11/30/05njm

**Forum Discussion**

**#1 Case Presentation in 2 part**

**#2 Discussion captured onto this document**

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

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

The following is the first 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 please address 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?**

**[Case: Part I]{.underline}**

A 40 year old American Indian female presents to a remote ambulatory
care clinic with intermittent blood in her stool for the last 3 months.
She reported having chronic constipation, and believed that the blood
was due to her hemorrhoids. She had no significant past medical history;
there was no family history of colon cancer or bowel disease. She was on
no chronic medication, and did not smoke tobacco or drink alcohol. She
was employed at the local health department.   The 8 room outpatient
clinic is 120 miles from the closest regional center by 2 lane highway,
which includes a 45 mile detour due to road construction. The price of
fuel is \$ 2.85 per gallon and her 1994 Dodge pickup gets 13 miles per
gallon.   ("There are only two seasons: winter and construction season"
= Her Midwestern state highway department's motto)

The patient was found to have a normal abdominal examination on physical
examination by her primary care provider. No masses were palpable during
rectal examination; however, obvious external hemorrhoids were noted, as
well as a guaiac positive stool. Lab evaluation, including CBC, was
within normal limits.  The patient was treated with stool softeners, and
given three hemoccult cards to test her stool. She was asked to return
to clinic in two weeks. She kept this appointment and indicated that she
felt better. Since starting on the stool softeners, she noted that she
had not seen any blood in her stool. She also returned the three cards
at the time of this visit; two of the cards were guaiac positive.  The
patient was given a primary care follow up appointment for 4 weeks.

**IHS Morbidity and Mortality** **Objectives: Case 1**

1.  create a forum to discuss primary care M&M cases within the I/T/U
    settings

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1.  discuss specific case based quality of care issues

2.  recognize and comment on the unique and ubiquitous constraints
    within the IHS system  to providing primary and specialty care

**Case: Part 2**

**Thu 11/3/2005 5:17 AM**

The patient was given a primary care follow up appointment for 4 weeks,
and also referred to a gastroenterologist for further evaluation.

The patient was referred to the appointment desk to make this
appointment. The referral was entered into the local CHS (contract
health services) system and given a priority 1 score by the ordering
provider. The referral was subsequently reviewed by the CHS committee,
who agreed with the referring provider's assessment. The patient was
scheduled to see gastroenterology in 6 weeks from the time of the CHS
review (12 weeks from when she had been seen by her primary care
provider). Transportation was arranged for this appointment, since the
provider's office was 70 miles from the health care facility (but 120
miles from the patient's home). The patient failed to keep this
appointment due to a miscommunication about the arranged transportation.

Patient was subsequently seen 7 times over the next 14 months; during
this time period, she reported that her symptoms had resolved except for
intermittent constipation that was accompanied by blood in her stool.
However, during these episodes, the patient increased her stool
softener, and her symptoms resolved. She was re-examined by the primary
care provider during this time, but did not undergo an additional rectal
examination. She was not re-referred to gastroenterology due to the
belief that her symptoms were due to hemorrhoids. Her labs remained
stable.

15 months after her initial visit, she presented with frank blood per
rectum. She was transported to the nearest hospital with
gastroenterology services; she was found to have a 4 cm mass on rectal
exam, and was subsequently diagnosed with rectal carcinoma.

**Commentary:**

Patients presenting in small rural facilities are evaluated and
diagnosed based upon available resources. Minimizing misdiagnosis of
colorectal cancer has always been and will remain a challenge, requiring
an enlightened system of care as well as informed, expert caregivers,
and increased access to appropriate diagnostic evaluations

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?

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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?

**Tom Warcup \[twarcup@NARRAIND.NASHVILLE.IHS.GOV\]**

**Thu 11/3/2005 8:05 AM**

I think that there are some history points that would help me answer
question number on: Were there any stool caliber changes? Was there any
weight loss over the last 6 months that were not intentional? And was
there any pain associated with the bowel movements?

We could have performed an anoscopy in the office to increase the yield
for a mass in the rectal vault not reached by digital rectal exam, if
the facility has radiological services it would be helpful to look for
an apple core lesion.

Limited CHS dollars are always going to effect our communities, but
there is a concern that it was considered Cat 1 at one point; therefore,
the doctor felt that there may be something concerning. We still didn't
have the necessary data to clarify if there was an intestinal mass. Even
if CHS dollars are short, medico legally we should still make the
referral and have the CHS make their determination.

