Working up rectal bleeding in adult primary care practices

Rationale, aims and objectivesVariation in the workup of rectal bleeding may result in guideline‐discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians’ initial rectal bleeding evaluation.MethodsWe studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients’ sociodemographic characteristics, rectal bleeding‐related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline‐discordant workups.ResultsClinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline‐discordant care, which occurred in 27% of cases. Compared with patients at hospital‐based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3–6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance.ConclusionWorkup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one‐quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136454/1/jep12596.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136454/2/jep12596_am.pd

Screening for Chronic Conditions Using a Patient Internet Portal: Recruitment for an Internet-based Primary Care Intervention

Background: Patient Internet portals have created new opportunities for assessment and management of chronic conditions. Objective: To conduct an online screening survey for a study recruitment using a secure patient Internet portal to identify primary care patients with untreated depression, chronic pain, or mobility difficulty before nonurgent office visits. Design: Internet-based screening survey for a randomized trial. Participants: Patients who were registered portal users who had scheduled primary care appointments. Approach: Electronic study invitations via the portal were sent to 4,047 patients with scheduled visits to 34 primary care physicians participating in the study. After clicking on a link in the study invitation, patients were consecutively shown the study description, consent form, and lastly, the screening survey to determine final eligibility for study participation. Results: Of the 2,113 (52%) patients who opened the study invitation, 1,001 consented online to join the study and 981 (98%) of these completed the screening survey. Of the respondents, 319 (33%) screened positive for 1 or more of the 3 conditions. Conclusions: The online screening survey conducted through the patient portal was effective in identifying patients with chronic conditions in advance of scheduled primary care visits for participation in an intervention study

Incidence of Severe Pain in Newly Diagnosed Ambulatory Patients with Stage IV Cancer

BACKGROUND: Pain is common among cancer patients. OBJECTIVE: To characterize the incidence of severe pain among newly diagnosed patients with stage IV cancer in ambulatory care. METHODS: A retrospective cohort of 505 ambulatory oncology patients with newly diagnosed stage IV solid tumours at a comprehensive cancer centre (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) was followed from January 1, 2004, to December 31, 2006. Pain intensity scores were extracted from electronic medical records. The incidence of severe pain was calculated using the maximum monthly pain scores reported at outpatient visits. RESULTS: Of the 505 patients included in the present study, 340 (67.3%) were pain-free at the initial visit, 90 (17.8%) experienced mild pain, 48 (9.5%) experienced moderate pain and 27 (5.4%) experienced severe pain. At least one episode of severe pain within one year of diagnosis was reported by 29.1% of patients. Patients with head and neck, gastrointestinal and thoracic malignancies were more likely to experience severe pain compared with patients with other types of cancer (52.6%, 33.9% and 30.5%, respectively). In the multivariable model, patients whose primary language was not English (OR 2.90 [95% CI 1.08 to 7.80]), patients who reported severe pain at the initial visit (OR 9.30 [95% CI 3.72 to 23.23]) and patients with head and neck (OR 10.17 [95% CI 2.87 to 36.00]) or gastrointestinal (OR 4.05 [95% CI 1.23 to 13.35]) cancers were more likely to report severe pain in the following year. CONCLUSIONS: The incidence of severe pain was high in ambulatory patients with newly diagnosed stage IV cancer

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales

Objectives To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales. Methods A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors. Results Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors. Conclusion Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safet

Review of the outputs of the Safer Medication Team: final report

Medication errors are an ongoing and serious threat to public health in the United Kingdom and around the world. In 2007-08, 9% of the 850,000 adverse events reported to the National Patient Safety Agency’s Reporting and Learning System (RLS) were medication errors – the second greatest number after slips, trips and falls (numbers include both England1 and Wales2). Since 2002, the Safer Medication Team (SMT) of the National Reporting and Learning Service (NRLS) has been responsible for producing reports and advice to promote safer use of medications in a variety of clinical settings. In early 2009, the NRLS commissioned a team from the York Health Economics Consortium (YHEC) at the University of York and Cardiff University School of Nursing and Midwifery to review the SMT’s outputs together with a member of the faculty of Harvard Medical School and Dana-Farber Cancer Institute in Boston. The review sought to examine the types of outputs, the selection of topics and the development, dissemination, implementation of guidance. It also sought to explore the perceptions of target audiences and, crucially, the impact of these work products on clinical care and outcomes

US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards

Given wide variation in the implementation of ASCO/Oncology Nursing Society chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement