Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA.
J Clin Oncol. 2010 Jul 10;28(20):3307-15. doi: 10.1200/JCO.2009.25.6636. Epub 2010 Jun 7.
Understanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-based records. We used an integrated electronic health record (EHR) to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer.
Using a retrospective cohort design, we evaluated 587 patients of primary lung cancer at two tertiary care facilities. Two physicians independently reviewed each case, and disagreements were resolved by consensus. Type I missed opportunities were defined as failure to recognize predefined clinical clues (ie, no documented follow-up) within 7 days. Type II missed opportunities were defined as failure to complete a requested follow-up action within 30 days.
Reviewers identified missed opportunities in 222 (37.8%) of 587 patients. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively (P < .001). Abnormal chest x-ray was the clue most frequently associated with type I missed opportunities (62%). Follow-up on abnormal chest x-ray (odds ratio [OR], 2.07; 95% CI, 1.04 to 4.13) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18) were associated with type II missed opportunities. Patient adherence contributed to 44% of patients with missed opportunities.
Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include EHR-based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.
要了解癌症诊断的延误情况，就需要详细了解及时识别和跟进体征和症状的信息。但这些信息很难从纸质记录中确定。我们使用集成的电子健康记录（EHR）来确定错失早期诊断肺癌机会的特征和预测因素。
我们使用回顾性队列设计，评估了两家三级保健机构的 587 名原发性肺癌患者。两名医生独立审查了每个病例，如果存在分歧，则通过共识解决。第一类错失机会被定义为在 7 天内未能识别预定的临床线索（即没有记录的随访）。第二类错失机会被定义为未能在 30 天内完成请求的随访行动。
在 587 名患者中，有 222 名（37.8%）被发现存在错失机会。有和没有错失机会的病例的中位诊断时间分别为 132 天和 19 天（P <.001）。异常的胸部 X 光检查是与第一类错失机会最相关的线索（62%）。对异常胸部 X 光检查进行随访（优势比 [OR]，2.07；95%置信区间，1.04 至 4.13）和完成第一次针吸活检（OR，3.02；95%置信区间，1.76 至 5.18）与第二类错失机会相关。患者的坚持性导致 44%的有错失机会的患者。
肺癌诊断的可预防延误主要源于未能及时识别记录的异常影像学结果和未能及时完成关键诊断程序。潜在的解决方案包括基于 EHR 的策略，以提高对异常影像学的识别和跟踪疑似癌症的患者。
