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

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 < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS: The 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.

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding.

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.