Fish, Robert G

Renal cell carcinoma (RCC) accounts for approximately 80% of all primary renal neoplasms in United States causing approximately 65 000 new cases of RCC and 14 000 deaths each year. Symptoms of RCC typically include weight loss and night sweats but may also feature paraneoplastic phenomena in advanced stages as well as flank pain, gross hematuria, scrotal varicocele, inferior vena cava pathology, and a palpable abdominal mass. In this article, we present the course of a patient with advanced RCC, from initial presentation through workup and to eventual diagnosis. The case features late-onset symptoms, extensive paraneoplastic phenomena, and significant physical examination findings. We also review the literature available on RCC and critically analyze inefficiencies of the workup retrospectively.

Introduction: In the traditional model of care, an annual visit was dedicated to the task of assessing and delivering preventive care. With the move away from annual physicals, primary care physicians are addressing preventive services at every clinic visit often aided by electronic clinical decision support (CDS) systems. Methods: We conducted a case study of a visit-driven CDS system in use at a primary care clinic. Steady-state performance was assessed via control charts of quality metrics, data regarding completion of recommendations, and an analysis of screening intervals achieved with patient visits. Results: Under this visit-driven CDS system, quality metric performance was poor and declining. Almost half of the patients were not screened (46.5%), and the other half were overscreened the majority of the time (83.3%). Recommended preventive services were ordered less than half the time (42.6%), despite CDS reminders. Discussion: Various barriers and systematic inefficiencies combined to produce ineffective screening in this visit-driven CDS preventive service delivery system. As a result, we conclude a visit-driven system cannot produce optimal results. In order to improve performance, preventive services should be delivered separately from clinical visits, perhaps by a “preventive service ranger” (PSR) utilizing the CDS system to review each patient once annually. Under such a system, patients would receive preventive services in an organized and efficient fashion, potentially leading to better continuity, higher quality metrics that are mathematically predictable, and improved satisfaction.