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Failure to Recognize and Act on Abnormal Test Results: The Case of Screening Bone Densitometry
Abstract
Failure to follow up on abnormal test results is common. A model was developed to capture the reasons why providers did not take action on abnormal test results.
A systematic review of the medical literature was conducted to identify why providers did not follow up on test results. The reasons were then synthesized to develop an operational model. The model was tested by reviewing electronic medical records of consecutive patients diagnosed with osteoporosis through a dual-energy x-ray absorptiometry (DXA) scan to determine whether: (1) the scan results had been reeviewed; (2) therapy was recommended; (3) the scan results were not reviewed and why this occurred.
Of the 48 newly diagnosed osteoporosis patients, 16 did not receive a recommendation to begin treatment. There was no evidence that the scan results wrere reviewed in 11 of the 16 cases (23% of all abnormal scans); the scan results of an additional 5 patients were reviewed but no treatment was recommended.
A clinically significant ercentage of DXA scan results went unrecognized. As a long-term solution, direct patient notification could theoretically reduce the burden on providers, activate and empower patients, and create a back-up system for ensuring that patients are notified of their test results.
... Then even when results are effectively communicated, appropriate treatment may not be initiated. [15][16][17][18][19][20] In an effort to overcome these barriers and to improve osteoporosis care, many investigators have undertaken interventions aimed at educating providers about osteoporosis; [20][21][22] however, many of these efforts have been unsuccessful at improving care. ...
... 26,27 Our model differs from traditional clinical practice in which bone density testing centers typically send DXA results to the ordering physicians only. 15,28 Our model is designed to overcome several of the barriers previously mentioned by ensuring that the DXA results are communicated to patients, something that other studies have found to be a problem. 15,17,29 In earlier studies, we have demonstrated that both physicians and patients would be amenable to a system of DXA centers directly reporting results to patients, 15,26,28 but at the present time we are unaware of a theoretically driven and rigorously derived letter for communicating DXA results to patients. ...
... 15,28 Our model is designed to overcome several of the barriers previously mentioned by ensuring that the DXA results are communicated to patients, something that other studies have found to be a problem. 15,17,29 In earlier studies, we have demonstrated that both physicians and patients would be amenable to a system of DXA centers directly reporting results to patients, 15,26,28 but at the present time we are unaware of a theoretically driven and rigorously derived letter for communicating DXA results to patients. ...
Purpose
To use a mixed-methods approach to develop a letter that can be used to notify patients of their bone mineral density (BMD) results by mail that may activate patients in their bone-related health care.
Patients and methods
A multidisciplinary team developed three versions of a letter for reporting BMD results to patients. Trained interviewers presented these letters in a random order to a convenience sample of adults, aged 50 years and older, at two different health care systems. We conducted structured interviews to examine the respondents’ preferences and comprehension among the various letters.
Results
A total of 142 participants completed the interview. A majority of the participants were female (64.1%) and white (76.1%). A plurality of the participants identified a specific version of the three letters as both their preferred version (45.2%; P<0.001) and as the easiest to understand (44.6%; P<0.01). A majority of participants preferred that the letters include specific next steps for improving their bone health.
Conclusion
Using a mixed-methods approach, we were able to develop and optimize a printed letter for communicating a complex test result (BMD) to patients. Our results may offer guidance to clinicians, administrators, and researchers who are looking for guidance on how to communicate complex health information to patients in writing.
... 32 39 The extent of failure to follow-up ranged from 1.0%33 to 22.9% of inpatients4 and from 20.04%39 to 61.9%3 when reported per test type. The range of test types included: urgent32 and critical20 laboratory results; abnormal actionable results pending at discharge3; diagnostic imaging4 33 39 and elevated Thyroid Stimulating Hormone levels.34 A study of radiology follow-up using an email alert system for important but not urgent imaging findings reported that 20.0% (10 598/52 883) of electronic reports were not viewed by the referring physician.39 ...
... Eight studies were conducted in the USA.3 4 20 33 34 36 38 39 Most study designs were medical record reviews, either retrospective4 20 32 33 36 37 39 or prospective.3 31 35 One study reviewed malpractice claims,38 while another retrospectively linked laboratory and pharmacy databases.34 ...
... Four of the seven studies reported the impact of failure to follow-up which included missed diagnoses of malignancy,33 hypothyroidism,34 hyperthyroidism,3 osteoporosis,4 microbiological results which necessitated the starting or changing of antibiotic therapy,3 and positive serological test results for Helicobacter pylori.3 ...
Failure to follow-up test results is a critical safety issue. The objective was to systematically review evidence quantifying the extent of failure to follow-up test results and the impact on patient outcomes.
The authors searched Medline, CINAHL, Embase, Inspec and the Cochrane Database from 1990 to March 2010 for English-language articles which quantified the proportion of diagnostic tests not followed up for hospital patients. Four reviewers independently reviewed titles, abstracts and articles for inclusion.
