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Singh H (HSR&D Houston Center for Quality of Care and Utilization Studies (HCQCUS); Baylor College of Medicine), Petersen LA
(HCQCUS; Baylor College of Medicine), Daci K
(Baylor College of Medicine), Khan M
(HCQCUS; Baylor College of Medicine), Collins C
(Baylor College of Medicine), El-Serag HB
(HCQCUS; Baylor College of Medicine)
Objectives:
Patient and provider-related delays in colorectal cancer (CRC) diagnosis have been described; however, delays due to colonoscopy consultations have not been studied. We evaluated the association between characteristics of the electronic consultation request and timeliness of diagnostic colonoscopy for CRC.
Methods:
We identified electronic consultations preceding the diagnosis of a primary CRC at a large VAMC from June 2001 to June 2007. Consulations for asymptomatic patients for screening were excluded. For patients with more than one consultation, only the first request was included. Data were collected on the nature of clinic information provided (i.e. symptoms, signs, test results), place of origin (inpatient/outpatient), urgency level, documented evidence of calling a consultant to expedite request, and the number of diagnostic clues provided in each consultation. We compared the distribution (as proportions) of diagnostic clues in two groups of patients with lag time, with < 60 and > 60 days from referral to colonoscopy performance, and used quantile regression to test associations between potential predictors of lag time identified in the consultation request and lag times.
Results:
Of 367 electronic consultations identified with a median lag of 57 days, 178 patients (48.5%) had lag > 60 days. Consultations more commonly 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 (203 days,p = 0.002) was used incorrectly as one of the diagnostic clues. The following variables had shorter median times in multivariable quantile regression: consultations with 3 clues (36.5 days; p = 0.0003), inpatient consultations (2.0 days, p < 0.0001), consultations with urgency marked for < 7 days (3.0 days; p < 0.0001), consultations with urgency marked for < 30 days (69.0 days; p < 0.0001), and outpatient consultations where additional discussion with a consultant was documented (20.0 days; p < 0.0001).
Implications:
Several characteristics of the consultation request were associated with lag times for diagnostic colonoscopy in patients with CRC. These include the nature as well as frequency of diagnostic clues, flagging urgency, and documenting discussions with consultants.
Impacts:
Closer attention to the quality and quantity of information transmitted to consultants and using certain features of electronic consult order-entry can expedite colonoscopy performance. In systems with limited endoscopic capacity, such as the VA; these techniques may reduce delays in CRC diagnosis.
