P81 A colorectal referral pathway incorporating primary care faecal haemoglobin testing safely and effectively prioritises investigation

IntroductionThere is increasing interest in using Quantitative Faecal Immunochemical Testing (QFIT) for Haemoglobin as a ‘rule out’ test for significant colonic disease in symptomatic patients. It has been demonstrated elsewhere in Scotland that incorporating faecal haemoglobin testing into a primary care clinical assessment tool can safely and effectively prioritise referral for colorectal investigation. Here we present results of our own experience in the largest Scottish Health board (population 1.14 million) following adoption of a primary care colorectal referral pathway incorporating QFIT.MethodsA new referral pathway incorporating primary care testing of faecal haemoglobin was incorporated into clinical practice in September 2018, regardless of patient age. Faecal haemoglobin was measured using the HMJack analyser (Kyowo-Medex), with a cut off for a positive test being 10 ug/g stool. The need for, and priority of, investigation, was determined according to the faecal haemoglobin concentration along with assessment for other pre-determined ‘red flag’ symptoms (iron deficiency anaemia, persistent rectal bleeding or daily diarrhoea > 4 weeks, rectal or abdominal mass). Ascertainment of significant colonic disease was determined after 1 year of follow up by linkage of faecal haemoglobin results to local endoscopy, radiology and pathology databases, and finally verified by linkage to the Scottish Cancer Registry.ResultsA minimum of 12 month follow up information is available for 3818 patients who submitted a QFIT sample between September and December 2018. A faecal haemoglobin result was available for 3547 patients, and positivity was 25.3%, with 4.4% of results being above the maximum quantifiable value (>400 ug/g stool). 1312 patients had undergone colonoscopy. 54 patients were diagnosed with colorectal cancer within 1 year of having faecal haemoglobin analysed. 51/54 (94.4%) patients had a positive QFIT test, and 53/54 patients (98.1%) had their investigation prioritised based on QFIT result or pre-determined ‘red flag’ symptoms. Only 1/3793 patients developed cancer within one year of an undetectable faecal haemoglobin and in the absence of ‘red flag’ symptoms. Advanced adenomas were found in 9.2% vs 2.1% investigated patients with detectable faecal haemoglobin, and inflammatory bowel disease was diagnosed in 6.2% vs 1.6%. In one sector of the board, introduction of this pathway has reduced demand for ‘direct to test’ colonoscopy by 20%, and demand for all luminal gastroenterology and colorectal surgery outpatient activity by 12.4%.ConclusionAdopting a pathway incorporating faecal immunochemical testing for haemoglobin in primary care as an adjunct to a formalised clinical assessment can safely determine a patient’s risk of significant colorectal pathology, particularly colorectal cancer, and help prioritise investigation.