Challenges in the Management of Positive Fecal Occult Blood Tests

  • Sandhya K. Rao
  • Thad F. Schilling
  • Thomas D. Sequist
Original Article



Many patients with a positive fecal occult blood test (FOBT) do not undergo follow-up evaluations.


To identify the rate of follow-up colonoscopy following a positive FOBT and determine underlying reasons for lack of follow-up.


It is a retrospective chart review.


The subject group consisted of 1,041 adults with positive FOBTs within a large physician group practice from 2004 to 2006.


We collected data on reasons for ordering FOBT, presence of prior colonoscopy, completed evaluations, and results of follow-up tests. We fit a multivariable logistic regression model to identify predictors of undergoing follow-up colonoscopy.


Most positive FOBTs were ordered for routine colorectal cancer screening (76%), or evaluation of anemia (13%) or rectal bleeding (7%). Colonoscopy was completed in 62% of cases, with one-third of these procedures identifying a colorectal adenoma (29%) or cancer (4%). Factors associated with higher rates of follow-up colonoscopy included obtaining the FOBT for routine colorectal screening (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.11–2.29) and consultation with gastroenterology (OR 1.99, 95% CI 1.46–2.72). Patients were less likely to undergo colonoscopy if they were older than 80 years old (OR 0.54, 95% CI 0.31–0.92), younger than 50 years old (OR 0.44, 95% CI 0.28–0.70), uninsured (OR 0.50, 95% CI 0.27–0.93), or had undergone colonoscopy within the prior five years (OR 0.32, 95% CI 0.23–0.44).


Clinical decisions and patient factors available at the time of ordering an FOBT impact performance of colonoscopy. Targeting physicians’ understanding of the use of this test may improve follow-up and reduce inappropriate use of this test.


colorectal cancer cancer screening quality of care risk management patient safety fecal occult blood test 



The authors would like to thank Amy Marston, BA for her efforts in data extraction and project management. This study was funded by a grant from the Harvard Risk Management Foundation. The funding agency played no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Dr. Sequist had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis

Conflict of Interest

None of the authors have any conflicts of interest to disclose.


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Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Sandhya K. Rao
    • 1
    • 2
    • 3
  • Thad F. Schilling
    • 2
  • Thomas D. Sequist
    • 1
    • 2
    • 4
  1. 1.Division of General Medicine and Primary CareBrigham and Women’s HospitalBostonUSA
  2. 2.Harvard Vanguard Medical AssociatesBostonUSA
  3. 3.Department of Ambulatory Care and PreventionHarvard Medical SchoolBostonUSA
  4. 4.Department of Health Care PolicyHarvard Medical SchoolBostonUSA

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