Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis.

BACKGROUND: Delays in diagnosis of colorectal cancer (CRC) are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied. AIMS: We used a mixed quantitative-qualitative approach to analyze postreferral colonoscopy delays in CRC patients and explored referring physician's perception of processes surrounding these delays. METHODS: Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine postreferral colonoscopy delays, which we defined as failures to perform colonoscopy within 60 days of referral for an established indication(s). To explore perceptions of colonoscopy processes, we conducted semistructured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach. RESULTS: Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of postreferral colonoscopy delays in 35 (33.7%) cases; κ = 0.99 (95% CI, 0.83-0.99). The median time between first referral and completion of colonoscopy was 123.0 days (range 62.0-938.0; interquartile range = 90.0 days). In about two-thirds of instances (64.8%), the reason for delay was a delayed future appointment with the gastroenterology service. On interviews, PCPs attributed long delays in scheduling to reduced endoscopic capacity and inefficient processes related to colonoscopy referral and scheduling, including considerable ambiguity regarding referral guidelines. Many suggested that navigation models be applied to streamline CRC diagnosis. CONCLUSION: Postreferral delays in CRC diagnosis are potentially preventable. A comprehensive mixed-methods methodology might be useful for others to identify the steps in the diagnostic process that are in most need for improvement.

Reducing referral delays in colorectal cancer diagnosis: is it about how you ask?

OBJECTIVES: Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC. METHODS: The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time. RESULTS: Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with 'positive faecal occult blood test' (92 days, p<0.0001), 'haematochesia' (75 days, p=0.02), 'history of polyps' (221 days, p=0.0006) and when 'screening' (vs specific symptoms) was given as the reason for diagnostic colonoscopy (203 days, p=0.002). Independent predictors of shorter wait times included three diagnostic clues, notation of urgency and documentation of verbal contact. CONCLUSIONS: Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.

OBJECTIVES: Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved. METHODS: We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described. RESULTS: Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR)=2.3; 95% confidence interval (CI) 1.3-4.1) or with iron deficiency anemia (OR=2.2; 95% CI 1.3-3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR=0.06; 95% CI 0.01-0.51), or imaging suspicious for CRC (OR=0.3; 95% CI 0.1-0.9). Anemia was the clue associated with the longest time to endoscopic referral (median=393 days). Most process breakdowns occurred in the provider-patient clinical encounter and in the follow-up of patients or abnormal diagnostic test results. CONCLUSIONS: Missed opportunities to initiate workup for CRC are common despite the presence of many clues suggestive of CRC diagnosis. Future interventions are needed to reduce the process breakdowns identified.

Efeito da metilprednisolona na lesão medular em ratos: análise funcional e histológica / Effect of methylprednisolone in medullar injury in rats: a functional and histological analysis

Os efeitos farmacológicos da metilprednisolona têm sido investigados no tratamento da lesão medular. Foi realizado estudo experimental com doze ratos wistar submetidos à lesão contusa da medula espinhal pelo sistema NYU. Os animais foram divididos em dois grupos: grupo MP, que recebeu metilprednisolona após a lesão contusa e o grupo controle, que recebeu soro fisiológico a 0,9 por cento. Foi realizada análise da recuperação funcional locomotora utilizando-se o teste de BBB no 2°, 7° e 14° dias após a contusão No décimo quarto dia, os ratos foram sacrificados e analisados os achados histólogicos da medula lesada. Observou-se que os ratos do grupo MP apresentaram melhora na recuperação da função locomotora em comparação com o grupo e que os achados histológicos da medula lesada não puderam ser correlacionados com a recuperação da função locomotora.

Prescriçäo e aderência das estatinas em pacientes com doença arterial coronariana e hipercolesterolemia / Prescription and adherence to statins of patients with coronary artery disease and hypercholesterolemia

OBJECTIVE: Statins have proved to be safe and effective in the secondary prevention of coronary artery disease, but the level of prescription and the reasons for nonadherence to treatment in many coronariopathy treatment centers has not been determined. The purpose of this study was to identify reasons for nonadherence to statin therapy. METHODS: We analyzed 207 consecutive patients with coronary artery disease and hypercholesterolemia (total cholesterol > or = 200mg/dL or LDL - cholesterol > or = 130mg/dL). Patients' average age was 61.7 + or - 10 year; 111 (53.6 percent) male were and 94 (46.6 percent) were female. We analyzed the level of prescription and adherence to treatment with statins. RESULTS: Statins were prescribed for 139 (67 percent) patients, but only 85 (41 percent) used the drug. In spite of being indicated, statins were not prescribed in 68 (33 percent) patients. Of 54 (26 percent) patients, nonadherent to statins, 67 percent did not use the drug due to its high cost, 31 percent due to the lack of instruction, and only 2 percent due to side effects. Total cholesterol (260.3Ý42.2 vs 226.4 + or -51.9; p<0.0001) and LDL cholesterol (174.6 + or -38.1 vs 149.6 + or - 36.1; p<0.0001) were lower in patients on medication. HDL-cholesterol increased from 37.6 + or -9.6 to 41.5 + or -12.9mg/dL (p=0.02), and triglycerides were not modified in patients using statins. CONCLUSION: The prescription of statins in patients with coronary artery disease and dyslipidemia is high; however, its adherence is far from satisfactory, due to the high cost of the medication. Reduction in total cholesterol and LDL cholesterol levels did not reach the targets recommended by the Brazilian Consensus on Dyslipidemia