Twelve studies met the inclusion criteria and demonstrated a wide variation in the extent of the problem and the impact on patient outcomes. A lack of follow-up of test results for inpatients ranged from 20.04% to 61.6% and for patients treated in the emergency department ranged from 1.0% to 75% when calculated as a proportion of tests. Two areas where problems were particularly evident were: critical test results and results for patients moving across healthcare settings. Systems used to manage follow-up of test results were varied and included paper-based, electronic and hybrid paper-and-electronic systems. Evidence of the effectiveness of electronic test management systems was limited.
Failure to follow up test results for hospital patients is a substantial problem. Evidence of the negative impacts for patients when important results are not actioned, matched with advances in the functionality of clinical information systems, presents a convincing case for the need to explore solutions. These should include interventions such as on-line endorsement of results.
... [1][2][3][4] Its success depends on effective communication, notification of any relevant laboratory test results, and appropriate timely intervention resulting from it. 5,6 The Institute of Medicine report "Crossing the Quality Chasm" suggested that enhancing the flow of information between patients and medical providers would help to reduce errors and improve quality. 7 In addition, prompt communication of test results may help patients with their decision making. ...
... 9,11 This failure often results in the deterioration of patients' health and may lead to medical errors, as reported in a study of bone densitometry. 6 This sequence of events has been highlighted through research about medical errors. 12 A vast body of literature indicates that most patients want to be notified of all their test results, whether normal or abnormal. ...
... 3,4,14 Most studies have concluded that patients generally prefer notification by mail. 5,6,10,12,15 Mailing the results with an explanation of abnormal results has been reported as one solution. 13 Reporting over the phone has been cited as a preferred method by a few studies. ...
This study assessed patient preferences and physician practices for laboratory test results notification in ambulatory care.
Patients aged 18 years or older (n=728) who were scheduled to see their primary care physician at 5 clinics were offered the opportunity to participate in an anonymous survey during their clinic visit. Their primary care physicians were also invited to participate in a separate online survey. Questions on both surveys included the current method of laboratory test results notification and satisfaction with the method.
The majority of patients reported satisfaction with the current method of notification of normal results-the US mail-which was also the preferred method for notification of normal test results by both patients and physicians. Direct phone contact by the physician was the preferred method for notification of abnormal results by both patients (64%) and physicians (41%). Patients' preferred method of notification of normal results significantly agreed with the current method (P<.0001), whereas that of abnormal results did not (P=.52).
Our findings indicate that patients and physicians both prefer the US mail for notification of normal laboratory test results and a direct phone call by the physician for notification of abnormal results.
... Failure to follow-up results of radiology and laboratory tests has the potential to compromise patient care [1][2][3][4]. Lack of follow-up of abnormal test results can lead to missed or delayed diagnoses [4][5][6][7][8][9] and impact adversely on patient outcomes with potential medico-legal implications [10][11][12][13]. Doctors [3,11] and patients [14] are concerned about this issue. ...
... The test result follow-up process is complex [5,6,19] with physicians required to review results, discuss these with the patient and colleagues, decide on an appropriate plan, institute and follow-up treatment and document their actions. When electronic systems are applied to a multipart clinical process, such as the management of test results, it is often the case that parts of the process are computerised and some elements are still reliant on docu-mentation in existing manual information systems, such as paper-based patient records. ...
... Information technology alone will not ensure improvements in communication of information: new work practices need to be developed to reduce errors in follow-up of test results. Direct patient notification of test results could also reduce the burden of test follow-up on providers, empower patients and create a backup system for ensuring that patients are notified of their test results [5,14,32,33]. ...
1) To measure the incidence and impact of missed radiology and microbiology test results in an emergency department with an electronic test order and results viewing system, and 2) to assess the average times from test order to test availability.
The study was conducted in the emergency department (ED) of a 370-bed metropolitan teaching hospital in Sydney, Australia. A computerised provider order entry (CPOE) system was used to order all diagnostic tests and view all test results. For microbiology and radiology tests electronic results were then printed for ED patients not admitted to the hospital to allow ED physicians to document follow-up. All radiology (n = 197) and microbiology (n = 66) tests ordered and results received for discharged ED patients were collected for a seven-day period. We measured the: 1) proportion of radiology and microbiology test results without follow-up for discharged patients; 2) impact of non follow-up on patient outcomes; 3) average time from radiological examination and microbiology specimen collection to reporting of results; and 4) average time from reporting of results to follow-up.
Two radiology (1.0%) and two microbiology reports (3.0%), all of which had negative findings, were never followed-up. Review of these patients' medical records indicated there was no impact on patient outcomes or management. The average time from radiological examination to reporting of a result was 1.5 days, and from microbiology specimen collection to reporting was 2.5 days. Eighty-nine percent of radiology and 68% of microbiology results were followed-up on the same day that they were available to physicians.
