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Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care

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Abstract

Background

Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer.

Objective

Identify loop closure rates and vulnerable process points for patients with rectal bleeding.

Design

Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices—an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020. Patients were classified as having completed recommended follow-up workup (“closed loop”) vs. not (“open loop”). Open loop patient cases were categorized into six types of process failures.

Participants

A total of 837 patients had coded diagnoses of rectal bleeding within study window. Sixty-seven were excluded based on prior colectomy, clinical presentation more consistent with upper GI bleed, no rectal bleeding documented on chart review, or expired during the follow-up period, leaving 770 patients included.

Main Measures

Primary outcomes were percentages of patient cases classified as “open loops” and distribution of these cases into six categories of process failure that were identified.

Key Results

22.3% of patients (N = 172) failed to undergo timely recommended workup for rectal bleeding. Largest failure categories were patients for whom no procedure was ordered (N = 62, 36%), followed by patients with procedures ordered but never scheduled (N = 44, 26%) or scheduled but subsequently cancelled or not kept (N = 31, 18%). While open loops increased after the onset of the COVID-19 pandemic, this difference was not significant within our study period.

Conclusions

Significant numbers of patients presenting to primary care with rectal bleeding fail to undergo recommended workup. The majority either have no procedure ordered, or procedure ordered but never scheduled or cancelled and not kept, suggesting these are important failure modes to target in future interventions. Ensuring reliable ordering and processes for timely scheduling and completion of procedures represent critical areas for improving the diagnostic process for patients with rectal bleeding in primary care.

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Funding

This work was supported in part by the Agency for Healthcare Research and Quality (AHRQ) grant 1R18HS027282.

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Authors and Affiliations

  1. Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Kirsti A. Campbell MD, Sarah N. Flier MD & Joseph Feuerstein MD

  2. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Scot B. Sternberg MS, Maelys Amat MD, MBA, Talya Salant MD, Leonor Fernandez MD, Umber Shafiq MPH & Mark D. Aronson MD

  3. Healthcare Systems Engineering Institute, College of Engineering, Northeastern University, Boston, MA, USA

    James Benneyan PhD & Keishi Nambara MS

  4. Harvard Medical School Center for Primary Care, Boston, MA, USA

    Russell S. Phillips MD & Gordon D. Schiff MD

  5. General Medicine Division, Brigham and Women’s Hospital, Boston, MA, USA

    Gordon D. Schiff MD

Authors
  1. Kirsti A. Campbell MD
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  2. Scot B. Sternberg MS
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  3. James Benneyan PhD
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  4. Sarah N. Flier MD
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  5. Maelys Amat MD, MBA
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  6. Talya Salant MD
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  7. Keishi Nambara MS
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  8. Leonor Fernandez MD
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  9. Joseph Feuerstein MD
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  10. Umber Shafiq MPH
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  11. Russell S. Phillips MD
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Corresponding author

Correspondence to Gordon D. Schiff MD.

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

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Mark D. Aronson and Gordon D. Schiff share senior authorship.

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Campbell, K.A., Sternberg, S.B., Benneyan, J. et al. Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care. J GEN INTERN MED 39, 985–991 (2024). https://doi.org/10.1007/s11606-023-08513-9

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  • DOI: https://doi.org/10.1007/s11606-023-08513-9

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