Weingart Saul N, Stoffel Elena M, Chung Daniel C, Sequist Thomas D, Lederman Ruth I, Pelletier Stephen R, Shields Helen M
Jt Comm J Qual Patient Saf. 2017 Jan;43(1):32-40. doi: 10.1016/j.jcjq.2016.10.001. Epub 2016 Oct 13.
Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.
In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.
Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.
Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.
虽然延迟性结直肠癌诊断在医疗事故索赔中占显著比例，但对于基层医疗临床医生对直肠出血的检查质量却知之甚少。
在本研究中，通过国际疾病分类第九版临床修订本（ICD - 9 - CM）编码，在波士顿的10家成人基层医疗诊所识别出438例直肠出血、痔疮和便血患者。在护士提取病历后，医生评审员评估了整体护理质量和关键护理流程。将受试者的特征和医生评审员的护理流程评估制成表格，并使用逻辑回归模型来检验流程失误与整体质量和指南一致性之间的关联。
尽管评审员在438例病例中的337例（77%）中判定整体护理质量为良好或优秀，但312例（71%）患者在直肠出血检查中至少经历了一次护理流程失误。临床医生在38%的病例中未获取充分的家族史，23%未完成相关体格检查，16%未开具实验室检查。未开具或未进行检查以及未制定后续计划与护理质量差或一般的几率增加相关。指南一致性与质量判断关系不大。评审员判定128例延迟情况本可减少或避免。
成年基层医疗直肠出血患者的护理流程失误频繁发生，且与质量一般或较差相关。对从业者进行教育并建立系统以确保充分采集病史、进行体格检查以及制定开具、执行和解读诊断检查的流程，可能会改善医疗表现。