Our rates of missed test results are lower than those reported from studies where paper ordering and reporting systems were used. This suggests that the availability of CPOE systems may reduce the risk of these events. Electronic result delivery, with electronic endorsement to allow documentation of follow-up of test results, may provide additional efficiency benefits and further reduce the risk of test results which are not followed up.
... In medical records review studies focusing on specific clinical pathology laboratory values (e.g., thyroid stimulating hormone, potassium, hemoglobin a1c, and glucose), 2-18% of cases were found to have clinically significant abnormalities but no evidence of clinician awareness123. Likewise, studies focusing on specific image types (e.g., mammograms, bone densitometry, and findings of incidental aortic aneurysms) found that 25-40% of cases with clinically significant abnormalities did not have documentation of a clinician response456. Surveys of primary care providers found that, within the two weeks prior to interview, the majority had seen a patient who had experienced a treatment delay due to missed results78910. ...
... lost to follow up). Although EMRs can efficiently deliver results to providers, this does not guarantee that the provider will interpret the findings correctly and respond appropriately [5,22]. The psychology literature demonstrates that as work increases and alarm sensitivity declines, 90% of individuals will produce progressively lower-quality work and their responsiveness to alarms will decline [32,33]. ...
... One solution that has been suggested to deal with data management issues is the direct notification of patients by the laboratory service upon completion of CRC screening [42]. While a slim majority of patients expressed a desire for direct notification, many physicians are uncomfortable with this solution as it can lead to increased patient anxiety and telephone calls, and additional non-compensated work for the clinicians [5]. However, when patients are not given their test results, they tend to be less motivated , experience lower levels of therapeutic adherence, and may have poorer outcomes [4,5,43,44]. ...
A cohort of colorectal cancer (CRC) patients represents an opportunity to study missed opportunities for earlier diagnosis.
To study the epidemiology of diagnostic delays and failures to offer/complete CRC screening.
To identify system- and patient-related factors that may contribute to diagnostic delays or failures to offer/complete CRC screening.
Rural Veterans Administration (VA) Healthcare system.
CRC cases diagnosed within the VA between 1/1/2000 and 3/1/2007.
progress notes, orders, and pathology, laboratory, and imaging results obtained between 1/1/1995 and 12/31/2007. Completed CRC screening was defined as a fecal occult blood test or flexible sigmoidoscopy (both within five years), or colonoscopy (within 10 years); delayed diagnosis was defined as a gap of more than six months between an abnormal test result and evidence of clinician response. A summary abstract of the antecedent clinical care for each patient was created by a certified gastroenterologist (GI), who jointly reviewed and coded the abstracts with a general internist (TW).
The study population consisted of 150 CRC cases that met the inclusion criteria. The mean age was 69.04 (range 35-91); 99 (66%) were diagnosed due to symptoms; 61 cases (46%) had delays associated with system factors; of them, 57 (38% of the total) had delayed responses to abnormal findings. Fifteen of the cases (10%) had prompt symptom evaluations but received no CRC screening; no patient factors were identified as potentially contributing to the failure to screen/offer to screen. In total, 97 (65%) of the cases had missed opportunities for early diagnosis and 57 (38%) had patient factors that likely contributed to the diagnostic delay or apparent failure to screen/offer to screen.
Missed opportunities for earlier CRC diagnosis were frequent. Additional studies of clinical data management, focusing on following up abnormal findings, and offering/completing CRC screening, are needed.
... 10 information technology (IT) could improve such communication processes and thereby enhance physician awareness of abnormal imaging test results, a problem of significant magnitude in previous studies. 4,11 We hypothesized that with standardized policies and procedures and educational efforts, use of IT to notify providers of abnormal radiology results would lead to few, if any, imaging results lost to follow-up. Our goals were to assess the effectiveness of a computerized test result notification system designed to minimize lapses in communication in the outpatient setting, to identify breakdowns in communication that could result from the use of this system, and to determine the potential impact of communication breakdowns on patients' health outcomes. ...
... To test its effectiveness we studied communication outcomes as a result of using this system and evaluated physician awareness of abnormal imaging test results, a problem of significant magnitude in previous studies. 4,11 Using a taxonomy of communication breakdowns, we categorized problems with alert acknowledgment and reception and identified lost to follow-up imaging results. Providers failed to electronically acknowledge over one-third of alerts according to established protocols and were unaware of abnormal results in 4% of cases 4 weeks after reporting. ...
... Two studies have reported similar data in systems that do not use similar IT and suggest that physician unawareness of abnormal imaging results is a substantial problem. 4,11 One of them reported 36% of abnormal mammograms to be lost to follow-up, 4 whereas another reported that 23% of abnormal dual-energy x-ray absorptiometry scans without evidence of review by the provider. 11 These numbers are strikingly high compared to the 4% reported in our study. ...
Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results.
We prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic.
In the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception.
Providers failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit.
Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.