There are reports that a good use of limited dollars would be to have a
GI clinic even one session a month for example. Several option
potentially are purchase a flex sig and have a provider come out for a
straight hourly fee, train the local primary care doc to perform them,
or schedule a block of time at the hospital and transport a number of
patients at once on a revolving basis.

Tom Warcup

Clinical Director

Narragansett Indian Health Center

Charlestown, RI 02813

**Steve Burns MD \[sburns@KARUK.US\]**

**Fri 11/4/2005 12:14 PM**

By the way, I agree completely with Tom Warcup\'s comments in his last
paragraph\....unfortunately none of those options has worked for us.
Steve

**Steve Burns MD \[sburns@KARUK.US\]**

**Fri 11/4/2005 1:04 PM**

In further thinking about this I would add that our little town (800) is
so small that in cases like this we almost always can prevail upon the
patient to let us transport them up to the colonoscopy\...The town is
like a little family; people really care about one another\...so my
experience here is that with enough nagging from me whatever referral I
make gets eventually done\...the key is that the referral coordinator
closes the loop with me on all referrals\....so they don\'t slip through
the cracks. Sorry to respond in pieces; I\'m doing this between
patients. Steve

**Steve Burns MD \[sburns@KARUK.US\]**

**Fri 11/4/2005 12:10 PM**

I am Medical Director for the Karuk Tribe of California. We are located
in a remote region of California (150 mile round trip, by winding two
lane road, to any specialist or hospital). My clinic is in Happy Camp
California, where it is myself and an FNP.

We have three clinic sites and a total Native American user population
of about 2000. We also serve non-Native American members of the
communities. We have tele-consultation ability but no on site
specialists.

Immediately upon receiving the result of positive occult blood in the
stool I would have asked our referral coordinator to schedule a
colonoscopy for this patient. Our referral coordinator would have
alerted me to the fact that the patient missed her appointment and we
would have kept trying to schedule her (and documenting that)until we
got her in\...or until we had documented at least three efforts. At that
point I would have sent her a letter expressing my concern over possible
cancer, but putting the responsibility back on her to make her own
appointment.

25 years ago I had a 26 year old xray tech working for me who had some
BRB in her stool and hemorrhoids. I ordered a colonoscopy and she had
wide spread colon cancer (from which she died). So I learned not to let
hemorrhoids throw off the work up. Hope this helps, Steve

**Reidhead, Charles \[Charles.Reidhead@IHS.GOV\]**

**Wed 11/2/2005 8:25 PM**

Because this is an M&M setting, it is easy to be more concerned about
these \"obvious external hemorrhoids\" from the outset. That being said,
colonoscopy for further evaluation of rectal bleeding, especially when
an \"obvious\" reason for bleeding is available, becomes more difficult
to obtain (motivationally on my part and the patient\'s).

Until recently, here in Whiteriver, flexible sigmoidoscopy + BE has been
available for years and would have probably been the route that I would
have pursued for further evaluation. Because of patients\' disinterest
in further evaluation when they are already convinced of a diagnosis,
and the discomfort of that testing, further workup by this route
frequently ended up in missed appointments for the procedures. The
availability of colonoscopy was a minimum of 30 miles away and more
likely at least a 2.5 hour drive. Fortunately, we now have on site
colonoscopy, which will hopefully improve the chances that a patient
will follow-up for this test.

Outside of this M&M setting\... if I had a patient who is right at an
arbitrary age cut-off of 40 years old with a known source for rectal
bleeding, I would still offer the patient further evaluation (especially
because it is a bit odd to have chronic constipation in a 40 year old).
I usually tell them that \"I recommend that you get this test done.\"
The patient would probably not want to proceed, so I would then follow
them up in clinic and if the problem persisted, then try again to get
them to do it.

Finally, guaiac cards in a patient with known rectal bleeding is
probably not very helpful.

