Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review
Centre for Health Systems and Safety Research, Faculty of Medicine, The University of New South Wales, Sydney, NSW, 2052, Australia, . Journal of General Internal Medicine
(Impact Factor: 3.42).
12/2011; 27(10):1334-48. DOI: 10.1007/s11606-011-1949-5
Serious lapses in patient care result from failure to follow-up test results.
To systematically review evidence quantifying the extent of failure to follow-up test results and the impact for ambulatory patients.
Medline, CINAHL, Embase, Inspec and the Cochrane Database were searched for English-language literature from 1995 to 2010.
Studies which provided documented quantitative evidence of the number of tests not followed up for patients attending ambulatory settings including: outpatient clinics, academic medical or community health centres, or primary care practices.
Four reviewers independently screened 768 articles.
Nineteen studies met the inclusion criteria and reported wide variation in the extent of tests not followed-up: 6.8% (79/1163) to 62% (125/202) for laboratory tests; 1.0% (4/395) to 35.7% (45/126) for radiology. The impact on patient outcomes included missed cancer diagnoses. Test management practices varied between settings with many individuals involved in the process. There were few guidelines regarding responsibility for patient notification and follow-up. Quantitative evidence of the effectiveness of electronic test management systems was limited although there was a general trend towards improved test follow-up when electronic systems were used.
Most studies used medical record reviews; hence evidence of follow-up action relied upon documentation in the medical record. All studies were conducted in the US so care should be taken in generalising findings to other countries.
Failure to follow-up test results is an important safety concern which requires urgent attention. Solutions should be multifaceted and include: policies relating to responsibility, timing and process of notification; integrated information and communication technologies facilitating communication; and consideration of the multidisciplinary nature of the process and the role of the patient. It is essential that evaluations of interventions are undertaken and solutions integrated into the work and context of ambulatory care delivery.
Figures in this publication
Available from: Paolo Fraccaro
- "As a consequence, physicians may not have the necessary time to focus on the most important alerts . This information overload contributes to alert fatigue  and can potentially generate patient safety issues . "
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ABSTRACT: Laboratory test results in primary care are flagged as 'abnormal' when they fall outside a population-based Reference Interval (RI), typically generating many alerts with a low specificity. In order to decrease alert frequency while retaining clinical relevance, we developed a method to assess dynamic, patient-tailored RIs based on mixed-effects linear regression models. Potassium test results from primary care were used as proof-of-concept test bed. Clinical relevance was assessed via a survey administered to general practitioners (GPs). Overall, the dynamic, patient-tailored method and the combination of both methods flagged 20% and 36% fewer values as abnormal than the population-based method. Nineteen out of 43 invited GPs (44%) completed the survey. The population-based method yielded a better sensitivity than the patient-tailored and the combined methods (0.51 vs 0.41 and 0.38, respectively) but a lower PPV (0.66 vs 0.67 and 0.76, respectively). We conclude that a combination of population-based and patient-tailored RIs can improve the detection of abnormal laboratory results. We suggest that lab values outside both RIs be flagged with high priority in clinical practice.
Available from: Andrew Georgiou
- "Considering the frequency of delayed follow-up of abnormal test results , patients may be more likely to experience anxiety while waiting for test results   . In view of this discrepancy between physicians' concerns, and the available evidence, effective strategies for implementing direct notification should provide patients access to tools to enhance context-based interpretation  . "
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ABSTRACT: To determine physician perspectives about direct notification of normal and abnormal test results.
We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia.
Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74).
Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results.
Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive.
Published by Elsevier Ireland Ltd.
Available from: Ian Litchfield
- "It has been reported that up to one-third of patients are not notified of abnormal results (3) and nor are normal results routinely communicated, despite the expressed preference of patients (7–9). A study in the USA found only half of general practices had written protocols for any result management steps and few providers documented key stages in the communication system such as patient notification or follow-up for abnormal results (4). "
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To understand how the results of laboratory tests are communicated to patients in primary care and perceptions on how the process may be improved.
Qualitative study employing staff focus groups.
Four UK primary care practices.
Staff involved in the communication of test results.
Five main themes emerged from the data: (i) the default method for communicating results differed between practices; (ii) clinical impact of results and patient characteristics such as anxiety level or health literacy influenced methods by which patients received their test result; (iii) which staff member had responsibility for the task was frequently unclear; (iv) barriers to communicating results existed, including there being no system or failsafe in place to determine whether results were returned to a practice or patient; (v) staff envisaged problems with a variety of test result communication methods discussed, including use of modern technologies, such as SMS messaging or online access.
Communication of test results is a complex yet core primary care activity necessitating flexibility by both patients and staff. Dealing with the results from increasing numbers of tests is resource intensive and pressure on practice staff can be eased by greater utilization of electronic communication. Current systems appear vulnerable with no routine method of tracing delayed or missing results. Instead, practices only become aware of missing results following queries from patients. The creation of a test communication protocol for dissemination among patients and staff would help ensure both groups are aware of their roles and responsibilities.
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