... A commonly performed test among older adults is dual energy x-ray absorptiometry (DXA), which is the standard screening tool for identifying patients at increased risk for hip or other fragility fractures. But even when a diagnosis of osteoporosis is made from the DXA, patients do not always receive appropriate pharmacotherapy consistent with treatment guidelines [11]. Indeed, one study found that two-thirds of patients with DXA results indicating osteoporosis did not receive appropriate pharmacotherapy. ...
... Indeed, one study found that two-thirds of patients with DXA results indicating osteoporosis did not receive appropriate pharmacotherapy. And using chart review methods, another study revealed among 23% of abnormal DXA results there was no evidence that the patient's clinician had reviewed their DXA results or communicated them to their patients [11]. One way to increase patient access to their DXA results would be to use web portals to communicate test results directly to patients. ...
Background:
Sharing test results with patients via patient web portals is a new trend in healthcare. No research has been done examining patient web portal use with bone density test results. The objective of our study was to identify patient characteristics associated with the use of patient web portals to view their bone density test results.
Methods:
A secondary analysis of data from a pragmatic randomized controlled trial of 7749 participants ≥50 years old that had presented for a dual energy X-ray absorptiometry (DXA) bone density test. Patients were interviewed at enrollment and 12 weeks later. Multivariable logistic regression identified patient characteristics that differentiated those who used the web portal from those who did not.
Results:
Our sample included 4669 patients at the two (University of Iowa [UI], and Kaiser Permanente of Georgia [KPGA]) clinical sites that had patient web portals. Of these patients, 3399 (72.8%) reported knowing their test results 12 weeks post-DXA, with 649 (13.9%) reporting that they viewed their DXA results using the web portal. Web portal users were more likely to be from UI than KPGA, and were younger, more educated, had higher health literacy, had osteopenia, and had the same sex as their referring physician (all p < 0.05).
Conclusion:
Only 19.1% of the 3399 patients who knew their DXA results used the available patient web portals to find out about them. Web portal users differed from non-users on several characteristics. This suggests that simply making patient web portals available for use may not be sufficient to appreciably enhance patient awareness of their test results. Based on these findings, a better understanding of the reasons why older, less educated, and less activated patients do not access their test results through patient web portals is needed.
... Osteoporosis and fragility fractures represent a growing health problem in developed countries in terms of social costs and increased risk of death, especially in the elderly [1]. Fracture incidence rates are closely related to the ageing of a population, as older people present higher fracture rates than younger subjects with the same bone mineral density [2]. This is due to a lower bone quality and higher tendency to fall. ...
... Significant linear trend with increasing BMI category, resultant p value of the score test for trend was <0.0001.2 ORs adjusted for age, physical activity, and the use of drugs causing osteoporosis. ...
Objectives: We aimed to analyze bone mineralization and the effect of different risk factors for osteoporosis in postmenopausal women. Methods: We found 4909 postmenopausal subjects within ≥10,000 records from the ROIS/EMEROS (Ionian and Salento Osteoporosis Registry/Euro Mediterranean Registry of Osteoporosis) registry, a population study carried out in an area characterized by heavy environmental pressure between Brindisi and Taranto from 2009 to 2016. All subjects were assessed via phalangeal quantitative ultrasound (QUS) to evaluate their bone mineralization (assessed via amplitude dependent speed of sound (AD-SoS)) and the association between demineralization and the presence of other conditions or risk factors. Results: Mean age was 64 ± 9.5 years and mean body mass index (BMI) was 28.7 ± 3.5 kg/m². Pearson correlation analyses revealed a negative association between bone mineralization (AD-SoS) and BMI (p < 0.001). By using multivariate logistic regression analysis, we observed significant values of odds ratios (ORs) of osteoporosis (adjusted for age, physical activity, and the use of drugs known to increase the risk of fractures) in subjects with diabetes and obesity: 1.39 (confidence interval (CI): 1.05-1.83) and 1.46 (CI: 1.20-1.78), respectively. A statistically significant linear trend of higher ORs of osteoporosis was found for increasing values of BMI. Conclusions: Our study confirmed the high impact of obesity and type 1 and type 2 diabetes on osteoporosis.
... In this study, we focused on achieving guideline-concordant pharmacological treatment after DXA testing because of the barriers that patients encounter on the pathway to appropriate pharmacological treatment after DXA screening [17][18][19]. For patients, this pathway involves (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options. ...
... Intervention patients were notified of their DXA results via a tailored letter and an educational brochure sent by postal mail. The decision to use postal mail was based on patient preferences discovered in our pilot study [17]. The intervention letter and brochure were developed using best practices in risk communication (described elsewhere [42][43][44]) and were sent from the central coordinating center (UI) approximately 4 weeks after their baseline DXA. ...
Introduction:
Patients often do not know or understand their dual-energy x-ray absorptiometry (DXA) test results, which may lead to suboptimal care. We tested whether usual care augmented by a tailored patient-activation DXA result letter accompanied by an educational brochure would improve guideline-concordant pharmacological treatment compared to usual care only.