Thanks for pulling this together, Ty

**Tillman, Laura (PIMC) \[Laura.Tillman@IHS.GOV\]**

**Tue 11/8/2005 7:15 AM**

Dr. Burns has the correct answer\-- we cannot let the distances or lack
of resources that we so often encounter in this system prevent us from
making the maximal effort to do the correct thing for the patient. A
barium enema is often used to visualize the colon, and often this is
easier to obtain than colonoscopy, but, as Dr. Reidhead pointed out,
this MUST be used with visualization of the rectum (flex sig) or you can
miss a rectal cancer. I had a young female in her 30s that had been told
for several years that her blood with BMs was from hemorrhoids. Her
primary care doctor even got a barium enema (negative); we met her
several years later when she perforated her rectal cancer and
subsequently expired from metastatic disease.

Laura A. Tillman, M.D., F.A.C.S.

Chief of Surgery

Phoenix Indian Medical Center

4212 North 16th Street

Phoenix, AZ 85016

Office (602) 263-1512

**Heath, Stephen W. (ASU) \[Stephen.Heath@IHS.GOV\]**

**Tue 11/8/2005 8:42 AM**

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.

Steve Heath

IHS Risk Management Program

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Tue 11/8/2005 2:38 PM**

Does anyone think that the provider made a mistake?

**North, Charles \[Charles.North@IHS.GOV\]**

**Wed 11/9/2005 7:39 AM**

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.  Those of us reading the email discussion will be less
likely to make this mistake again, thanks to Dr. Cullen and to those of
you who commented.

 

I was surprised myself to have a sigmoidoscopy and barium enema ordered
after presenting to the local Air Force Base with hematochezia and an
anal fissure when in my 40's.  However, this relatively aggressive
approach should be the standard of care.  For those of us living in
cities, driving 120 miles seems like a long trip, but for those in rural
areas and reservations it is common to drive a long distance for any
service and should not deter clinicians from making referrals to
evaluate patients for cancer.  It is a shame that some people need to
hold bake sales to pay for medical bills while others receive free care,
but the cost of having colon cancer is much higher when it progresses,
so the case should be made for payment of screening, early diagnosis and
prompt treatment for many conditions.  Our federal government and most
at risk health providers have concluded that such a strategy is a winner
for individuals and payers.  It is our duty to convince our leaders and
managers to use Contract Health dollars for evaluations like the one
illustrated here.  In the absence of IHS or third party payment, it is
still our duty as clinicians to advocate appropriate evaluations for our
patients and assist them in receiving recommended care as other
discussants have said.

**Saari, John \[John.Saari@IHS.GOV\]**

**Wed 11/9/2005 7:53 AM**

There was a case in California, I believe, some years back where a
physician requested a diagnostic study that was not covered by the
payer.  He was held partially responsible for the patient's bad outcome
because, even though it was not covered, it was still medically
necessary, and it was his obligation to document that he told the
patient that he or she should still obtain it even if it was not
covered.  I believe the payer was also held partially responsible.  What
implications does this have for us when contract care denies a service?

**North, Charles \[Charles.North@IHS.GOV\]**

**Wed 11/9/2005 8:25 AM**

If the Federal Tort Claims Act covered the clinician, the tort claim
probably cost the ITU much more than the diagnostic study, clearly a
"penny wise and pound foolish" approach.  I believe it is incumbent upon
clinicians, especially clinical directors, chief clinical consultants
and service chiefs, to advocate for screening, early detection and
treatment of disease in the earliest possible stage to prevent loss of
life and function but also to use our resources wisely.  We as an Agency
have no problem paying for pap smears, but more of a problem paying for
mammograms and many problems with colon and rectal cancer screening and
evaluations for the disease.  I believe it is our duty to change the
agency approach which allows Contract Care to avoid paying for screening
and treatment of diseases of the colon and rectum.  Thanks again to Dr.
Cullen for bringing this topic to national discussion.

**Hays, Howard (PIMC) \[Howard.Hays2@IHS.GOV\]**

**Wed 11/9/2005 8:18 AM**

I think providers need to be very clear about the difference between
medical recommendations and CHS priorities, and we need to document all
medically indicated referrals, and our recommendations to the patient,
even if we know that CHS will deny them.  There is a tendency not to
refer if we know they will be denied -- to save work -- and then the
record looks like we haven't made the recommendation. 

