Center for Vulnerable Populations, UCSF.
J Patient Saf. 2022 Jan 1;18(1):e163-e171. doi: 10.1097/PTS.0000000000000718.
Safety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net.
We conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay.
We identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes.
Current protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperability between PCP and gastroenterology scheduling systems, protocols to follow-up on incomplete colonoscopies, accommodation for support and transport needs, and patient-friendly education. Interviewing both patients and PCPs leads to richer analysis of the root causes leading to delayed diagnosis of colorectal cancer.
为弱势群体服务的安全网医疗保健系统在阳性粪便潜血试验 (FOBT) 后进行及时结肠镜检查的延迟时间更长，这可能导致现有的差异。我们试图确定初级保健安全网中阳性 FOBT 结果后结肠镜检查延迟的根本原因。
我们对延迟结肠镜检查的病例进行了多地点根本原因分析，确定了在阳性 FOBT 后，完成或安排后续结肠镜检查的时间超过 6 个月的病例。我们在 5 个为低收入、弱势群体服务的加利福尼亚卫生系统中确定了病例。我们根据以往的工作制定了一个半结构化访谈指南。我们对初级保健提供者 (PCP) 和患者进行了电话个人访谈。然后，我们使用综合归纳演绎分析方法对访谈进行了定性内容分析，以确定与结肠镜检查延迟的反复根本原因相关的主题。
我们确定了 12 个独特的病例，包括 5 名患者和 11 名 PCP 访谈。8 名患者完成了结肠镜检查；结肠镜检查的中位时间为 11.0 个月（四分位间距，6.3 个月）。3 名患者有高级腺瘤性发现。初级保健提供者强调了系统层面的根本原因，包括无法在初级保健和胃肠病学之间跟踪转诊、缺乏跟进患者的协议、电子病历互操作性差以及缺乏时间或人员资源，这迫使工作人员付出巨大的额外努力。相比之下，患者强调的个人层面的根本原因包括合并症、社会需求和对 FOBT 重要性的误解。PCP 和患者引出的根本原因之间几乎没有重叠。
目前的方案不适应初级保健和胃肠病学之间的沟通。为解决确定的特定障碍而采取的干预措施包括改善初级保健和胃肠病学预约系统之间的互操作性、针对不完整结肠镜检查的跟进协议、适应支持和运输需求以及患者友好的教育。对患者和 PCP 进行访谈可更深入地分析导致结直肠癌诊断延迟的根本原因。
