Dataset Information

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

ABSTRACT:

Background

Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions.

Objectives

To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion.

Design

A retrospective cohort study using explicit chart abstraction methods.

Participants

Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016.

Main measures

Rates and timing of test ordering and completion and patterns of visits and communications.

Key results

At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p?LimitationsThe study relied on documented care, and findings may be most generalizable to academically affiliated institutions.

Conclusions

Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.

SUBMITTER: Pace LE

PROVIDER: S-EPMC6614558 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Publications

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

Pace Lydia E LE Percac-Lima Sanja S Nguyen Kevin H KH Crofton Charis N CN Normandin Katharine A KA Singer Sara J SJ Rosenthal Meredith B MB Chien Alyna T AT

Journal of general internal medicine 20190422 7

<h4>Background</h4>Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions.<h4>Objectives</h4>To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding w ...[more]

PMID: 31011969

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Project description:BACKGROUND:Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE:To assess 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 demographic characteristics, visit patterns, and clinical presentations. DESIGN:Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS:Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES:1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS:Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96). CONCLUSIONS:Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.

Project description:BackgroundPostmenopausal bleeding (PMB) is a common gynecologic condition. Although it can be a sign of uterine cancer, most patients have benign etiology. However, research on quality of diagnostic evaluation for PMB has been limited to cancer patients. To extend this research, we examined the timeliness of diagnostic evaluation for PMB among patients with benign conditions.MethodsUsing the 2008-2019 MarketScan Research Databases, we identified 499176 patients (456741 with commercial insurance and 42435 with Medicaid insurance) who presented with PMB but did not have gynecologic cancer. For each patient, we measured the time from their PMB reporting to the date of their first diagnostic procedure. The association between patient characteristics and time to first diagnostic procedure was examined using Cox proportional hazards models (for the overall sample and then stratified by insurance type).ResultsOverall, 54.3% of patients received a diagnostic procedure on the same day when they reported PMB and 86.6% received a diagnostic procedure within 12 months after reporting PMB. These percentages were 39.4% and 77.1%, respectively, for Medicaid patients, compared to 55.7% and 87.4%, respectively, for commercially insured patients (p<0.001 for both). Medicaid patients had an 18% lower rate of receiving a diagnostic procedure at any given time point than commercially insured patients (adjusted hazard ratio = 0.82, 95% CI: 0.81-0.83). Meanwhile, older age and non-gynecologic comorbidities were associated with a lower rate whereas concomitant gynecologic conditions and recent use of preventive care were associated with a higher rate of receiving diagnostic procedures. Analysis stratified by insurance type identified additional risk factors for delayed diagnostic procedures (e.g., non-metropolitan versus metropolitan location for commercially insured patients and Black versus White race for Medicaid patients).ConclusionA sizable proportion of patients did not receive prompt diagnostic evaluation for PMB. Both clinical and non-clinical factors could affect timeliness of evaluation.

Dataset Information

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

Background

Objectives

Design

Participants

Main measures

Key results

Conclusions

Publications

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

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