**Heath, Stephen W. (ASU) \[Stephen.Heath@IHS.GOV\]**

**Wed 11/9/2005 8:32 AM**

We have had several tort claims filed against IHS where it was alleged
we should have paid for a particular service but did not.  All the
claims had other twists involved.  Basically, if it was the standard of
care for a patient to have a particular service and it was not provided,
then the IHS is potentially liable.  If the provider tried to order a
test/procedure but was blocked because of CHS regulations from obtaining
it for his/her patient, then the provider would not be held clinically
responsible, rather it would be considered a "system failure" that
resulted in the adverse outcome.  I know of one claim where the claimant
tried to find the CHS committee at fault for failing to approve a
particular test but the claim was unmerited in the first place.  A CHS
committee would not ever (in my opinion) be found at fault for following
Federal regulations, e.g. denying care that was not within medical
priorities

**Domer, Tim (FDIH) \[Tim.Domer@IHS.GOV\]**

**Wed 11/9/2005 8:45 AM**

The case that was presented was not a case of failing to obtaining a
screening study. The patient had documented blood in the stool and a
change in bowel habits.

I cannot imagine that if the CHS request was presented with this history
that anyone would deny CHS funds. I agree with Howard that documentation
is key -- this includes documentation on CHS requests.

I frequently have to return forms for more information.

**Beymer, Charles H. (PIMC) \[Charles.Beymer@IHS.GOV\]**

**Wed 11/9/2005 9:34 AM**

Excellent points have been made so far. I\'m struck that most involved
have been clear that 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.

**Masis, Kathleen (Billings) \[Kathleen.Masis@IHS.GOV\]**

**Wed 11/9/2005 9:59 AM**

What is the significance of a positive FOBT done at the time of an
annual Pap smear and breast exam?

Is it worth doing? It is not a recommended method of screening for colon
cancer.

Why do we still do it?

**North, Charles \[Charles.North@IHS.GOV\]**

**Wed 11/9/2005 10:43 AM**

According to "Accuracy of Screening for Fecal Occult Blood on a Single
Stool Sample Obtained by Digital Rectal Examination: A Comparison with
Recommended Sampling Practice" by Judith F. Collins et al from the VA
Cooperative Study #380 Group published in the 18 January 2005 Annals of
Internal Medicine (2005; 142:81-85) in a group of VA patients, almost
all men, they found:

 

-   A single result from DRE FOBT "is a poor screening method for
    colorectal neoplasia and cannot be recommended as the only test."

-   When performed as part of a primary care exam, a negative digital
    FOBT result does not correlate with a decreased risk of having
    advanced neoplasia.

-   Decreased mortality seen with use of FOBT in carefully controlled
    clinical trials often is not replicated in community practice
    because of the common use of in-office tests and inadequate
    follow-up.

 

I can think of no reason why these findings would not apply equally to a
population of women.  I do not use the rectal exam obtained stool as a
cancer screening tool.  It has been shown to be inadequate.  It may
provide diagnostically useful information and should not be abandoned
altogether in symptomatic patients, but it is not adequate as a
screening test for colon or rectal cancer in men or women.

**Neufeld, Brenda G (TUC) \[Neufeld@IHS.GOV\]**

**Wed 11/9/2005 11:00 AM**

Indeed we should always recommend needed tests and consults, and make
these referrals. This does point out, however, that the care that we are
actually able to provide to individual patients varies substantially.
CHS eligible patients have a good chance of receiving services depending
on available money. However, non-CHS eligible uninsured (\"notch
group\") urban patients receiving IHS care from facilities without
specialty services often find themselves with few or no options\--and
the provider finds him or herself in the role of chief commiserator.

**Tillman, Laura (PIMC) \[Laura.Tillman@IHS.GOV\]**

**Wed 11/9/2005 11:46 AM**

I agree with the point Dr. Beymer just made, that it must be clear to
the patient that colonoscopy is the only acceptable next step\-- often
these patients are referred to the surgeon to \"fix the hemorrhoids\"
without the appropriate screening work up to rule out other more serious
cause of bleeding.

Laura A. Tillman, M.D., F.A.C.S.\
Chief of Surgery\
Phoenix Indian Medical Center

**Tobe Propst \[TobePropst@SEMTRIBE.COM\]**

**Wed 11/9/2005 1:04 PM**

Great case and comments.