Methods:
We conducted a randomized, controlled, double-blinded, pragmatic clinical trial at three health care centers in the USA. We randomized 7749 patients ≥50 years old and presenting for DXA between February 2012 and August 2014. The primary clinical endpoint at 12 and 52 weeks post-DXA was receiving guideline-concordant pharmacological treatment. We also examined four of the steps along the pathway from DXA testing to that clinical endpoint, including (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options.
Results:
Mean age was 66.6 years, 83.8 % were women, and 75.3 % were non-Hispanic whites. Intention-to-treat analyses revealed that guideline-concordant pharmacological treatment was not improved at either 12 weeks (65.1 vs. 64.3 %, p = 0.506) or 52 weeks (65.2 vs. 63.8 %, p = 0.250) post-DXA, even though patients in the intervention group were more likely (all p < 0.001) to recall receiving their DXA results letter at 12 weeks, correctly identify their results at 12 and 52 weeks, have contact with their provider at 52 weeks, and have discussed their results with their provider at 12 and 52 weeks.
Conclusion:
A tailored DXA result letter and educational brochure failed to improve guideline-concordant care in patients who received DXA.
... Fortunately, Dual Energy X-Ray Absorptiometry (DXA) provides low-cost screening, making it possible to diagnosis osteoporosis and initiate treatment before fracture occurs [2,3]. Unfortunately, patients at risk for fractures are not always aware of their risk and thus do not recognize the need to take action to reduce this risk [4][5][6][7][8][9][10][11][12][13][14][15][16][17]. ...
... Problems in virtually all aspects of the test result reporting and communication process have been documented and result in important test results being overlooked or missed [18][19][20][21][22][23]. We have shown that 23% of DXA reports appeared not to have been reviewed by a provider [4]. Others found that 20% of study participants said they were not informed of their DXA results [9] and almost half of women with documented low bone mineral density (BMD) reported having normal BMD [8]. ...
Introduction
To describe the rationale and design of an NIH funded randomized controlled trial: the Patient Activation after DXA Result Notification (PAADRN) study. The aim of this trial is to evaluate the effect that a direct mailing of Dual-energy X-ray absorptiometry (DXA) results from bone density testing centers to patients will have on patients' knowledge, treatment and self-efficacy.
Methods
We will enroll approximately 7,500 patients presenting for DXA at three study sites, the University of Iowa, the University of Alabama at Birmingham, and Kaiser Permanente of Atlanta, Georgia. We will randomize providers (and their respective patients) to either the intervention arm or usual care. Patients randomized to the intervention group will receive a letter with their DXA results and an educational brochure, while those randomized to usual care will receive their DXA results according to standard practice. The seven discrete outcomes are changes from baseline to 12-weeks and/or 52-weeks post-DXA in: (1) guideline concordant pharmacologic and non-pharmacologic therapy; (2) knowledge of DXA results; (3) osteoporosis-specific knowledge; (4) general health-related quality of life; (5) satisfaction with bone-related health care, (6) patient activation; and, (7) osteoporosis-specific self-efficacy.
Conclusion
This trial will offer evidence of the impact of a novel approach—direct-to-patient mailing of test results—to improve patient activation in their bone health care. The results will inform clinical practice for the communication of DXA and other test results.
... Differences between clinicians in the integration of information systems into their work practices have previously been reported [25]. Other studies have also reported that the test result follow up process is complex and multifaceted [26,27]. It is important to recognize this complexity when designing and implementing clinical information systems. ...
... This study was qualitative and undertaken in one Emergency Department so results may not be generalisable to other settings. The study did not explore physicians' perceptions of direct reporting of test results to patients through secure webbased portals however this has been reported in other studies as an option [26,27] and future studies should investigate physicians' attitudes towards this. ...
Follow-up of abnormal test results for discharged Emergency Department (ED) patients is a critical safety issue. This study aimed to explore ED physicians' perceptions, practices, and suggestions for improvements of test result follow-up when using an electronic provider order entry system to order all laboratory and radiology tests and view results. Interviews were conducted with seven ED physicians and one clinical information system support person. Interviews were analyzed to elicit key concepts relating to physicians' perceptions of test result follow-up and how the process could be improved. Results described the current electronic test result follow-up system with two paper-based manual back-up systems for microbiology and radiology results. The key issues for physicians were: responsibility for test follow-up; the unique ED environment and time pressures, and the role of the family physician in test result follow-up. The key suggestion for improvement was a complete integrated electronic information system with on-line result endorsement. The study highlighted the complexity of the test result follow-up process and the importance of engaging clinicians in devising solutions for improvements.
... Furthermore, DEXA scan results are inadequately followed in treating patients undergoing osteoporosis screening. For example, one study showed that 33% of patients who underwent DEXA did not receive treatment for abnormal results, and most did not have their results reviewed [11]. ...
