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Journal of General Internal Medicine

, Volume 33, Issue 4, pp 415–422 | Cite as

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

  • Sanja Percac-Lima
  • Lydia E. Pace
  • Kevin H. Nguyen
  • Charis N. Crofton
  • Katharine A. Normandin
  • Sara J. Singer
  • Meredith B. Rosenthal
  • Alyna T. Chien
Original Research

Abstract

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.

KEY WORDS

primary care rectal bleeding patient safety health services research 

Notes

Prior Presentations

This study was presented at the 40th Society of General Internal Medicine Annual Meeting in Washington, DC, April 2017.

Contributors

The authors would like to thank Dr. Gordon Schiff for his comments on a pre-submission draft of this paper.

Funders

Harvard Medical School Center for Primary Care; the Controlled Risk Insurance Company Risk Management Foundation of the Harvard Medical Institutions Incorporated. Sanja Percac-Lima was supported in part by the American Cancer Society Cancer Control Career Development Award for Primary Care Physicians, CCCDAA-14-012-01-CCCDA, and the Lazarex Cancer Foundation. While the funders supported the AIC and/or AIC CARES interventions, they were not involved in the design or conduct of the study, or the collection, management, analysis, or interpretation of the data, and had no role in shaping, approving, or deciding to submit the editorial content of this manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Sanja Percac-Lima
    • 1
    • 2
  • Lydia E. Pace
    • 1
    • 3
  • Kevin H. Nguyen
    • 4
  • Charis N. Crofton
    • 5
  • Katharine A. Normandin
    • 5
  • Sara J. Singer
    • 1
    • 4
    • 6
  • Meredith B. Rosenthal
    • 4
  • Alyna T. Chien
    • 1
    • 5
  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.Division of General Internal MedicineMassachusetts General HospitalBostonUSA
  3. 3.Division of Women’s HealthBrigham and Women’s HospitalBostonUSA
  4. 4.Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonUSA
  5. 5.Division of General Pediatrics, Department of MedicineBoston Children’s HospitalBostonUSA
  6. 6.Mongan InstituteMassachusetts General HospitalBostonUSA

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