However, I feel like the provider in the case is getting beat up pretty
bad by all of us Monday morning quarterbacks. Here\'s my 2 cents:

I think the discussion should be rounded out with a few more points.
Timing is an issue here. Some journal articles have been cited, but
there are others that somewhat defend the provider\'s approach initially
at least. UpToDate has a great article on this called \"Approach to
minimal BRBPR\"\... here\'s an excerpt (the pt was 40, but what if she
was 39?):

Ages 40 to 50 - Patients with minimal BRBPR who are aged 40 to 50 and
who do not appear to be at increased risk for colorectal cancer based on
their presentation and history do not require additional testing, if an
actively bleeding anorectal source is found on physical examination or
anoscopy/proctoscopy. In the absence of such a source, patients should
undergo additional diagnostic testing with either sigmoidoscopy or
colonoscopy.

Age less than 40 - Patients with minimal BRBPR younger than 40 years are
at low risk of colorectal cancer (show figure 1). Thus, further
evaluation is not necessary, if the presentation and history do not
suggest an increased risk of cancer and a potential source of bleeding
(such as hemorrhoids or an anal fissure) is identified on physical
examination or anoscopy/proctoscopy. If no potential source is
identified, such patients should undergo sigmoidoscopy or perhaps
colonoscopy (see \"Sigmoidoscopy versus colonoscopy\" above).

This provider had at least a \"potential source\" of the blood in the
exernal hemorrhoids. More history asking about constitutional symptoms
or abdominal pain may have been useful, too. But what about the
constipation? That\'s is a historical clue that suggests possible
cancer. (The \"constipation\" is not really defined in the case and more
history would be important, but most would probably agree with a
definition of \"less than 3 BM\'s per week\"). Again, history as to
caliber and consistently may have been helpful too. Had the constipation
not been \"chronic\", but more acute/sub-acute, the majority might agree
that it would not be necessary to jump to endoscopy/imaging at the 1st
visit. Certainly we do not immediately send every patient with probable
hemorrhoids for colonoscopy.

This provider actually did order colonoscopy pretty quickly, and it was
actually approved by CHS, but the pt missed the appt. What\'s puzzling
is why it\'s not rescheduled during the course of multiple follow-ups
with continued intermittent constipation & blood. One might say the
BRBPR is from the hemorrhoids, and we know they\'re relieved if the
constipation is relieved with stool softeners, but what\'s the source of
the constipation? Perhaps a medication she takes or hypothyroidism or
something more rare like colorectal cancer. There should be some
progress made into also addressing the constipation in say, 2-3 months
of f/u. Otherwise, even without the blood, some further studies would be
indicated.

Also, colon cancer screening for average risk patients is not
recommended until 50yo by most groups, although this patient is not
average risk given these symptoms.

**Espey, David K (OPHS) \[David.Espey@IHS.GOV\]**

**Wed 11/9/2005 1:13 PM**

Greetings to the group and thanks for the invitation to join this
discussion. I\'ll briefly introduce myself - I\'m a medical
epidemiologist assigned from the CDC Division of Cancer for the last 5
years to the IHS Division of Epidemiology in Albuquerque. Before joining
CDC in 93 I worked for IHS at GIMC as staff internist for 2 yrs. My main
comment on this case is to concur with recommending and encouraging the
patient to undergo colonoscopy.

More importantly, since screening and follow-up capacity is a recurring
theme in this discussion, I would like to acquaint you with 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.

**McGee, Sue Ellen \[SueEllen.McGee@SRPMIC-NSN.GOV\]**

**Wed 11/9/2005 1:31 PM**

Wouldn\'t a positive be a positive, whenever it was obtained? A negative
wouldn\'t be much help, it wouldn\'t be adequate screening, but a
positive would require colonoscopy - This was demonstrated to me in a
truly unforgettable way about twenty years ago, when I found an operable
rectal cancer in a youngish woman that way.

S. E. McGee, M.D. Salt River

**Johnson, David E**

**Wed 11/9/2005 4:46 PM**

I think this raises two important issues.  Obviously if the screening
test is positive then it should be followed up with a definitive test. 
However, if the population for screening is not selected well, then you
increase the incidence of false positive tests, which will result in
unnecessary and potentially harmful tests.  Secondly, there is a concern
that doing a single FOBT in the clinic decreases the likelihood of
complete testing for FOB (3 cards with diet restriction, \...).  This is
supported by an article in the same Annals of Internal Medicine volume
referred to by Dr. North.  A study which looked at physician practices
in screening for FOB found that 32.5 % of primary care providers used
only in-office testing.  A normal test in the office may falsely
reassure both the provider and/or the patient and actually prevent
appropriate testing.

