FIT Unfit for Inpatient, Emergency Settings

Michael Vlessides

November 04, 2020

Most Fecal Immunochemical Tests (FIT) in the hospital setting or the emergency department are performed for inappropriate indications, a data show.

"This is the largest study that focuses exclusively on the use of FIT in the ED, inpatient wards, and in the ICU, and it shows significant misuse," said investigator Umer Bhatti, MD, from the Indiana University School of Medicine in Indianapolis.

The only "validated indication" for FIT is to screen for colorectal cancer. However, "99.5% of the FIT tests done in our study were for inappropriate indications," he reported at the American College of Gastroenterology (ACG) 2020 Annual Scientific Meeting, where the study was honored with an ACG Presidential Poster Award.

And the inappropriate use of FIT in these settings had no positive effect on clinical decision-making, he added.

For their study, Bhatti and his colleagues looked at all instances of FIT use in their hospital's electronic medical records from November 2017 to October 2019 to assess how often FIT was being used, the indications for which it was being used, and the impact of its use on clinical care.

They identified 550 patients, 48% of whom were women, who underwent at least one FIT test. Mean age of the study cohort was 54 years. Only three of the tests, or 0.5%, were performed to screen for colorectal cancer (95% CI, 0.09% - 1.52%).

Among the indications documented for FIT were anemia in 242 (44.0%) patients, suspected gastrointestinal (GI) bleeding in 225 (40.9%), abdominal pain in 31 (5.6%), and change in bowel habits in 19 (3.5%).

The tests were performed most often in the emergency department (45.3%) and on the hospital floor (42.2%), but were also performed in the intensive care unit (10.5%) and burn unit (2.0%).

Overall, 297 of the tests, or 54%, were negative, and 253, or 46%, were positive.

"GI consults were obtained in 46.2% of the FIT-positive group, compared with 13.1% of the FIT-negative patients" (odds ratio [OR], 5.93; 95% CI, 3.88 - 9.04, P < .0001), Bhatti reported.

Among FIT-positive patients, those with overt bleeding were more likely to receive a GI consultation than those without (OR, 3.3; 95% CI, 1.9 - 5.5; P < .0001).

Of the 117 FIT-positive patients who underwent a GI consultation, upper endoscopy was a more common outcome than colonoscopy (51.3% vs 23.1%; P < .0001). Of the 34 patients who underwent colonoscopy or sigmoidoscopy, one was diagnosed with colorectal cancer and one with advanced adenoma.

Overt GI bleeding was a better predictor of a GI consultation than a positive FIT result. In fact, use of FIT for patients with overt GI bleeding indicates a poor understanding of the test's utility, the investigators report.

"For patients with overt GI bleeding, having a positive FIT made no difference on how often a bleeding source was identified on endoscopy, suggesting that FIT should not be used to guide decisions about endoscopy or hospitalization," Bhatti said.

In light of these findings, the team urges their peers to consider measures to reduce FIT tests for unnecessary indications.

"We feel that FIT is unfit for use in the inpatient and emergency settings, and measures should be taken to curb its use," Bhatti concluded. "We presented our data to our hospital leadership and a decision was made to remove the FIT as an orderable test from the EMR."

These results are "striking," said Jennifer Christie, MD, from the Emory School of Medicine in Atlanta.

"We should be educating our ER providers and inpatient providers about the proper use of FIT," she told Medscape Medical News.

"Another option — and this has been done in many settings with the fecal occult blood test — is just take FIT off the units or out of the ER, so providers won't be tempted to use it as an assessment of these patients. Because often times, as this study showed, it doesn't really impact outcomes."

In fact, unnecessary FIT testing could put patients at risk for unnecessary procedures. "We also know that calling for an inpatient or ER consult from a gastroenterologist may increase both length of stay and costs," she added.

Bhatti and Christie have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2020 Annual Scientific Meeting: Abstract P2576. Presented October 26, 2020.

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