Lack of follow-up common for rectal bleeding in primary care

Patients who present with rectal bleeding in primary care often don't undergo further testing, a recent study found.

Researchers performed a retrospective cohort study of patients with an index diagnosis of rectal bleeding at an academic primary care practice and a community health center in Massachusetts between Jan. 1, 2018, and Dec. 31, 2020. Patients were categorized as having completed or not completed recommended follow-up (“closed loop” or “open loop”). A case was considered “closed loop” if an adequate diagnostic procedure had been done in the 24 months before or 12 months after the index diagnosis, if there was appropriate documentation that the patient had declined a recommended procedure, or if an alternative workup plan was documented and subsequently executed. “Open loop” cases were further classified as involving one of six categories of process failures. The study results were published Nov. 8 by the Journal of General Internal Medicine.

Of 770 included patients, 598 (77.7%) had timely recommended workup for rectal bleeding and 172 (22.3%) did not. “Closed loop” rates were similar in female and male patients (79.2% vs. 76.3%; P=0.338) and were lower in patients ages 40 to 49 years than in older patients (P=0.004) and in patients with Medicaid (66.7%) versus commercial insurance (78.0%) or Medicare (83.2%) (P=0.003). Most “closed loop” cases (87.5%) were considered closed because the patient had had a colonoscopy or sigmoidoscopy. Among the “open loop” cases, the most common categories of process failure were no procedure ordered (36%), procedures ordered but never scheduled (26%), or procedures scheduled but subsequently canceled or not completed (18%). Lack of completed follow-up testing increased after the COVID-19 pandemic began, but the difference during the study period was not statistically significant.

The authors concluded that their study adds to the literature indicating that many patients with rectal bleeding do not undergo timely follow-up testing. “Targeting patients for whom a procedural order has been placed but not completed or who have a high-risk problem coded in the chart with no procedural follow-up appear to be the highest-yield process interventions to create more effective closed loop follow-up of rectal bleeding,” they wrote. Potential solutions could include direct scheduling or patient self-scheduling, text message reminders, patient portal reminders, and clinician education, the authors said.