Njm2/5/06

**Primary Care Forum Discussion**

**Morbidity and Mortality, Indian Health: Primary Care Discussion
Forum**

**Moderator: Terry Cullen, M.D.**

The following is the Summary of a 3 part morbidity and mortality case
conference presentation.  Web based materials and the other 2 segments
will be distributed at appropriate intervals.

(Multiple resources at the bottom of this document)

After reviewing the material presented below the Forum addressed these
questions in your initial discussion:

-What would be the next appropriate step?

-Would this have been managed differently at your clinic?

-How does the location of this clinic (or your clinic) affect your
decisions?

And then.....

Questions for discussion:

1.  Did the physician at the clinic make the right decision to wait to
    refer the patient to gastroenterology until the results of the stool
    guaiac on the second visit? Did the physician make a medical
    mistake?

```{=html}
<!-- -->
```
1.  What else could have been done during the next 14 months for this
    patient?

2.  Discuss the policies at your Service Unit regarding the referral of
    patients to and from specialty services.

3.  Discuss ways to increase access to diagnostic and screening services
    for colorectal cancer. What is the impact of limited CHS dollars?

4.  Other comments?

The full Discussion is captured here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#rectalBleed>

**Summary:**

**How to handle problems that seem to fall through the cracks?**

The health care provider, the health care system, and the patient all
bear some responsibility. As we really only have control over the first
two issues, the discussion centered on the provider and systematic
issues.

**The medical evidence:**

An evidence based answer can be found in the Annals of Internal Medicine
2002; 136:99-110, "Initial Evaluation of Rectal Bleeding in Young
Persons: A Cost-Effectiveness Analysis" by James D. Lewis, et al at U of
Pennsylvania.  The authors developed a Markov analytic decision model of
a 35 year old patient presenting with asymptomatic rectal bleeding.  Our
patient fits the description but also has constipation which strengthens
the case for evaluation.  Colonoscopy or barium enema plus flexible
sigmoidoscopy in all patients produced the greatest life expectancy. 
Diagnostic strategies visualizing the entire colon offered greater life
expectancy than strategies visualizing only part of the colon.  The
authors conclude that, based on cost-effectiveness analysis, rectal
bleeding in adults older than the mid-30's should be evaluated with
colonoscopy regardless of findings on anoscopy.  Based on the comments
of our peers and the authors, the provider did make a mistake.  It is a
common error that many of us have made.  We should not overlook the
possibility of colon or rectal cancer in patients with a hemorrhoid or
anal fissure. 

Known hemorrhoids should not dissuade one from pursuing a more
aggressive endoscopic evaluation of rectal bleeding at age 40 in an
average risk individual. The difficulties faced by a remote clinic are
only overcome by obsessive follow up and excellent records that other
providers can follow.  

Be clear with the patient that a colonoscopy is the only acceptable next
step, and document the potential consequences of noncompliance. A BE is
no longer an acceptable evaluation of rectal bleeding, by ACP and GI
society 2003 guidelines. It\'s sensitivity of 50% is well known to the
attorneys.

**The system:**

From a risk management standpoint, this type of case would benefit from
some type of defined

case coordination. Many facilities have individuals identified as
coordinators for Pap smear follow-ups due in part to the extreme
importance of pap smears in the early detection of cervical cancer. At
this time colon cancer screening is now also considered paramount, and a
similar case management coordinator could be identified to follow-up on
colon cancer screening. Although this case was not an example of
screening, rather one of a patient who already had a history of visible
blood in the stool, it represents the difficulties of getting these
people properly referred.

I realize it is difficult for small, remote facilities, but if a
protocol for follow-up and referral of heme-positive stool results could
be defined locally, a case manager could be notified of all positive
studies and help ensure that certain patients do not get lost to
follow-up.

**How to improve the system?**

The Indian Health system has a project we are supporting in Anchorage
with Ellen Provost to train mid-level providers from regional hospitals
in Alaska to perform flexible sigmoidoscopy as a primary screening for
Native Alaskans in rural areas where very little screening is currently
taking place. Training is didactic with hands on experience with a pt
simulator followed by 20 supervised procedures in Anchorage and 10
supervised on site in their facility by the NP/Trainer (the very
competent, Claudia Christensen). In the absence of dedicated screening
and very tight staffing, our premise is to select NP/PAs from facilities
that would commit to allowing the trainee to return and have dedicated
time to screen in a population with a very high burden of CRC. Three
providers have been trained to date and an additional 10-12 providers
over the next 2 and 1/2 years and hope to expand to primary care
physicians and interested providers from lower 48 who are in a position
to establish regular screening after training. We are using as a model
Alan Waxman\'s successful colposcopy training over the last 13 years in
which over 200 providers have been trained to do colposcopy.

