Harvard Medical School, Boston, MA, USA.
Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
J Gen Intern Med. 2018 Apr;33(4):415-422. doi: 10.1007/s11606-017-4273-x. Epub 2018 Jan 4.
Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.
To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.
Cross-sectional study using explicit chart abstraction methods.
Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.
Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96).
Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
直肠出血是一种常见且常为良性的问题，但也可能是结直肠癌的早期症状。直肠出血的诊断评估较为复杂，临床实践可能与现有指南不符。
评估初级保健医生在记录有直肠出血症状的患者的结直肠癌风险因素方面的程度，并评估在有指征的情况下是否开具结肠镜检查单，以及根据人口统计学特征、就诊模式和临床表现，医生开具和患者接受推荐的结肠镜检查的可能性。
使用明确的图表提取方法进行的横断面研究。
2012 年至 2016 年期间，15 家学术附属的初级保健机构共招募了 300 名 40-80 岁的出现直肠出血的成年人。
1）记录患者病历中结直肠癌风险因素的频率，2）医生开具结肠镜检查单的频率和患者接受检查的频率，以及 3）根据患者的人口统计学特征、就诊模式和临床表现，评估医生开具和患者接受推荐的结肠镜检查的可能性。
记录结直肠癌风险因素的时间在 9%-66%之间。根据临床指南，大多数（89%）有直肠出血症状的患者需要进行结肠镜检查。医生为这些患者中的 74%开具了结肠镜检查单，其中 56%在一年内（36%在 60 天内）完成了结肠镜检查。与 40-50 岁的患者相比，50-64 岁的患者接受推荐的结肠镜检查的可能性显著更高（OR=2.23，95%CI：1.04，4.80），与最近一次结肠镜检查超过 5 年的患者相比（OR=4.04，95%CI：1.50，10.83）。对于每次与直肠出血无关的初级保健就诊，医生开具和患者接受推荐的结肠镜检查的可能性都显著降低（OR=0.85，95%CI：0.75，0.96）。
由于对风险因素评估不足以及优先考虑患者其他同时存在的医疗问题，对到初级保健机构就诊的出现直肠出血症状的患者进行的诊断评估可能并不理想。
