Evaluation of Intervention Strategies to Improve Follow-Up Colonoscopy After Abnormal FIT/FOBT Result: A Systematic Review and Meta-Analysis.

Abstract

Importance: Colorectal cancer is the second leading cause of cancer mortality worldwide. Early detection through screenings has been shown to improve morbidity and mortality. While fecal immunochemical test (FIT) or fecal occult blood test (FOBT) are established cost-effective screening modalities for colorectal cancer, follow-up colonoscopy screening rates remain suboptimal.

Objective: To evaluate interventions targeting colonoscopy completion and the prevalence of colonoscopy completion after an abnormal FIT/FOBT result.

Data sources: MEDLINE, Embase, and Cochrane databases were searched from inception to May 9, 2026, and the bibliographies of relevant studies were screened.

Study selection: Original studies, published in English, examining nonrandomized interventional studies or randomized clinical trials comparing interventions to improve follow-up colonoscopy after an abnormal FIT/FOBT result were included. Prevalence and risk ratios (RRs) with accompanying 95% CIs for each study were computed, and the results were pooled using a random-effects meta-analysis.

Data extraction and synthesis: This study was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Two authors reviewed each study and extracted the data independently, with discrepancies referred to a third independent author.

Main outcomes and measures: Outcomes included prevalence and RR of various interventions.

Results: A total of 21 studies involving 19 613 patients (8101 female individuals [41.3%] and 11 512 male individuals [58.7%]; age range, 50-75 years) evaluating interventions to improve colonoscopy completion after an abnormal FIT/FOBT result were included. Patient navigation (RR, 1.24; 95% CI, 1.15-1.33; I2 = 57.1), patient reminders (RR, 1.32; 95% CI, 1.04-1.67; I2 = 89.9), clinician reminders (RR, 1.36; 95% CI, 1.12-1.65; I2 = 94.4), and automated referrals to gastrointestinal consult (RR, 1.68; 95% CI, 1.09-2.60; I2 = 91.9) were effective in increasing follow-up colonoscopy completion with moderate to high heterogeneity detected within and across intervention types. Sensitivity analyses excluding outliers resulted in low heterogeneity for patient navigation, patient reminders (messaging), and clinician reminders, while moderate heterogeneity remained for automated referrals. Follow-up colonoscopy increased from 4755 of 10 263 in control to 6272 of 9350 after interventions; pooled prevalence estimates were 47.8% and 69.1%, respectively.

Conclusions and relevance: In this systematic review and meta-analysis, patient-level and system-level interventions, including patient navigation, patient reminders, and clinician reminders, are associated with increased completion of follow-up colonoscopy after an abnormal FIT/FOBT result. More studies are required to evaluate the efficacy of automated referrals to gastrointestinal consult due to large heterogeneity between studies and to study the incremental effect of each intervention in multicomponent interventions.