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



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.


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.


Cross-sectional study using explicit chart abstraction methods.


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).


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.


primary care rectal bleeding patient safety health services research 


Prior Presentations

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


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


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

11606_2017_4273_MOESM1_ESM.docx (15 kb)
ESM 1 (DOCX 14.7 kb)
11606_2017_4273_MOESM2_ESM.docx (155 kb)
ESM 2 (DOCX 155 kb)
11606_2017_4273_MOESM3_ESM.docx (52 kb)
ESM 3 (DOCX 52.4 kb)


  1. 1.
    American Cancer Society. Cancer Facts & Figures. 2016. American Cancer Society. Published 2016. Accessed 2 November 2017.
  2. 2.
    Neal RD, Tharmanathan P, France B, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review Br J Cancer. 2015;112:S92–107. doi: Scholar
  3. 3.
    Thompson MR, Asiimwe A, Flashman K, Tsavellas G. Is earlier referral and investigation of bowel cancer patients presenting with rectal bleeding associated with better survival? Color Dis. 2011;13(11):1242–8. doi: Scholar
  4. 4.
    Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol. 1998;93(11):2179–83. doi: Scholar
  5. 5.
    Eslick GD, Kalantar JS, Talley NJ. Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study. Color Dis. 2009;11(9):921–6. doi: Scholar
  6. 6.
    Crosland A, Jones R. Rectal bleeding: prevalence and consultation behaviour. BMJ. 1995;311(7003):486–8. doi: Scholar
  7. 7.
    Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc. 1999;49(2):228–38. doi: Scholar
  8. 8.
    Astin M, Griffin T, Neal RD, Rose P, Hamilton W. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br J Gen Pract. 2011;61(586):231–43. doi: Scholar
  9. 9.
    Tørring ML, Murchie P, Hamilton W, et al. Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries. Br J Cancer. 2017. doi:
  10. 10.
    Bishop TF, Ryan AM, Ryan AK, Casalino LP. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA. 2011;305(23):2427–31. doi: Scholar
  11. 11.
    Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145(7):488–96. doi: Scholar
  12. 12.
    Schiff GD, Puopolo AL, Huben-Kearney A, et al. Primary Care Closed Claims Experience of Massachusetts Malpractice Insurers. JAMA Intern Med. 2013;173(22):2063. doi: Scholar
  13. 13.
    Ford AC, Veldhuyzen van Zanten SJO, Rodgers CC, Talley NJ, Vakil NB, Moayyedi P. Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis. Gut. 2008;57(11):1545–53. doi: Scholar
  14. 14.
    Wahls TL, Peleg I. Patient- and system-related barriers for the earlier diagnosis of colorectal cancer. BMC Fam Pract. 2009;10(1):65. doi: Scholar
  15. 15.
    Weingart SN, Stoffel EM, Chung DC, et al. Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. Jt Comm J Qual Patient Saf. 2017;43(1):32–40. doi: Scholar
  16. 16.
    Singh H, Khan R, Giardina TD, et al. Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis. Qual Manag Health Care. 2012;21(4):252–61. doi: Scholar
  17. 17.
    Tomlinson C, Wong C, Au H-J, Schiller D. Factors associated with delays to medical assessment and diagnosis for patients with colorectal cancer. Can Fam Physician. 2012;58(9):e495–501. Accessed 2 November 2017.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Siminoff LA, Rogers HL, Thomson MD, Dumenci L, Harris-Haywood S. Doctor, what’s wrong with me? Factors that delay the diagnosis of colorectal cancer. Patient Educ Couns. 2011;84(3):352–8. doi: Scholar
  19. 19.
    Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims. J Gen Intern Med. 2012;27(11):1416–23. doi: Scholar
  20. 20.
    Allen AS, Orav EJ, Lee TH, Sequist TD. Clinician personality and the evaluation of higher-risk patient symptoms. J Patient Saf. 2011;7(3):122–6. doi: Scholar
  21. 21.
    Weingart SN, Stoffel EM, Chung DC, et al. Working up rectal bleeding in adult primary care practices. J Eval Clin Pract. 2016. doi:
  22. 22.
    Shields HM, Stoffel EM, Chung DC, et al. Disparities in evaluation of patients with rectal bleeding 40 years and older. Clin Gastroenterol Hepatol. 2014;12(4):669–75; quiz e33. doi: Scholar
  23. 23.
