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Reducing referral delays in colorectal cancer diagnosis: is it about how you ask?
  1. Hardeep Singh1,
  2. Laura A Petersen1,
  3. Kuang Daci2,
  4. Clyde Collins2,
  5. Myrna Khan1,
  6. Hashem B El-Serag3
  1. 1Houston VA HSR&D Center of Excellence, and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  2. 2Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  3. 3Section of Gastroenterology and Hepatology, Michael E DeBakey Veterans Affairs Medical Center and Houston VA HSR&D Center of Excellence, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Dr Hardeep Singh, VA Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030, USA; hardeeps{at}


Objectives Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC.

Methods The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time.

Results Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with ‘positive faecal occult blood test’ (92 days, p<0.0001), ‘haematochesia’ (75 days, p=0.02), ‘history of polyps’ (221 days, p=0.0006) and when ‘screening’ (vs specific symptoms) was given as the reason for diagnostic colonoscopy (203 days, p=0.002). Independent predictors of shorter wait times included three diagnostic clues, notation of urgency and documentation of verbal contact.

Conclusions Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

  • Delayed cancer diagnosis
  • colorectal cancer
  • colonoscopy referrals
  • computerised order entry
  • electronic medical records
  • primary care
  • communication
  • information technology
  • medical error
  • patient safety
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  • Funding The study was supported by an NIH K23 career development award (K23CA125585) to HS, the VA National Center of Patient Safety, and in part the Houston VA HSR&D Center of Excellence (HFP90-020).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Baylor College of Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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