Singh Hardeep, Khan Rashid, Giardina Traber Davis, Paul Lindsey Wilson, Daci Kuang, Gould Milena, El-Serag Hashem
Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA.
Qual Manag Health Care. 2012 Oct-Dec;21(4):252-61. doi: 10.1097/QMH.0b013e31826d1f28.
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.
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.
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.
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.
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.
结直肠癌（CRC）诊断延迟是医疗事故索赔的最常见原因之一，并导致不良后果。然而，对此研究并不充分。
我们采用定量与定性相结合的方法分析CRC患者转诊后结肠镜检查的延迟情况，并探讨转诊医生对这些延迟相关过程的看法。
两名医生评估者对一个大型综合安全网系统中的新发CRC病例进行独立的电子健康记录审查，以确定转诊后结肠镜检查的延迟情况，我们将其定义为未能在转诊既定指征后的60天内进行结肠镜检查。为了探讨对结肠镜检查过程的看法，我们对初级保健医生（PCP）样本进行了半结构化访谈，并采用了内容分析方法。
在104例符合纳入标准的CRC病例中，评估者对35例（33.7%）存在转诊后结肠镜检查延迟达成一致；κ=0.99（95%CI，0.83 - 0.99）。首次转诊至结肠镜检查完成的中位时间为123.0天（范围62.0 - 938.0；四分位间距=90.0天）。在约三分之二的情况（64.8%）中，延迟原因是与胃肠病科服务的未来预约延迟。在访谈中，初级保健医生将长时间的预约延迟归因于内镜检查能力下降以及与结肠镜检查转诊和预约相关的低效流程，包括转诊指南存在相当大的模糊性。许多人建议应用导航模型来简化CRC诊断。
CRC诊断中的转诊后延迟可能是可预防的。一种全面的混合方法学可能有助于其他人识别诊断过程中最需要改进的步骤。
