Cancer prevention tests vs. cancer detection tests prevention tests have the potential to image both cancer and polyps, whereas cancer detection tests have low sensi- tivity for polyps and typically lower sensitivity for cancer compared with that in cancer prevention tests preferred cancer prevention test—colonoscopy every 10 years (Grade 1 B) and a preferred cancer detection test—annual fecal immunochemical test (FIT) FIT FIT. This test has superior performance characteristics when compared with older guaiac-based Hemoccult II cards 10 and 12% gains in adherence with the FIT in the first two randomized controlled trials comparing the FIT with guaiac- based testing superior perform- ance and improved adherence was a doubling in the detection of advanced lesions, with little loss of positive predictive value ACG supports the joint guideline recommendation that older guaiac-based fecal occult blood testing be abandoned higher sensitivity Tests: guaiac-based Hemoccult Sensa – Less data fecal DNA test – Higher Cost [1] Rex, D.K., et al., American College of Gastroenterology guidelines for colorectal cancer screening 2008. The American journal of gastroenterology, 2009. 104(3): p. 739-750. [1] Rex, D.K., et al., American College of Gastroenterology guidelines for colorectal cancer screening 2008. The American journal of gastroenterology, 2009. 104(3): p. 739-750.

Background FIT and gFOBT available at UCI gFOBT FIT HemoQuant Fecal DNA Methodology Heme catalyzes guaiac color change when H2O2 is added Globin detected by antibody Heme moiety acidically converted to protoporphyin and quantified by fluorescence Detects DNA alterations associated with cancer List Price $24 $95 $74 $350 [3] Medicare pays $22 ?? [2] Table modified from: The Mayo Clinic. "Fecal Occult Blood Testing." Hot Topic. Mayo Clinic, 01 Oct. 2011. Web. 21 Apr. 2015. FIT and gFOBT available at UCI gFOBT Lots of things can falsify results iron supplements, red meat (the blood it contains can turn the test positive), certain vegetables (which contain a chemical with peroxidase properties that can turn the test positive), and vitamin C and citrus fruits (which can turn the test falsely negative) for a period of time before the test. In fact the ACG guidline for diagnosis and management of patients presenting with Lower GI bleeding specifically says, “This guideline is not intended for patients presenting with stool that is positive for occult blood, chronic bleeding of obscure origin, or obvious self-limited bleeding where the likelihood of a change in vital signs or anemia is low” [2] GI Bleeding Current Guidelines[4] No Mention of occult blood testing “This guideline is not intended for patients presenting with stool that is positive for occult blood…where the likelihood of a change in vital signs or anemia is low.” [3] Zauber AG, Lansdorp-Vogelaar I, Wilschut J, et al. Cost-effectiveness of DNA stool testing to screen for colorectal cancer. AHRQ Technology Assessment Program 2007 [4] Zuccaro, G., Jr., Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol, 1998. 93(8): p. 1202-8.

Aim Premise: There is no indication for fecal occult blood testing in patients with GI bleeding as testing will not change management. Examine Cases of Patient admitted to UCI for GI bleeding Determine whether fecal occult blood testing had taken place Determine clinical context of such testing

Methods Retrospective Chart Review Time period: 1/1/2015 – 4/20/2015 Admitting diagnosis: GI bleeding Admitted to MICU, Medicine, or Family Medicine

60 Total patients admitted for GI bleeding Results Patients: 60 Total patients admitted for GI bleeding 4 MICU 2 Family Medicine 54 Internal Medicine 6 patients (10%) tested for FIT or gFOBT

Results Clinical Context: 6/6 patients reported clinical history of GI bleeding at time of admission 4/6 patients had history of GI bleeding in past 3/6 patients had exam confirmed presence of active GI bleeding documented by a physician prior to occult blood testing 1/6 had known history of colorectal cancer prior to occult blood testing Clinical service: 5/6 patients were on the Internal Medicine service 1/6 patients was on the Family Medicine service

Results Possible Rationale: 2/6 were OSH transfers for obscure GI bleeding that did not seem to have active bleeding at time of transfer 1/6 seemed that clinicians may not have believed patient’s story of ostomy bleeding as not readily apparent at time of admission 1/6 test sent by ED physician at time of rectal exam in context of, “maroon colored stool.” Clinical Outcome: 0/6 did chart indicate that testing changed management 5/6 patients were on the Internal Medicine service 1/6 patients was on the Family Medicine service

Conclusions/Discussion Fecal occult blood testing is only indicated as a cancer detection tool It is not indicated in diagnosis and management of GI bleeding and does not change management of GI bleeding In up to 10% of cases of admissions for GI bleeding at UCI clinicians continue to test for fecal occult bleeding This data review only included patients with the listed admitting diagnosis of GI bleeding. Far more patients have other diagnosis listed as primary admitting diagnosis while still receiving workup and treatment for GI bleeding while admitted at UCI.

Conclusions/Discussion In recognition that there were more patients admitted with GI bleeding just not as their admitting diagnosis: Per the Healthcare blue book: “Stool Testing for blood” Cost to consumer: $82 Cost to hospital: $41 If 60 patients January to April then roughly 180/year with 10% receiving testing 18 unnecessary tests: - costs to patients: $1,476 - cost to hospital: $738