Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study.
Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study.
复制标题
比较初级保健中直肠出血和乳房肿块的诊断评估：一项回顾性队列研究。
DOI：
10.1007/s11606-019-05003-9
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发表时间：
2019
影响因子：
5.7
通讯作者：
Chien,AlynaT
中科院分区：
文献类型：
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作者：
Pace,LydiaE;Percac-Lima,Sanja;Nguyen,KevinH;Crofton,CharisN;Normandin,KatharineA;Singer,SaraJ;Rosenthal,MeredithB;Chien,AlynaT
背景：在初级保健中，对乳腺肿块和直肠出血的诊断评估不充分是医疗差错的重要来源。延迟在直肠出血的评估中尤为常见。比较在相同的实践环境中对这两种疾病进行和完成诊断检测的情况，可以帮助突出障碍并为干预措施提供信息。目的：研究在相同的实践中对乳房肿块和直肠出血进行诊断评估的过程，并在(a)根据指南订购诊断测试的可能性和(b)订单放置和完成的及时性方面进行比较。设计采用显式图表抽象方法进行回顾性队列研究。参与者：2012-2016年，来自15个学术附属初级保健诊所的300名年龄在30-80岁之间的乳房肿块女性和300名年龄在40-80岁之间的直肠出血男性和女性。主要措施测试订购和完成的比率和时间以及访问和沟通的模式。关键结果：与直肠出血患者相比，在初次就诊时，医生推荐乳房肿块患者接受影像学检查或手术的比例更高（97%对86%推荐接受影像学检查或内窥镜检查的患者；p< 0.01）。大多数（90%）乳房肿块患者在1个月内完成了推荐的诊断检查，而直肠出血患者的这一比例为31% （p< 0.01）。1年后，7%的乳房肿块患者没有完成指示性影像学检查，而直肠出血患者的这一比例为27%。有乳房肿块的患者在随后与症状相关或无关的初级保健就诊较少，与专家的相关交流较少。局限性：该研究依赖于有记录的护理，研究结果可能最适用于学术附属机构。结论直肠出血的诊断过程比乳腺肿块的诊断过程更不符合指南和及时。最大的差异发生在指定测试的初始排序和测试完成的及时性方面。
BackgroundInadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions.ObjectivesTo examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion.DesignA retrospective cohort study using explicit chart abstraction methods.ParticipantsThree hundred women aged 30–80 presenting with breast lumps and 300 men and women aged 40–80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012–2016.Main MeasuresRates and timing of test ordering and completion and patterns of visits and communications.Key ResultsAt initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy;p< 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p< 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists.LimitationsThe study relied on documented care, and findings may be most generalizable to academically affiliated institutions.ConclusionsDiagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.