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J Eval Clin Pract. 2017 Apr;23(2):279-287. doi: 10.1111/jep.12596. Epub 2016 Jul 20.

Working up rectal bleeding in adult primary care practices.

Author information

1
Tufts Medical Center, Boston, MA, USA.
2
Tufts University School of Medicine, Boston, MA, USA.
3
University of Michigan Medical School, Ann Arbor, MI, USA.
4
Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA.
5
Harvard Medical School, Boston, MA, USA.
6
Partners Healthcare System, Boston, MA, USA.
7
Survey and Data Management Core, Dana-Farber Cancer Institute Boston, Boston, MA, USA.
8
Center for Evaluation, Harvard Medical School, Boston, MA, USA.
9
Division of Medical Communications, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Abstract

RATIONALE, AIMS AND OBJECTIVES:

Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation.

METHODS:

We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups.

RESULTS:

Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance.

CONCLUSION:

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.

KEYWORDS:

medical error; missed diagnosis; practice guidelines; practice variation; rectal bleeding

PMID:
27436515
DOI:
10.1111/jep.12596
[Indexed for MEDLINE]
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