**Alan Waxman \[AWaxman@SALUD.UNM.EDU\]**

**Thu 11/10/2005 10:34 AM**

Hopefully no one is doing an \"annual\" Pap smear on previously well
screened 40 year olds. If they\'ve been previously negative, every 2-3
years is sufficient. I still do an annual gyn exam, but I no longer do
the digital fecal occult blood test. I do send asymptomatic women home
with guiac cards to collect under controlled circumstances and bring in
to the lab.

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Thu 11/10/2005 9:45 AM**

I appreciate everyone\'s discussion so far. I wonder if people want to
respond to the following questions:

1.  Dave Espey's information on training mid-level providers or others
    for rural sites

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1.  the nature of errors; perhaps this is really a 'blunt end' error ??
    I have copied some definitions from the AHRQ M&M glossary here for
    your information.

2.  

**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

**North, Charles \[Charles.North@IHS.GOV\]**

**Thu 11/10/2005 10:28 AM**

1.  I find Dr. Espey's comments about training midlevels in Alaska to be
    very interesting. There is precedence for training community members
    and other paraprofessionals to perform many functions in Alaska and
    it is the perfect site for such a program.  It will be important to
    have a well developed support, tracking and case management system
    to make the screening an effective public health tool that can
    actually reduce morbidity and mortality, which gets us to #2

2.   Errors, regardless of which end of the system, (we could get more
    colorful here) may be seen as opportunities for improvement for
    health systems.  The M&M case demonstrates the lack of a system to
    support the physicians plan.  We have improved the system for
    diabetics through our Diabetes National Program and for cervical
    dysplasia patients through the Breast and Cervical Cancer Program. 
    These programs have been successful to the extent that they have
    helped us garner support services that take non-medical activities
    from physicians and put them with nurses, pharmacists and clerks who
    have specific assignments to track and manage patients at risk.  I
    feel strongly that we will not make significant improvements in
    colon and rectal cancer screening, early detection and treatment
    until we take it out of the doctor dependent mode and create systems
    to support screening as we have for diabetes and pap smears.  One
    simple solution would be to add CRC screening to our diabetes
    summary sheets which serve as reminders. This would leverage the
    current diabetes system as we have for adult immunizations.
    Eventually we will have to commit resources and hire nurses and
    clerks to track and manage the system and patients who fall through
    the cracks. Of course training primary care providers is also an
    important part of improving access to colonoscopy.  We have plenty
    of examples, where will we find the resources and political will to
    develop the system?

**Kennon, Roy S (NSH) \[Roy.Kennon@IHS.GOV\]**

**Thu 11/10/2005 10:34 AM**

Thanks, Terry, for major contributions and insights.

It seems universal that deficiencies are present in every health care
system, and review of this fact situation would seem to confirm that in
this case. Further, however, the apparent deficiency of patient
education and clinical follow through, **and/or** **their
documentation**, amount to clinical errors of omission. The risk of a
finding of negligence appears quite substantial. Whether or not that
would afford the patient any benefit, or result in any financial
liability for the I.H.S. may track into a different discussion.

**Wilcox, Michael \[Michael.Wilcox@IHS.GOV\]**

**Thu 11/10/2005 12:26 PM**

Regarding the suggestion to train mid-level providers to perform
procedures at rural sites, I refer you to the document

**#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)

Regarding the suggestion to train mid-level providers to perform
procedures at rural sites, I refer you to the document \"Ensuring
Competence in Endosocopy,\" prepared by the American Society of
Gastrointestinal Endoscopy (ASGE) Taskforce on Ensuring Competence in
Endoscopy.  It is too lengthy to reproduce here.  The ASGE recognizes
that endoscopy is a tehnical skill, and also that cognitive skills are
required to place the findings of endoscopy in \"the approriate clinical
context so that appropriate diagnoses are made,\" and appropriate
treatment given.  The ASGE recommends that \"training in
gastrointestinal endoscopy should take place within the context of a
global training program in the fields of adult or pediatric
gastroenterology or general surgery.\" 

 

The ASGE has developed guidelines for training practitioners who seek
training outside of formal training programs, called \"Alternative
Pathways to Training in Gastrointestinal Endoscopy.\"

 

If you decide to proceed at your site to train providers to perform
gastrointestinal endoscopy, you should be aware of recommendations from
organizations such as ASGE.  You may decide not to follow their
recommendations, but that decision should be an informed decision.

