Working up rectal bleeding in adult primary care practices

Abstract

Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

“…Compared to a previous study, physicians documented rectal exams at a higher level; however, still 41% of patients were not examined. 21 Physicians initiated colonoscopies for 74% of the patients for whom they were recommended by the CRICO guideline, but only 56% of patients received them during the study period (within 1 year of initial presentation). This rate is comparable to that in prior studies, 15,21,22 despite the advent of the patient-centered medical home concept 24,25 and more widespread adoption of electronic health records.…”

“…21 Physicians initiated colonoscopies for 74% of the patients for whom they were recommended by the CRICO guideline, but only 56% of patients received them during the study period (within 1 year of initial presentation). This rate is comparable to that in prior studies, 15,21,22 despite the advent of the patient-centered medical home concept 24,25 and more widespread adoption of electronic health records. [26][27][28] A recently published study in the UK and Fisher's investigation of a VA system in the United States revealed delays in CRC diagnosis in patients with comorbid conditions.…”

“…15 Several studies-most conducted nearly a decade ago (i.e., 2006-2010) have investigated the diagnostic evaluation of patients presenting to primary care with rectal bleeding. 15,[20][21][22][23] Both academic primary care and Veterans Affairs (VA) settings have been studied, but for the non-VA setting, this timing is notable for several reasons. First, these studies were conducted prior to the advent of patient-centered medical home concepts in adult primary care (joint principles were published in 2007).…”

“…30,31 We were interested in whether the changes in clinical practice had improved the ability of physicians and other members of primary care teams to evaluate rectal bleeding, to document related activities such as colonoscopy orders/referrals, care coordination, and communication efforts, and to mitigate differences in care based on patient sex, race/ethnicity, or income. 16,21,32 The aim of this study was to examine the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on patients' demographic characteristics, visit patterns, and clinical presentations.…”

Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study

“…8,15,16 Variable quality has been noted in primary care evaluations for both breast lumps 17 and rectal bleeding. 15,18,19 However, breast lump and rectal bleeding evaluations have rarely been examined within the same practices, limiting investigation into potential differences and contributing factors. 16,20 One trial of patient navigation in 11 clinics found that patients with rectal bleeding or positive fecal occult blood tests were less likely to achieve diagnostic resolution than patients with breast concerns.…”