Background and Aims In July 2019, the fecal immunochemistry test (FIT) replaced the fecal occult blood test (FOBT) in England as the Bowel Cancer Screening Program (BCSP) screening tool. We aimed to assess the impact of this on healthcare resources at our BCSP center. Methods Two 6-month periods were initially analyzed for stool sample return and positivity rates. A subsequent comparative analysis of patient screening episodes assessed utilization of specialist screening practitioner (SSP) time, endoscopy, histology, radiology, surgical, and oncology service usage. Results A total of 42,234 patients received FOBT and 42,545 patients received FIT stool kits, with FIT showing higher return (61.8% vs 58.58%, FIT vs FOBT, P < .001) and sample positivity rates (2.41% vs 1.45%, FIT vs FOBT, P < .001). Four hundred patients commenced FOBT and 616 FIT screening episodes, a 54% increase. The FIT group had of a lower mean age (67.5 vs 69.5 years, FIT vs FOBT, P = .0001) with a lower nonattendance rate (.16% vs 1.5%, FIT vs FOBT, P = .01). With higher patient numbers, the FIT group required 69% more endoscopic procedures, 58% increased SSP time, 40% more radiologic tests, and 68% higher surgical procedures. FIT also led to a 109% increase in endoscopy-derived histology samples from an increase in the proportion of patients with polyps with FIT (54.8% vs 47.2%, P = .020) and a greater number of polyps per patient in whom polyps were found (3.00 vs 2.50 polyps, P = .017). This additional service burden equated to additional financial costs of approximately $558,000 per annum. Conclusions The implementation of FIT led to notable increases in SSP time, endoscopy procedures, radiology tests, surgical procedures, and histopathology services, resulting in considerable ongoing financial implications on the organization. Findings can be used to aid workforce and service planning in National Health Service sites delivering BCSP and countries that have already adopted or are considering FIT within their national screening programs.

Introduction From July 2019, FIT replaced Faecal Occult Blood Test (FOBt) as the BCSP screening tool for individuals aged 60 to 75. As FIT detects and quantifies human haemoglobin in stool, changes in service demands were expected due to increased sensitivity. Additionally, pilot testing noted increased screening uptake from 59.3% to 66.4%.1 The extent of the change upon service demand has not been assessed in the full BCSP. We aimed to assess the impact of this change on BCS associated resources at our screening centre. Methods Data was analysed from all patients attending appointments with a Specialist Screening Practitioner (SSP) after either a positive FOBt (March to May 2019) or FIT (September to November 2019) test. The June to August 2019 period was excluded due to a cross over period between the 2 kits. Endoscopy, radiology and surgical procedures as well as histology and SSP time were recorded. 45’ slots of SSP time were allocated for each of initial consultations, attendance at colonoscopy and colorectal multidisciplinary team meeting (if applicable); 20’ slots for flexible sigmoidoscopy and EMR consent. Subsequent follow up telephone or clinic consultations were allocated 10’. Statistical testing was undertaken with an unpaired t-test. Results 164 patients attended in the FOBt group and 216 patients in FIT- a increase of 32% (n=52) in patients with positive tests attending for appointments. Comparing the 3 month periods, FIT testing required 63 more endoscopic procedures (212 vs 149 colonoscopies and 4 vs. 7 flexible sigmoidoscopies). There were 102 hours of additional SSP time required and a 112% increase in the endoscopic polyp/biopsy samples with 190 extra specimens. There were significantly more polyps found within the FIT group (n=337 vs. 154, p=0.004). Total numbers of radiological investigations remained similar (31 FIT vs. 28 FOBt). Patients with malignancy requiring surgery (13 vs. 6) or palliative oncologogical treatment (2 vs. 1) were higher in the FIT group thereby doubling surgery and oncology resource needed. Estimation of financial impact is underway. Conclusions The change to FIT testing within our service has led to notable increases in service demand on SSP time, endoscopy procedures and histopathology services. There has also been a doubling of cancers resulting in impact on surgery and oncology resource. Analysis of this impact aids workforce and service planning in NHS sites delivering BCS. Reference Sue Moss, Christopher Mathews, T J Day, Steve Smith, Helen E Seaman, Julia Snowball, Stephen P Halloran. Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. GutSep 2017;66 (9):1631–1644.

Introduction Direct Oral Anticoagulants (DOACs) are rapidly replacing warfarin as drugs of choice for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Advantage of DOACs over warfarin include fixed dosing, predictable pharmacokinetics, less interaction with food/ medication and no requirement for frequent monitoring of their therapeutic efficacy. Obesity is a risk factor for the development of AF. However, robust scientific data assessing the safety of DOACs in obese patients is lacking. The International Society of Thrombosis and Haemostasis (ISTH) suggests that DOACs should not be used in patients with a Body Mass Index (BMI) > 40 kg/m2 or a weight >120kg, and if a DOAC is used in these patients, a peak and trough level should be obtained to ensure the levels fall within the expected range. On the other hand, the European Heart Rhythm Association (EHRA) recommends only estimating trough levels at extremes of body weight. Aims The objective of this study was to evaluate the safety of the use of DOACs in obese patients with NVAF undergoing elective Direct Current Cardioversion (DCCV) in a tertiary cardiology centre. Methods Retrospective, single-centre cohort analysis of all adult patients ≥18 years of age with body weight >120kg, undergoing elective DCCV for NVAF between January 2018 and January 2020 while anticoagulated with either DOACs or therapeutic warfarin for ≥3 weeks prior to the procedure. Patients on DOACs were compared with those on warfarin. Shocks were delivered using a biphasic defibrillator starting at 150 Joules in a well established nurse-led Cardioversion Service. Results Of the 486 DCCV procedures undertaken during the study period, 52 (10.7%) were in patients weighing >120kg. Six patients underwent the procedure twice. The cohorts’ mean age was 59.7 ± 8.2 years (median: 59.5; range: 38-75); 76.9% were male; the mean weight was 134.40 ± 13.65 kg (median: 130; range: 120-167.8) and mean body mass index (BMI) was 43.26 ± 5.51 kg/m2 (median: 42.8; range: 32.9-58.8). Majority (33/52, 63.5%) of the procedures were undertaken in patients with a BMI of ≥40 kg/m2 (morbidly obese) and while on DOACs (36/52, 69.2% versus warfarin: 16/52, 30.8%). Distribution of DOACs was as follows: rivaroxaban 25/52 (48.1%), apixaban 9/52 (17.3%) and dabigatran 2/52 (3.8%). DOAC trough levels were estimated in 18/36 (50%) patients prior to the procedure. Mean CHA2DS2VASc score was 2 ± 1 (median: 2; range: 0-4). Sinus rhythm was restored in 38/52 (73.1%) procedures using a mean of 2.2 ±1.3 shocks (median: 2, range: 1-5). Conclusions/Implications The results of this single-centre study suggest that in this population of morbidly obese patients undergoing DCCV, the recommendations of ISTH and EHRA were only partially adhered to. While healthcare professionals were preferring warfarin over DOACs in very heavy patients, a majority still received the latter drug. Non-adherence to the recommendations with regards to measuring trough levels of patients on DOACs to ensure efficacy was seen with only half having their levels estimated. However, DOACs appeared to be safe in this population with no adverse events at 30 days. The results of this study are relevant in view of rising levels of obesity and NVAF worldwide with a potential for increased demand for DCCV in such patients in the future. Conflict of Interest None