Michael Wilcox, M.D., FACS

**Provost, Ellen M \[EMProvost@ANMC.ORG\]**

**Thu 11/10/2005 6:39 PM**

Thank you.

We are aware of the ASGE recommendations.

However in our health care delivery environment, which includes
significant geographic barriers and limited capacity to provide
colonoscopy statewide, we are trying innovative ways to address the
pressing need to improve colorectal cancer screening. Our Alaska Native
population has a mortality rate that is about 2x the U.S. White rates.
We are compelled to do something.

**Steele, Lois F (TUC) \[Lois.Steele@IHS.GOV\]**

**Thu 11/10/2005 2:42 PM**

Is anyone doing rectal exams? I lost a dear friend to colon/rectal
cancer, when the cancer was easy reach of an examing finger. The person
was told by an Indian Health Service physician the bloody stool was just
the result of hemorrhoids. A rectal exam would have found this cancer.

I also send guiac cards home with patients, and these are often brought
back. However, I will do a rectal in the clinic. We are lucky enough to
be able to get colonoscopies done when needed but have to send these
out. We were doing flex sig and BE in house but that has fallen by the
way side as more patients are sent out.

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Sat 11/12/2005 7:19 PM**

The following was in this week\'s ADA Newsletter, 01-NOV-2005

**Diabetes Raises Colon Cancer Risk**

People with diabetes \-- long known to be at higher risk for heart
disease, kidney failure, and eye and foot trouble \-- now have one more
thing to be concerned about: A new study finds they are also more
vulnerable to colon cancer.

\"Diabetics are 1.4 times more likely to have been told they have colon
cancer,\" says Dr. Donald Garrow, a clinical instructor and a masters in
clinical research fellow at the Medical University of South Carolina,
Charleston.

Garrow says other studies have found the same association, but he
believes his study is the largest cross-sectional survey to evaluate the
question of whether diabetics face a higher colorectal cancer risk.

Garrow was to present the findings Tuesday at the annual scientific
meeting of the American College of Gastroenterology in Honolulu.

His team based its findings on data involving more than 226,000
Americans, collected from 1997 to 2003 as part of the National Health
Interview Survey.

A total of 5.9 percent of respondents had a history of diabetes.

Even after compensating for other factors that affect risk \-- age,
gender, alcohol use, tobacco use and exercise \-- the researchers found
that individuals with diabetes were more likely than nondiabetics to
develop colon cancer.

Exactly why that might be isn\'t certain, Garrow says, but he notes that
elevated insulin levels in the blood of those with diabetes are thought
to affect cells in the colon\'s mucosal lining.

\"In the lab, these mucosal cells, when exposed to high levels of
insulin, develop into cancer cells,\" he says. \"There are insulin-like
receptors on the colon\'s mucosal cells. The insulin seems to attach
itself to the mucosal cells and cause changes that become cancer.\"

Most diabetics surveyed in the study had obesity-linked type 2 diabetes,
in which the body becomes insensitive to insulin. A minority had the
inherited type 1 form of diabetes, which results from the body\'s
failure to produce insulin: the hormone that helps glucose enter cells
of the body and supply them with energy.

An estimated 14.6 million people in the United States have been
diagnosed with diabetes, according to the American Diabetes Association.
More than 145,000 new cases of colorectal cancer are expected to be
diagnosed in the United States this year, according to the American
Cancer Society, and more than 56,000 patients will die from the disease.

Garrow says the study highlights the fact that diabetics must be
especially careful to follow colorectal cancer screening guidelines. The
American Cancer Society now recommends that, beginning at age 50, men
and women at average risk should be screened with tests such as the
fecal occult blood test, invasive exams such as sigmoidoscopy and
colonoscopy, and/or double barium enema.

Another expert, Dr. Kevin Adgent, says the research will inspire him to
\"look at my diabetic patients more closely.\"

Adgent, an internal medicine physician in Wilmington, N.C., says he
treats many patients with diabetes. Praising the study\'s large sample
size, he says the finding \"makes me more aware of getting my diabetic
patients screened properly.\"

(The HealthDay Web site is at
[[http://www.HealthDay.com]{.underline}](http://www.HealthDay.com/).)

