Using Literature Review and Structured Hybrid Electronic/Manual Mortality Review to Identify System-Level Improvement Opportunities to Reduce Colorectal Cancer Mortality

Article-at-a-Glance Background Despite colorectal cancer (CRC) screening and survival rates exceeding national averages in the United States, Kaiser Permanente Southern California (KPSC) aimed to identify system-level improvement opportunities to further reduce mortality from CRC. Methods To examine modifiable factors contributing to CRC mortality, a structured hybrid electronic/manual mortality review was used to examine 50 randomly selected cases among 524 individuals aged 25–75 years diagnosed with stage II, III, or IV CRC after July 2008 who subsequently died. Physicians conducted chart reviews using a standardized data extraction tool based on evidence-based best practices. Results Eighty-six percent (43) of the 50 decedents were initially diagnosed with stage III or IV CRC; two cases of appendiceal cancer were excluded. Thirty-one percent (15) of the remaining 48 cases presented with no history of screening; 15% (7) had documented iron deficiency anemia and abdominal pain or rectal bleeding; and 6% (3) had no follow-up colonoscopy after positive screening. Eleven (52%) of the 21 patients with initial stage II-III CRC received appropriate surveillance after curative surgery; 57% (12) developed metastases. Adjuvant chemotherapy was offered to 88% (14/16) of patients with stage III (node-positive) CRC; chemotherapy initiation was delayed in 6 patients. Missed opportunities for surgical oncology evaluation occurred among 61% (11/18) of patients with liver metastases at diagnosis. Failure to report clinically significant features on pathology occurred in 2 patients; they received appropriate treatment for other reasons. Conclusions Improvement opportunities existed at multiple stages of care, including screening, evaluation of symptoms, timeliness of care, use of adjuvant chemotherapy, and surgical oncology practices.