GI Claims Case Study:  Failure to Follow Up With Recommended Treatment

Colonoscopy is the most commonly ordered test for the diagnosis and treatment of colon disorders, including colon cancer. According to the American Cancer Society, when colorectal cancer is found at an early stage before it has spread, the five-year survival rate is roughly 90%. However, when cancer has metastasized outside of the colon or rectum, survival rates significantly decrease.

Most colorectal cancers develop from growing polyps that were not removed, and screening tests for colorectal cancer can detect pre-cancerous polyps before they become malignant. In this case study, we will examine how a failure to follow up with the recommended treatment plan delayed the diagnosis of colon cancer, resulting in the patient’s untimely death. We’ll also provide risk management strategies to help avoid a similar situation.

The Case:

A 25-year-old patient was referred to the gastroenterologist for abdominal cramps, rectal bleeding, and esophageal reflux. The physician performed a colonoscopy, which revealed a large pandiculated polyp, located approximately 20 cm from the anal verge. The pathology results indicated cancer cells in the polyp, but the stalk of the polyp appeared to be clear. The physician advised the patient that he would require a yearly colonoscopy for follow up, and the pathologist sent the slides out for a second opinion. The second pathology report confirmed the first pathology findings, but also found a cluster of cancer cells in another area. This area was described as a retraction artifact or a lymphovascular channel invasion (when the cancer cells have traveled to the lymph or blood systems). This second report did not make a firm therapeutic recommendation.

Based on the second pathology report, the physician contacted the patient and requested he schedule an appointment to discuss the findings and next steps. The patient was given the option of surgical resection or a follow-up colonoscopy in six months. The patient decided not to undergo surgery and chose to have a colonoscopy in six months.

Six months later, the physician performed a follow-up colonoscopy and found no evidence of cancer or polyps. The physician recommended follow up in one year. The patient did not return for the one-year follow up despite several reminder letters sent from the practice.

The patient later moved to Maine and a colonoscopy was performed 15 months after the follow-up colonoscopy. The colonoscopy performed in Maine showed the presence of another large polyp. Surgery was performed, which revealed the presence of cancer that had metastasized to multiple organs. The patient died two years later.

What Went Wrong?

All the experts consulted agreed that the patient would have had a high probability of cure with surgical resection after the first colonoscopy. The physician discussed the option for surgery or follow-up colonoscopy (based on the second pathology report) with the patient, but the physician was criticized for failing to urge the patient to undergo surgery. In addition, the gastroenterologist failed to contact the referring physician to inform him that the patient had refused the recommended treatment.

Risk Management Takeaways:

• Practices should have a comprehensive tracking process in place for patients that need follow-up care. This process should include steps to follow when patients are not compliant with the recommended follow up and information for notifying the ordering and referring providers so that they can determine next steps.
• Communication with the referring physician should occur with the initial consultation and every visit or missed visit thereafter.
• Practices should implement an informed refusal process to use when patients refuse the recommended treatment plan. The physician should have patients sign an informed refusal form to acknowledge they understand the consequences of refusing surgery, diagnostic tests, or other treatments.