Background
Hip fracture is a major medical and surgical topic and is a significant cause of morbidity and mortality. Older women, especially those with osteoporosis, are at an increased risk for hip fractures. Multiple studies have shown the effect of osteoporosis on the refracture rate among the elderly population. Therefore, selecting a targeted population for screening and treating osteoporosis has an essential role in decreasing the hip fracture rate. This study aimed to determine the association between osteoporosis treatment and refracture rate among patients with hip fractures at King Abdulaziz Medical City, Jeddah, Saudi Arabia.
Methods
Collected data included patient demographics (men: ≥55 years old; women: ≥50 years old), the used osteoporosis investigation method, osteoporosis treatment history, presence of comorbidities, and refracture as a primary outcome. The refracture rate among patients with hip fracture was calculated and used to determine the association between hip refracture and osteoporosis.
Results
Our study included a total of 292 patients who presented to our hospital due to hip fractures. The patients were divided into two groups, the osteoporotic and non-osteoporotic groups. These groups were then compared. There was no statistical significance between osteoporosis and hip refracture (p = 0.721), and there was no association between the treatment of osteoporosis and hip refracture (p = 0.493). Statistical difference was found between patients who had undergone dual-energy X-ray absorptiometry scan and were not treated for osteoporosis (p = 0.00). Lastly, the mortality of the refracture group was 10%, while it was 11% in the no-refracture group (p = 1.00).
Conclusion
Morbidity and mortality rates are higher among patients with hip fractures. Our study showed that there was no association between hip refracture rate and osteoporosis whether the patient is treated for osteoporosis or not. We recommend a systematic review that can include more studies in this field to acquire more definitive results regarding this topic.
... Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results runs the risk of missed diagnoses, thus compromising on the quality of care for patients and resulting in poor patient outcomes [1][2][3]. Negligent misdiagnoses may also result in medical malpractice lawsuits; in 2019, a lawsuit was filed against a local healthcare institution that was reported for negligence that resulted in a delayed diagnosis of lung cancer in a patient [4,5]. This sparked a nationwide conversation on the importance of having a proper system for results management [6]. ...
Background
Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results pose a significant problem to patient safety. A study team was formed to mitigate the clinical risks of poor results management, which was identified as a top clinical risk in our organisation, in order to make improvements to the results management process and to ensure the timely review, acknowledgement, and follow-up of test results.
Methods
The institutional expectations of results management were set and published as a hospital policy, which was communicated to all clinical departments for compliance. Improvements to the electronic medical records system were made to facilitate the results acknowledgement process, and physicians were engaged to educate them on the importance of results management.
Results
The study team observed a decrease in unacknowledged results from approximately 16,000 in March 2017 to 2673 in December 2020. The compliance rate for acknowledgement results increased from a monthly average of 83.7% (from March to December 2017) to a monthly average of 99.3% (in 2020). The risk score for results management decreased from 16 to 6.5, and was excluded from the organisation’s top clinical risks.
Conclusion
This study showed the importance of both system improvements and culture changes that are required to improve the process of results management, and provides a step forward for the hospital to safeguard patient safety and mitigate clinical risk.
... 14 Although electronic test result transmission is more reliable than one on paper, action on test results may be delayed. [15][16][17][18][19][20][21][22][23] More than one-third of patients with lung cancer experience diagnostic delays, mostly from delayed follow-up of abnormal imaging findings. 24 Similar follow-up failures can occur in bladder, gastrointestinal, and breast cancer diagnosis. ...
Importance
Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged.
Objective
To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system.
Design, Setting, and Participants
This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018.
Main Outcomes and Measures
Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved.
Results
Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.
Conclusions and Relevance
This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.
... Osteoporosis is the most common osteometabolic disorder affecting post-menopausal women [3]. The menopauserelated estrogen deprivation is the main etiopathogenic cause of this disorder, which is characterized by reduction in bone mineral density (BMD) and deterioration of microarchitecture, leading to an increased risk of fractures [4][5][6]. ...
Introduction
The relationship between post-menopausal osteoporosis and obesity has been mainly investigated using bone mineral density (BMD) as marker of bone health. Since BMD does not reflect bone microarchitecture, another analytical tool, the Trabecular Bone Score (TBS), has been recently developed for this purpose. In this study, we intended to investigate the validity of TBS as marker of bone quality in obese post-menopausal women.
Methods and materials
Three hundred fifty-two post-menopausal women were consecutively enrolled in the study and underwent anthropometric and dual-energy X-ray absorptiometry (DXA) examination. DXA-based BMD was used to classify subjects into osteoporotic (9%), osteopenic (58%), and controls (33%) categories. As TBS is sometimes sensitive to the effects of increased image noise with higher BMI, a corrected version of the TBS (TBS*) was also used to assess bone microarchitecture quality in this cohort.
Results
As expected, BMI was positively and negatively related to total BMD (r = 0.22, p < 0.0001) and TBS (r = − 0.12, p < 0.05), respectively. TBS* was found positively and significantly correlated with femoral neck BMD (r = 0.40, p < 0.001), total hip (r = 0.33, p < 0.001) and lumbar spine BMD (r = 0.50, p < 0.001).