    Fisher DA, Zullig LL, Grambow SC, et al. Determinants of medical system delay in the diagnosis of colorectal cancer within the Veteran Affairs Health System. Dig Dis Sci. 2010;55(5):1434–41. doi: Scholar
  24. 24.
    American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. 2007. Accessed 2 November 2017.
  25. 25.
    Bitton A, Ellner A, Pabo E, et al. Launching the Harvard Medical School Academic Innovations Collaborative: Transforming primary care practice and education. Acad Med. 2014;89(9):1239–44. doi: Scholar
  26. 26.
    Chien AT, Kyle MA, Peters AS, et al. The degree to which practice configuration, size, and composition change while practices establish teams. J Ambul Care Manage forthcoming.Google Scholar
  27. 27.
    Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC. Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices. J Gen Intern Med. 2009;24(2):162–9. doi: Scholar
  28. 28.
    Xierali IM, Hsiao C-J, Puffer JC, et al. The rise of electronic health record adoption among family physicians. Ann Fam Med. 2013;11(1):14–9. doi: Scholar
  29. 29.
    Simon SR, McCarthy ML, Kaushal R, et al. Electronic health records: which practices have them, and how are clinicians using them? J Eval Clin Pract. 2008;14(1):43–7. doi: Scholar
  30. 30.
    Pasha SF, Shergill A, Acosta RD, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014;79(6):875–85. doi: Scholar
  31. 31.
    Controlled Risk Insurance Company. Prevention & Early Detection of Colorectal Cancer: A CRICO Decision Support Tool. Published 2014. Accessed 2 November 2017.
  32. 32.
    Zapka J, Taplin SH, Anhang Price R, Cranos C, Yabroff R. Factors in Quality Care—The Case of Follow-Up to Abnormal Cancer Screening Tests—Problems in the Steps and Interfaces of Care. JNCI Monogr. 2010;2010(40):58–71. doi: Scholar
  33. 33.
    Schiff GD, Bearden T, Hunt LS, et al. Primary Care Collaboration to Improve Diagnosis and Screening for Colorectal Cancer. Jt Comm J Qual Patient Saf. 2017;24(0):211–7. doi:
  34. 34.
    Agency for Healthcare Research and Quality. Chronic Condition Indicator (CCI) for ICD-9-CM. Accessed 2 November 2017.
  35. 35.
    Mounce LTA, Price S, Valderas JM, Hamilton W. Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records. Br J Cancer. 2017;116(12):1536–43. doi: Scholar
  36. 36.
    Murphy DR, Laxmisan A, Reis BA, et al. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf. 2014;23(1):8–16. doi: Scholar
  37. 37.
    Berkowitz SA, Percac-Lima S, Ashburner JM, et al. Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management. J Gen Intern Med. 2015;30(7):942–9. doi: Scholar
  38. 38.
    Percac-Lima S, Ashburner JM, Zai AH, et al. Patient Navigation for Comprehensive Cancer Screening in High-Risk Patients Using a Population-Based Health Information Technology System. JAMA Intern Med. 2016;176(7):930. doi: Scholar
  39. 39.
    Leffler DA, Neeman N, Rabb JM, et al. An Alerting System Improves Adherence to Follow-up Recommendations From Colonoscopy Examinations. Gastroenterology. 2011;140(4):1166–73.e3. doi:
  40. 40.
    Meyer AND, Murphy DR, Singh H. Communicating Findings of Delayed Diagnostic Evaluation to Primary Care Providers. J Am Board Fam Med. 2016;29(4):469–73. doi: Scholar
  41. 41.
    Lee J-H, Fulp W, Wells KJ, Meade CD, Calcano E, Roetzheim R. Effect of Patient Navigation on Time to Diagnostic Resolution among Patients with Colorectal Cancer-Related Abnormalities. J Cancer Educ. 2014;29(1):144–50. doi: Scholar
  42. 42.
    Reuland DS, Brenner AT, Hoffman R, et al. Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population. JAMA Intern Med. 2017;173(18):1725–32. doi: Scholar
  43. 43.
    Lasser KE, Murillo J, Lisboa S, et al. Colorectal Cancer Screening Among Ethnically Diverse, Low-Income Patients. Arch Intern Med. 2011;171(10):906–12. doi: Scholar
  44. 44.
    Wu CA, Mulder AL, Zai AH, et al. A population management system for improving colorectal cancer screening in a primary care setting. J Eval Clin Pract. 2016;22(3):319–28. doi: Scholar
  45. 45.
    Percac-Lima S, López L, Ashburner JM, Green AR, Atlas SJ. The longitudinal impact of patient navigation on equity in colorectal cancer screening in a large primary care network. Cancer. 2014;120(13):2025–31. doi: Scholar

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

Personalised recommendations