Missed Opportunities to Initiate Endoscopic Evaluation for Colorectal Cancer Diagnosis

Abstract

Objectives-Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved.Methods-We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described.Results-Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR) = 2.3; 95% confidence interval (CI) 1.3-4.1) or with iron deficiency anemia (OR = 2.2; 95% CI 1.3-3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR = 0.06; 95% CI 0.01-0.51), or imaging suspicious for CRC (OR = 0.3; 95% CI 0.1-0.9). Anemia was the clue associated with the longest time to endoscopic referral (median = 393 days). Most process Correspondence: Hardeep Singh,

General Internists in Pursuit of Diagnostic Excellence in Primary Care: a #ProudtobeGIM Thread That Unites Us All

“…These findings echo previous work in this area 5,6 and, while concerning, are not surprising when situated within the longitudinal and fragmented outpatient experience. Making a diagnosis such as colorectal cancer challenges the resilience of our primary care system.…”

“…Prior studies have established that process failures in the diagnosis of colorectal cancer most commonly occur during the provider-patient clinical encounter, follow-up of test results, and/or closure of the referral loop. 5,6 Sure enough, colorectal cancer remains high on the list of conditions that are cited in primary care malpractice claims.…”

“…One can now generate a list of patients who did not receive follow-up for new-onset rectal bleeding at 60 days, as well as develop similar mechanisms to identify other patients at risk of Bfalling through the cracks.^1 1 Furthermore, electronic health records (EHRs) contain rich data to facilitate a Bmissed opportunity^analysis, which helps determine what could have be done differently to make the diagnosis earlier, framed within the context of an evolving diagnostic process. 6 There are no primary care practices we are aware of that routinely utilize metrics related to diagnostic error, but such an approach can be especially powerful for uncovering data needed for improvement. As general internists, we can lead the way in partnering with our institutions toward better measurement around diagnosis.…”

Improving the Follow-Up of Positive Hemoccult Screening Tests: An Electronic Intervention

“…A recent study evaluating 531 patients with newly diagnosed CRC identified 161 patients with at least one missed opportunity to diagnose CRC (or polyps) earlier. 12 In addition, they found that FOBT+ results were missed 128 times in 64 patients who waited a median of 146 days after a FOBT+ finding before GI referral. Thus, a program that improves test follow-up has the potential to improve quality of care at the individual as well as the population level.…”

“…[11][12][13] These studies all evaluated multifaceted interventions involving provider education, tracking systems and reminders, and none involved directly notifying GI of FOBT+ results. Our study results suggest that a simple modification of the electronic medical record system that involves directly notifying GI of FOBT+ results can lead to increases in FOBT+ follow-up comparable to those observed in prior studies.…”