Conclusion
TBS, once removed the effect of BMI, can serve as a good surrogate maker of bone microarchitecture in obese post-menopausal women in addition to BMD.
... First, it is important to acknowledge the documented harms of missed test results including untreated infections, 9,24 missed malignancies, 5, 25, 26 missed aortic aneurysms, 27 missed osteoporosis, 28 and other abnormalities. 29 Much of the existing literature is becoming dated and comes from the US outpatient setting. ...
Background
Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.
Objective
To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.
Design
Cross-sectional survey.
Participants
General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals.
Main Measures
Methods used to track test results; satisfaction with these methods; personal encounters with results respondents “wish they had known about sooner.”
Key Results
We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic “inbox”) (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they “wish they had known about sooner” in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001).
Conclusions
Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.
... In this report, we demonstrate that the rate of suboptimal follow-up of actionable test results in inpatient tests ordered by the GI consult service at a busy tertiary care service is as high as 18%. While consistent with prior reports on general medicine inpatients in the literature [3], this observation is much higher than was anticipated, yet [5][6][7], diseases [8,9], and practice locations [10], to our knowledge, this appears to be the first study to focus exclusively on GI inpatients. We demonstrate that there are differences between genders, insurance coverage, and affiliation of attending gastroenterologist performing endoscopic procedures in how often test results are communicated adequately to patients and their PCPs. ...
Background:
Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service.
Methods:
Test recommendations on 304 consecutive new GI consults (age 60.2 ± 1.0 year) over a 2-month period were recorded. Demographic factors (age, race, gender, zip code, insurance status) were extracted from the electronic medical record (EMR). Charts were independently reviewed 6 months later to determine results of recommended tests, follow-up of actionable test results, 30-day readmission rates, and predictors of suboptimal communication.
Results:
Of 490 recommended tests, 437 (89.2%) were performed, and 199 (45.5%) had actionable findings. Of these, 48 (24.1%) did not have documented follow-up. Failure of follow-up was higher for upper endoscopy (31.9%) compared to colonoscopy (18.0%, p = 0.07). Women (p = 0.07), patients on Medicare (p = 0.05), and procedures supervised by advanced GI fellows (p = 0.06) were less likely to receive follow-up. Median income and identification of a primary provider did not influence follow-up rates; 30-day readmission rates were not impacted. Female gender, insurance (Medicare) status, and attending type remained independent predictors of failure of follow-up on multivariate regression (p ≤ 0.03).
Conclusions:
Failure to follow up test results on inpatient services at a large academic center was unacceptably high. Maximizing personnel participation together with diligence and technology (EMR) will be required to improve communication.
... 2 However, studies have shown that patients undergoing DXA receive inadequate information on their test results and the consequences, prevention, or treatment of osteoporosis. [3][4][5][6] Inadequate information is a barrier for patients making behavior changes in support of a lifestyle for good bone health, such as increasing their calcium intake or weight-bearing exercise. ...
Context
Patient education materials can provide important information related to osteoporosis prevention and treatment. However, available osteoporosis education materials fail to follow best-practice guidelines for patient education.
Objective
To develop an educational brochure on bone health for adults aged 50 years and older using mixed-method, semistructured interviews.
Design
This project consisted of 3 phases. In Phase 1, we developed written content that included information about osteoporosis. Additionally, we designed 2 graphic-rich brochures, Brochure A (photographs) and Brochure B (illustrations). In Phase 2, interviewers presented the text-only document and both brochure designs to 53 participants from an academic Medical Center in the Midwest and an outpatient clinic in the Southeastern region of the US. Interviewers used open- and closed-ended questions to elicit opinions regarding the brochures. In Phase 3, using feedback from Phase 2, we revised the brochure and presented it to 11 participants at a third site in the Southeastern US.
Main Outcome Measures
Participants’ comprehension of brochure text and acceptability of brochure design.
Results
We enrolled 64 participants. Most were women, white, and college-educated, with an average age of 66.1 years. Participants were able to restate the basic content of the brochure and preferred Brochure A’s use of photographs.
Conclusions
Using feedback from older adults, we developed and refined a brochure for communicating bone health information to older adults at risk of osteoporosis and fragility fractures. The methods outlined in this article may serve to guide others in developing health educational brochures for chronic medical conditions.
... We notified intervention patients of their DXA results using a tailored letter and an educational brochure sent by postal mail.The reliance on postal mail was based on patient preferences expressed in our pilot study (27). Intervention materials were sent from the central coordinating center (UI) about 4 wk after the baseline DXA. ...
In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk (p < 0.001) and to 77.2 (p = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels.