We chose flex-sig as a starting point given substantial practical
advantages over colonoscopy (training time, risks, prep, no anesthesia,
precedents for NP/PAs doing, etc) and the fact that providing flex-sig
is vastly preferable to no screening whatsoever. FOBT has limited
usefulness in AK given high prevalence of H. pylori infection. The
reason I bring this project up is to get feedback from this group on
whether this training might be useful for your facility and other
possible models of increasing CRC screening capacity.

The target population for this project isn\'t symptomatic patients as in
this case but capacity for screening as well as diagnosis is an enormous
issue that we are trying to address

**How to approach error in general?**

**MISTAKES-** Mistakes reflect failures during attentional behaviors, or
incorrect choices. Rather than lapses in concentration (as with slips),
mistakes typically involve insufficient knowledge, failure to correctly
interpret available information, or application of the wrong cognitive
"heuristic" or rule. Thus, choosing the wrong diagnostic test or
ordering a suboptimal medication for a given condition represent
mistakes. A slip, on the other hand, would be forgetting to check the
chart to make sure you ordered them for the right patient.

**ERROR -** Errors of omission are more difficult to recognize than
errors of commission but likely represent a larger problem. In other
words, there are likely many more instances in which the provision of
additional diagnostic, therapeutic, or preventive modalities would have
improved care than there are instances in which the care provided quite
literally should not have been provided. In many ways, this point echoes
the generally agreed-upon view in the health care quality literature
that underuse far exceeds overuse, even though the latter historically
received greater attention.

**Blunt End** -- The \"blunt end\" refers to the many layers of the
health care system not in direct contact with patients, but which
influence the personnel and equipment at the "[sharp
end](http://www.webmm.ahrq.gov/glossary.aspx#sharpend%23sharpend)" who
do contact patients. The blunt end thus consists of those who set
policy, manage health care institutions, design medical devices, and
other people and forces, which, though removed in time and space from
direct patient care, nonetheless affect how care is delivered.\
\
Thus, an error programming an intravenous pump would represent a problem
at the sharp end, while the institution's decision to use multiple
different types of infusion pumps, making programming errors more
likely, would represent a problem at the blunt end. The terminology of
"sharp" and "blunt" ends corresponds roughly to "[active
failures](http://www.webmm.ahrq.gov/glossary.aspx#activefailures%23activefailures)"
and "[latent
conditions](http://www.webmm.ahrq.gov/glossary.aspx#latentcondition%23latentcondition)."

Refer to <http://www.webmm.ahrq.gov/glossary.aspx> for additional
details

**Other resources shared during this Discussion**

1.  **Colorectal cancer information, as well as patient hand outs**

> <http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp> -

2.  **Information on use of the clinical reporting system and
    documentation for colorectal cancer screening**

> <http://www.ihs.gov/cio/crs/>

3.  **Information on answering clinical questions**

> <http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir>

4.  **Information on different clinical guidelines**

> [www.guidelines.gov](http://www.guidelines.gov/)

5.  **Monthly M&M rounds sponsored by AHRQ on the web**

> <http://www.webmm.ahrq.gov/>

6.  **Many more resources and glossary found here**

> <http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp#rectalBleed>

**Privileges and Training Principles Documents**

**#1 American College of Gastroenterology**

Ensuring Competence in Endoscopy (for the GI physician)
[[http://www.acg.gi.org/physicians/pdfs/EnsuringCompetence.pdf]{.underline}](http://www.acg.gi.org/physicians/pdfs/EnsuringCompetence.pdf)

Ensuring Competence in Endoscopy Executive Briefing (for the hospital or
health plan administrator)

[[http://www.acg.gi.org/physicians/pdfs/ExecutiveBriefing.pdf]{.underline}](http://www.acg.gi.org/physicians/pdfs/ExecutiveBriefing.pdf)

**#2 American Society for Gastrointestinal Endoscopy**

Alternative Pathways to Training in Gastrointestinal Endoscopy

<http://www.askasge.org/pages/guidelines/tg_alternative.cfm>

Principles of Training in Gastrointestinal Endoscopy

<http://www.askasge.org/pages/guidelines/tg_principles.cfm>

Statement on Role of Short Courses in Endoscopic Training\
GUIDELINES for Clinical Application

<http://www.askasge.org/pages/guidelines/tg_short.cfm>

Training

<http://www.askasge.org/pages/guidelines/training.cfm>

**\# 3 Society of American Gastrointestinal Endoscopic Surgeons**

GRANTING OF PRIVILEGES FOR GASTROINTESTINAL ENDOSCOPY

<http://www.sages.org/sagespublication.php?doc=11>