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GI Claims Study: Failure to Follow Preventative Guidelines

By: Tracey Wilson, BSN, RN, CPHRM, CCM
4 Minute Read

The U.S. Preventive Services Task Force (USPSTF) was created as an independent, volunteer panel of national experts in prevention and evidence-based medicine. They work to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.

Colorectal cancer (CRC) is the second most common cause of cancer death among the U.S. population, most often occurring in adults 50 years of age and older. For this reason, the USPSTF recommends screening for CRC starting at age 50 and continuing until age 75. The survival rate of CRC can be up to 90% when diagnosed at the localized stage, making early diagnosis particularly critical. Most commonly, physicians will perform a colonoscopy to diagnose colon cancer. When performed properly, colonoscopies are generally safe, accurate, and well-tolerated by patients.

In this case study, we will examine the importance of following the recommended preventive guidelines from the USPSTF and the American Cancer Society for colon cancer screening. In this instance, failure to follow the guidelines as well as to provide appropriate referrals created a delay in diagnosing a patient with colon cancer, which resulted in her untimely death. We’ll also provide risk management strategies to help avoid a similar situation.

The Case:

A female in her 40s was an established patient with her family medicine practice for over six years. When the patient turned 50, she was seen for her annual physical and was never offered a screening colonoscopy, as recommended by the USPSTF and the American Cancer Society. In addition, the patient had a family history of colon cancer, yet there was no documentation in the medical record of a discussion with the patient regarding the recommended preventive care.

The patient was seen over a period of four years for various reasons:

  • During the year that the patient turned 50, she was seen by the physician assistant (PA) four times for general care and once by the insured physician. The insured physician also supervised all the PA visits. When the physician saw the patient that year, she was experiencing problems with her stomach, and he prescribed Zantac. Neither the PA nor the insured physician counseled or ordered a colonoscopy, as recommended by the USPSTF guidelines.
  • One year later, the PA saw the patient for a physical and again did not recommend a screening colonoscopy.
  • Two years later, the physician saw the patient for complaints of abdominal pain and symptoms consistent with irritable bowel syndrome. Levsin was prescribed, and “consideration of colonoscopy” was noted in the treatment plan. Unfortunately, the procedure was never ordered. The patient was seen again three months later for a follow-up visit, and again there was no mention of ordering a colonoscopy.
  • One year later, the patient returned to the office reporting blood in her stool and a two-week history of malaise. Due to the onset of chest pain during the office visit, the patient was transported to the local hospital for evaluation. During the hospitalization, rectal bleeding continued in small amounts. A rectal exam revealed tender external hemorrhoids and an anal fissure. On discharge from the hospital, a gastroenterology consult was strongly recommended.
  • A second PA saw the patient the day after she was discharged from the hospital. The PA documented a one-year history of abdominal pain, a five-to-ten-pound weight loss, and chronic fatigue. The PA did not discuss the recommendation for a gastroenterology consult or recommend a colonoscopy.
  • One month later, another physician in the practice saw the patient and ordered/performed a sigmoidoscopy with biopsy. A 25-cm, friable, and obstructing mass was discovered and biopsied. The pathology results indicated tubulovillous adenoma suspicious for invasive adenocarcinoma.

A surgical consult was ordered, and the patient underwent resection with omentectomy and colostomy six weeks later. The pathology report revealed widely-advanced recto sigmoid cancer with extensive intra-abdominal metastases. The patient underwent chemotherapy but the cancer continued to progress. She died eight months post diagnosis.

What Went Wrong?

Multiple providers in the practice saw the patient for a period of more than four years; however, none discussed the recommendation for the patient to schedule a screening colonoscopy at age 50. If the colonoscopy had been ordered and performed, then the cancer would have likely been detected and treated earlier, resulting in a more favorable outcome.

Once the patient began having problems, she saw multiple providers, and still no one checked to see if she had ever had a colonoscopy. After a hospitalization, a referral for gastroenterology was recommended, but no follow up was documented by any of the providers in the practice. The physician also supervised the PA who saw the patient on four occasions during this time, yet neither healthcare provider discussed the importance of a screening colonoscopy.

Risk Management Takeaways:

  • Physicians and advance practice providers (APPs) should follow the recommended preventative care guidelines for colonoscopy screening established by the USPSTF and the American Cancer Society. Counseling should be provided for any preventive care that is recommended, with questions answered and documented in the medical record. If the patient refuses to have the recommended preventive service, it should be documented in the medical record and an informed refusal form should be signed by the patient.
  • Hospital discharge instructions should be reviewed by the provider at the patient’s next office visit, and appropriate follow up should occur.
  • Previous problems should always be addressed at subsequent office visits to ensure the issues have been resolved.
  • The documentation of APPs should be periodically reviewed by supervising physicians to ensure care guidelines are being followed and documented.

To evaluate risk within your practice, Curi members are invited to take our Self Risk Assessments (SRAs), including the newly available GI SRA. Members can click here to begin their SRA today and receive actionable insights and suggestions as developed by our expert team of risk management professionals.

Tracey Wilson, BSN, RN, CPHRM, CCM
Tracey Wilson is a Senior Risk Consultant at Curi
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