**Espey, David K (OPHS) \[David.Espey@IHS.GOV\]**

**Tue 11/15/2005 8:41 AM**

Thanks to Drs. Wilcox and Provost,

The ASGE document referred to by Dr. Wilcox also recognizes the evidence
basis for training non-physician endocospists for screening flexible
sigmoidoscopy.

<http://www.acg.gi.org/physicians/pdfs/EnsuringCompetence.pdf>

 

\"The safety and efficacy of non-physicians performing flexible
sigmoidoscopy (i.e., the direct visual examination of a portion
comprising the lower 30--40% of the entire colon) as part of colon
cancer screening programs has been established.\"

 

It also includes legal cases and scenarios that emphasize legal
liability for inadequately trained clinicians. The document underscores
the importance of conducting this training such that Native Alaskans
receive safe, effective screening flexible sigmoidoscopy by adequately
trained providers who don\'t exceed their level of training, experience,
expertise or comfort.

 

Though our motivation is to address the capacity issue as stated by Dr.
Provost, a related matter is that colorectal cancer screening (and other
cancer screening) are now the standard of care in the US and the failure
to meet that standard has been and will increasingly be the subject of
medical liability claims. Providing CRC screening to such a high risk
population as Native Alaskans is a high prevention priority.

 

Finally, the success of this project hinges on several factors not the
least of which is the availability and willingness of endoscopists with
more advanced training and experience to perform diagnostic colonoscopy
on persons with positive findings on flexible sigmoidoscopy. Involving
these providers in the planning of screening programs in individual
facilities is crucial. Ideally they would also serve as mentors for the
trainees.

 

We appreciate comments and suggestions for improving colorectal cancer
in IHS and Tribal facilities. We will be sending out a survey sometime
in the near future to gather information about CRC screening practices
and capacity in your individual settings and thank you in advance for
taking a small amount of time to complete it.

 

Thanks to Neil for locating other relevant links relevant to the
discussion below:

 

**American Society for Gastrointestinal Endoscopy:**

**Ensuring Competence in Endoscopy Executive Briefing**

(for the hospital or health plan administrator)

<http://www.acg.gi.org/physicians/pdfs/ExecutiveBriefing.pdf>

**Alternative Pathways to Training in Gastrointestinal Endoscopy**

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

**American Society for Gastrointestinal Endoscopy:**

**Principles of Training in Gastrointestinal Endoscopy**

[[http://www.askasge.org/pages/guidelines/tg_principles.cfm]{.underline}](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]{.underline}](http://www.askasge.org/pages/guidelines/tg_short.cfm)

**Training**

[[http://www.askasge.org/pages/guidelines/training.cfm]{.underline}](http://www.askasge.org/pages/guidelines/training.cfm)

**Cullen, Theresa (OIT-Tucson) \[Theresa.Cullen@IHS.GOV\]**

**Wed 11/16/2005 5:12 PM**

Posting for someone listening in on the conversation. Terry

Fascinating discussion. Wonder what the consensus would be if she had
had a longer hx of irregular bowel movements (constipation, occasional
bloating, diarrhea).  I read that same article on rectal bleeding in
young people and was actually impressed at how little the overall
improvement in life expectancy was considering the aggressiveness of the
interventions. Hemorrhoids are obviously incredibly common (20-25%?) and
bleed with some frequency. I actually did a little bit of a lit review
and could find little commentary on this fact and how that then
translates to \"screening\" concerns. A rectal exam might be reasonable
but without otherwise obvious \"alarm\" signs such as more frank melena,
anemia, hematochezia etc. I need more convincing that it makes a
significant difference for me personally to get that colonoscopy. As a
patient I\'m not interested in it (colonscopy) for the sake of some
national screening goal - and  I\'m also not doing it to satisfy the
gastroenterology industry.

And I\'m impressed how anecdotes/experience also continue to drive our
behavior

Revisiting your comments\-- there may actually be some protective value
in the opacity of the system. Several related lines of interest - the
tendency for procedures to be performed based on the availability of the
proceduralist and not necessarily based on the known value of the
procedure with a concordant law that the more proceduralists there are
the more procedures there will be as long as someone is paying for
them - regardless of the disease burden; keeping in mind the relative
contributions to mortality of health risk factors vs. social/economic
risk factors with socioeconomic risk factors by far the larger
contributor; and the medical industry\'s internal economies which are
always pushing on expanding possibilities for reimbursement.

**Forum Discussion Resources available:**

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>