The edition · Internal Medicine
Reminders and navigation lifted follow-up colonoscopy after a positive FIT from about half to two-thirds
Closing the loop after an abnormal stool test is a system problem with system answers. Also: what a mandatory medical referral for preoperative sodium below 130 did and did not change, and PSA testing in men least likely to benefit.
The edition in brief
A meta-analysis of 21 studies and 19,613 patients found that follow-up colonoscopy after an abnormal faecal immunochemical or occult blood test rose from a pooled 47.8% to 69.1% with intervention. Patient navigation (RR 1.24), patient reminders (RR 1.32), clinician reminders (RR 1.36) and automated gastroenterology referral (RR 1.68) each helped, with heterogeneity that fell for the first three once outliers were removed. A Singapore registry study of 24,803 surgical patients used a regression discontinuity design to test a protocol of mandatory internist referral and treatment for preoperative sodium below 130 mmol/L. Sodium below 130 carried higher mortality, ICU admission and length of stay, but the protocol showed no effect on 30-day mortality, ICU admission or stay; a signal for lower one-year mortality appeared, strongest in cardiac and kidney disease. In 1.41 million dually enrolled US veterans aged 65 or over, VA primary care was associated with about 30% less PSA testing and biopsy than fee-for-service Medicare in men aged 80 or over, and less testing in men with under five years' predicted life expectancy.
Mandatory medical review for preoperative sodium below 130 did not change 30-day outcomes
Use a preoperative sodium below 130 mmol/L to prompt a search for its cause, rather than to delay surgery for correction alone.
VA primary care was linked to less PSA testing in older veterans least likely to benefit
Stop routine PSA screening in older men whose life expectancy is too short to benefit.
In chronic hyponatraemia, the danger is correcting too fast
Cap the rise in chronic hyponatraemia at 8–10 mmol/L per 24 hours and watch urine output closely.
Navigation, reminders and automatic referral raised colonoscopy completion after an abnormal FIT
Build a system that tracks every abnormal FIT to completed colonoscopy, using reminders, navigation or automatic referral.
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