Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures

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Background

Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.

Methods

In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.

Results

Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.

Conclusion

Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

Section snippets

Setting

This analysis of process-of-care errors is part of a larger study of the workup of rectal bleeding performed at 10 adult primary care practices selected from among practices affiliated with three Boston-based academic medical centers and a large multispecialty group practice. Study sites included the hospital-based teaching practice at each hospital. To streamline site recruitment and simplify data collection, the study team selected at random and enrolled a subset of community practices from

Patient Characteristics

The sociodemographic, clinical, and practice characteristics of the 438 members of the study cohort are shown in Table 1. Subjects' mean age was 56, 19% were nonwhite, and 10% were Hispanic. English was the preferred language for most (92%) respondents. About one quarter lived in neighborhoods with a mean income below the US average, and 16% had Medicaid or were uninsured. A family history of colorectal cancer or colon polyps was present in 14% of subjects, 32% had a previous episode of rectal

Discussion

In this retrospective review of 438 patients cared for at 10 Boston adult primary care practices, 1 in 4 patients experienced a process-of-care failure in the workup of rectal bleeding. The most common problems included failure to elicit a complete family history, to perform an adequate physical examination, or to order, perform, or interpret a diagnostic test. Patients' behavior often contributed to process failures. Failure to order or perform diagnostic or laboratory tests and failure to

Summary

Process-of-care failures occurred frequently among adult primary care patients with rectal bleeding and were associated with overall fair or poor quality. Educating practitioners and creating office-based systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests are needed to improve the quality of care.

Conflicts of Interest

All authors report no conflicts of interest.

Saul N. Weingart, MD, PhD, is Chief Medical Officer, Tufts Medical Center, Boston, and Professor of Medicine, Tufts University School of Medicine, Boston.

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    Saul N. Weingart, MD, PhD, is Chief Medical Officer, Tufts Medical Center, Boston, and Professor of Medicine, Tufts University School of Medicine, Boston.

    Elena M. Stoffel, MD, MPH, is a Gastroenterologist and Director, Cancer Genetics Clinic, University of Michigan Health System, Ann Arbor.

    Daniel C. Chung, MD, is Associate Professor of Medicine, Harvard Medical School, Boston, and Clinical Chief, Gastrointestinal Unit, Massachusetts General Hospital, Boston.

    Thomas D. Sequist, MD, is Chief Quality and Safety Officer, Partners HealthCare System, Boston, and Associate Professor of Medicine and Health Care Policy, Harvard Medical School and Brigham and Women's Hospital.

    Ruth L. Lederman, MPH, is Survey Manager, Survey Data Management Core, Dana-Farber Cancer Institute, Boston.

    Stephen R. Pelletier, PhD, is Senior Project Manager, Center for Evaluation, Harvard Medical School, Boston.

    Helen M. Shields, MD, is Professor of Medicine, Harvard Medical School, and Associate Chief, Division of Medical Communications, Brigham and Women's Hospital.

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