Introduction
Fecal occult blood test (FOBT) detects the microscopic presence of hemoglobin in the stool. Initially developed as a modality for colorectal cancer screening, the use of FOBT has expanded to the hospital setting in an off-label manner as part of the workup of GI bleeds without data, evidence, or endorsement by professional societies. Our quality improvement project aimed to eliminate the misuse of FOBT in the hospital setting.

Methods
We performed a retrospective analysis of patients hospitalized from 2019 to 2023 to characterize FOBT ordering practices. We implemented interventions in a stepwise fashion aimed at limiting FOBT utilization. First, we provided formal education to both providers and nurses through lectures, emails, and handouts in April 2022. Next, we made changes to the electronic ordering system removing FOBT from orders and order sets in June 2022. Prior to and after each intervention, we quantified the number of FOBT performed. We also analyzed whether a decrease in FOBT use had any effect on meaningful patient outcomes for those admitted with GI bleeds including the number of endoscopic procedures performed, 30-day readmissions, and inpatient mortality.

Results
In the year 2019, a baseline of 6.8 FOBT per 1000 patient days were ordered of which a majority (> 90%) were performed by the Emergency Department. After implementing our interventions, the number of FOBT performed reduced to 4.3 FOBT per 1000 patient days in 2022 and 4.6 FOBT per 1000 patient days in 2023. Trends in the number of FOBT ordered over time can be seen in Figure 1.

During this period, patient outcomes for those admitted with GI bleeds largely remained stable as can be seen in Figure 2. The number of endoscopic procedures performed was 7.85 per 1000 patient days in 2019 and 9.30 per 1000 patient days in 2023. The 30-day readmission rate was 0.79 per 1000 patient days in 2019 and 0.51 per 1000 patient days in 2023. Inpatient mortality was 0.04 per 1000 patient days in 2019 and 0.01 per 1000 patient days in 2023.

Discussion
Prior studies have demonstrated the limited clinical utility of FOBT in the hospital setting. While many studies have investigated the clinical utility of FOBT, our study is one of the few that evaluates the impact of reduction on patient outcomes. As we can see, reductions in the number of FOBT ordered had no significant impact on patient outcomes in terms of the number of endoscopic procedures performed, 30-day readmission rates, or inpatient mortality for those admitted with GI bleeds. Our interventions thus far have amounted to a reduction in FOBT ordering by more than 30%. Future steps include involvement and buy-in of high users of FOBT, including the Emergency Department, as well as divestment with removal of the physical test which has been successful at other institutions.

Figure 1. Control chart showing trends in the number of FOBT ordered over time.

Figure 2. Trends in patient outcomes for those admitted with GI bleeds over time.

Eric Nellis

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