Use and de-implementation of fecal occult blood tests in the acute care setting: a systematic review and meta-analysis

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Abstract
Background: To determine methods of FOBT de-implementation in acute care practice while summarizing the reasons and contraindications for inappropriate FOBT in acute care settings. Fecal occult blood testing is valuable for colorectal cancer screening in ambulatory settings but is not valuable for diagnostics in acute care with consistent indications for discontinuation as a tradition-based practice. Methods: We included all English language prospective and retrospective evaluation studies of FOBT use in acute care settings with or without de-implementation interventions and published as original research articles in peer-reviewed journals. A meta-analysis of FOBT positivity was conducted using a random effects model. Quality was assessed using Critical Appraisals Skills Programme criteria. Results: Of 2471 abstract/titles screened, 157 full-text articles were reviewed, and 22 articles met inclusion criteria of measuring prevalence or de-implementation of FOBT use in acute care settings. All 22 studies evaluated either FOBT use or de-implementation. Twenty articles reported FOBT positivity, with some illustrating that FOBT results were inconsequential to subsequent endoscopy decisions (n = 7, 32%). The included studies represent a publication date range spanning 32 years, with limited documentation of de-implementation strategies. Four published studies described system-level disinvestment to administratively eliminate access to inpatient FOBT orders. Conclusion: Overall, all studies endorse that the use of FOBTs in acute care settings results in increased workload and/or cost without diagnostic benefit. Critical appraisal of low-value tradition-based practices such as FOBT use in acute care settings are essential for deploying deliberate and effective de-implementation strategies.

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