Outcomes of anorectal disease in a health maintenance organization setting. The need for colorectal surgeons.

PURPOSE: The current trend in health delivery is managed care, in which the primary care provider (PCP) manages patient care and triages specialty referrals. It has not been established, however, that PCPs can accurately diagnose, treat, or triage anorectal disorders.
MATERIALS AND METHODS: A retrospective study was undertaken at a health maintenance organization that hired a colon and rectal surgeon. Charts of the first 100 consecutive consultations for anorectal complaints were analyzed for accuracy of diagnosis and appropriateness of care.
RESULTS: Correct diagnoses were made by 45 of 85 (53 percent) PCP physicians, 6 of 15 (40 percent) PCP physician assistants, and 8 of 15 (53 percent) general surgeons. A delay to diagnosis or appropriate treatment occurred in 25 patients (25 percent), resulting in an adverse outcome in 15 people. Of these, five complications were caused by delayed diagnosis, and ten patients had symptoms that persisted from 5 months to 14 years (mean, 4.5 years). Seven unnecessary referrals to a gastroenterologist resulted in three unnecessary colonoscopies. Of 19 patients evaluated by a general surgeon, 4 had inadequate/inappropriate operations, 5 were untreated because of misdiagnosis, 3 correctly diagnosed were untreated, 3 had inappropriate follow-up, 1 was referred to a gastroenterologist, and 2 were advised to have appropriate treatment.
SUMMARY: The PCP correctly diagnosed anorectal disorders in 51 percent of cases and referred patients promptly 75 percent of the time. Of the 25 percent with delay, 60 percent experienced a complication of persistent symptoms. Fifteen of 19 (79 percent) patients seen by a general surgeon were inappropriately managed.