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1.  Post-Referral Colonoscopy Delays in Diagnosis of Colorectal Cancer: A Mixed-Methods Analysis 
Quality management in health care  2012;21(4):252-261.
Background
Delays in colorectal cancer (CRC) diagnosis are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied.
Aims
We used a mixed quantitative-qualitative approach to analyze post-referral colonoscopy delays in CRC patients and explored referring physician’s perception of processes surrounding these delays.
Methods
Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine post-referral 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 semi-structured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach.
Results
Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of post-referral 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; IQR=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.
Conclusion
Post-referral 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.
doi:10.1097/QMH.0b013e31826d1f28
PMCID: PMC3702372  PMID: 23011072
Diagnostic delays; colorectal cancer; primary care; referrals; practice patterns
2.  Reducing Referral Delays in Colorectal Cancer Diagnosis: Is It about How You Ask? 
Objectives
Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. We tested whether certain details of information transmitted through computerized provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed colorectal cancer (CRC).
Methods
We studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees, and other specialists. From the colonoscopy referral preceding CRC diagnosis, we determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. We compared distributions of proportions of diagnostic clues between patients with > 60 and ≤ 60 day lag and examined predictors of lag time.
Results
Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had lag > 60 days. Referrals associated with longer lag times included those with “positive fecal occult blood test” (92 days, P<0.0001), “hematochezia” (75 days, P=0.02), “history of polyps” (221 days, P=0.0006), and when “screening” (versus specific symptoms) was given as reason for diagnostic colonoscopy (203 days, P=0.002). Independent predictors of shorter wait times included 3 diagnostic clues, notation of urgency, and documentation of verbal contact.
Conclusions
Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.
doi:10.1136/qshc.2009.033712
PMCID: PMC2965264  PMID: 20584706
delayed cancer diagnosis; colorectal cancer; colonoscopy referrals; computerized order entry; electronic medical records; primary care
3.  Missed Opportunities to Initiate Endoscopic Evaluation for Colorectal Cancer Diagnosis 
Objectives
Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved.
Methods
We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described.
Results
Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR) = 2.3; 95% confidence interval (CI) 1.3–4.1) or with iron deficiency anemia (OR = 2.2; 95% CI 1.3–3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR = 0.06; 95% CI 0.01–0.51), or imaging suspicious for CRC (OR = 0.3; 95% CI 0.1–0.9). Anemia was the clue associated with the longest time to endoscopic referral (median = 393 days). Most process breakdowns occurred in the provider–patient clinical encounter and in the follow-up of patients or abnormal diagnostic test results.
Conclusions
Missed opportunities to initiate workup for CRC are common despite the presence of many clues suggestive of CRC diagnosis. Future interventions are needed to reduce the process breakdowns identified.
doi:10.1038/ajg.2009.324
PMCID: PMC2758321  PMID: 19550418
4.  Irritable Bowel Syndrome and Dyspepsia among Women Veterans: Prevalence and Association with Psychological Distress 
Background
The burden of functional GI disorders and their associations with psychological distress in women veterans is unclear.
Aim
To examine one-year prevalence of IBS and dyspepsia symptoms and their associations with anxiety, depression and PTSD among women veterans receiving primary care at a Veteran Affairs Medical Center Women’s Clinic.
Methods
IBS, dyspepsia and psychological distress were assessed using the validated self-administered Bowel Disorder Questionnaire, the Beck Depression and Anxiety Inventories, as well as the Mississippi Scale for Combat-Related posttraumatic stress disorder (PTSD) questionnaire.
Results
We enrolled 248 women (84% participation rate). Ninety-three (38%) reported IBS and 51 (21%) dyspepsia symptoms. Women with IBS and dyspepsia reported higher mean scores of anxiety (IBS: 24 vs. 12, p<.0005 and dyspepsia: 26 vs. 12, p <.0005), depression (IBS: 22 vs. 11, p=.0005 and dyspepsia: 23 vs. 11, p <.0005), and PTSD (IBS: 87 vs. 69, P<.001 and dyspepsia: 86 vs. 69, p <.0005). Age- and ethnicity-adjusted logistic regression analyses showed a 3- to 46-fold increase in odds of IBS and dyspepsia among women with anxiety, depression, or PTSD.
Conclusions
Women veterans have high prevalence of IBS and dyspepsia symptoms, both of which are highly associated with presence of depression, anxiety and PTSD.
doi:10.1111/j.1365-2036.2008.03847.x
PMCID: PMC2939246  PMID: 18785989

Results 1-4 (4)