title: Postreferral colonoscopy delays in diagnosis of colorectal cancer:  a mixed-methods analysis.
abstract: BACKGROUND
  Delays in diagnosis of colorectal cancer (CRC) are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied.
  
  
  OBJECTIVE
  We used a mixed quantitative-qualitative approach to analyze postreferral colonoscopy delays in CRC patients and explored referring physician's perception of processes surrounding these delays.
  
  
  METHODS
  Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine postreferral colonoscopy delays, which we defined as failures to perform colonoscopy within 60 days of referral for an established indication(s). To explore perceptions of colonoscopy processes, we conducted semistructured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach.
  
  
  RESULTS
  Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of postreferral colonoscopy delays in 35 (33.7%) cases; κ = 0.99 (95% CI, 0.83-0.99). The median time between first referral and completion of colonoscopy was 123.0 days (range 62.0-938.0; interquartile range = 90.0 days). In about two-thirds of instances (64.8%), the reason for delay was a delayed future appointment with the gastroenterology service. On interviews, PCPs attributed long delays in scheduling to reduced endoscopic capacity and inefficient processes related to colonoscopy referral and scheduling, including considerable ambiguity regarding referral guidelines. Many suggested that navigation models be applied to streamline CRC diagnosis.
  
  
  CONCLUSIONS
  Postreferral delays in CRC diagnosis are potentially preventable. A comprehensive mixed-methods methodology might be useful for others to identify the steps in the diagnostic process that are in most need for improvement.
authors.affiliation: Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA. hardeeps@bcm.edu
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
authors.forename: Rashid
authors.initials: R
authors.lastname: Khan
authors.forename: Traber Davis
authors.initials: TD
authors.lastname: Giardina
authors.forename: Lindsey Wilson
authors.initials: LW
authors.lastname: Paul
authors.forename: Kuang
authors.initials: K
authors.lastname: Daci
authors.forename: Milena
authors.initials: M
authors.lastname: Gould
authors.forename: Hashem
authors.initials: H
authors.lastname: El-Serag
mesh_terms: D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D012017:Referral and Consultation; D013997:Time Factors; D014481:United States