... Some randomized controlled trials (RCTs) have demonstrated that educational interventions improve OPrelated knowledge [7][8][9][10][11][12][13][14][15][16]. Less is known about whether such interventions affect patient satisfaction or QOL [17,18]. Most of these RCTs examining OP patienteducation interventions have been multifaceted or lengthy [7,12,13,15,16], which are not scalable. ...
Background
Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge. Methods
The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates. ResultsAt 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point. ConclusionsA tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care. Trial registrationClinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011.
... rates are closely related to the ageing of population, as older people present higher fracture rates than younger subjects with the same bone mineral density (2). This is due to a lower bone quality and a higher tendency to fall. ...
We aimed to analyze bone mineralization and the effect of different risk factors for osteoporosis in
postmenopausal women. We studied 2,756 postmenopausal subjects out of ≥10,000 records from the
ROIS registry in the frame of the PROF Project, a population study carried out in Salento (Taranto,
Brindisi, Lecce) from 2009 to 2012. All subjects were assessed by phalangeal Quantitative Ultrasound
(QUS) to evaluate their bone mineralization (assessed by Amplitude Dependent Speed of Sound, ADSoS)
and the association between demineralization and the presence of other conditions or risk factors.
Mean age was 64±9.5 years and mean BMI was 28.7±3.5 Kg/m2
. Pearson correlation analyses revealed a
negative association between bone mineralization (AD-SoS) and BMI (P<0.001). By using multivariate
logistic regression analysis, we observed significant values of Odds Ratios of osteoporosis (adjusted for
age, physical activity and the use of drugs known to increase the risk of fractures) in subjects with
diabetes and obesity: 1.39 (CI: 1,05-1,83) and 1.46 (CI: 1.20-1.78), respectively. A statistically significant
linear trend of higher Odds Ratios of osteoporosis was found for increasing values of BMI. The percent
change in the odds of vertebral fractures per single SD decrease of AD-SoS was 47% (P<0.001). Diabetes
and obesity in postmenopausal women are likely to represent independent risk factors for osteoporosis.
Phalangeal QUS showed a good power of predictivity in identifying subjects with vertebral fractures.
... Because OP is asymptomatic and DXA alone is insufficient to predict fracture risk, providing individualized risk is an important strategy for reducing fracture risk and related morbidity. Unfortunately, it is unclear whether patients understand their DXA results, are able to act on this vital information in an appropriate way, or that health care providers know how to convey DXA results and FRAX® in a way that patients understand [3][4][5][6][7]. ...
To determine patients' preferences for, and understanding of, FRAX® fracture risk conveyed through illustrations.
Drawing on examples from published studies, four illustrations of fracture risk were designed and tested for patient preference, ease of understanding, and perceived risk. We enrolled a convenience sample of adults aged 50 and older at two medical clinics located in the Midwestern and Southern United States. In-person structured interviews were conducted to elicit patient ranking of preference, ease of understanding, and perceived risk for each illustration.
Most subjects (n = 142) were female (64%), Caucasian (76%) and college educated (78%). Of the four risk depictions, a plurality of participants (37%) listed a bar graph as most preferred. Subjects felt this illustration used the stoplight color system to display risk levels well and was the most "clear," "clean," and "easy to read". The majority of subjects (52%) rated the pictogram as the most difficult to understand as this format does not allow people to quickly ascertain their individual risk category.
Communicating risk to patients with illustrations can be done effectively with clearly designed illustrations responsive to patient preference.
ClinicalTrials.gov Identifier: NCT01507662.
... Although previous studies have described failures in test-result follow-up, 5 6 10 30 including some focused on EHR-enabled health systems, [31][32][33][34][35] little is known about vulnerabilities predisposing clinicians or organisations to missed test results in EHR-based settings. Because EHRs change both individual as well as the healthcare environment or setting where they are implemented in many important ways, it is important to understand contextual factors that influence test result follow-up in order to improve safety in this area. ...
Objectives
Electronic health record (EHR)-based alerts can facilitate transmission of test results to healthcare providers, helping ensure timely and appropriate follow-up. However, failure to follow-up on abnormal test results (missed test results) persists in EHR-enabled healthcare settings. We aimed to identify contextual factors associated with facility-level variation in missed test results within the Veterans Affairs (VA) health system.
Design, setting and participants
Based on a previous survey, we categorised VA facilities according to primary care providers’ (PCPs’) perceptions of low (n=20) versus high (n=20) risk of missed test results. We interviewed facility representatives to collect data on several contextual factors derived from a sociotechnical conceptual model of safe and effective EHR use. We compared these factors between facilities categorised as low and high perceived risk, adjusting for structural characteristics.
Results
Facilities with low perceived risk were significantly more likely to use specific strategies to prevent alerts from being lost to follow-up (p=0.0114). Qualitative analysis identified three high-risk scenarios for missed test results: alerts on tests ordered by trainees, alerts ‘handed off’ to another covering clinician (surrogate clinician), and alerts on patients not assigned in the EHR to a PCP. Test result management policies and procedures to address these high-risk situations varied considerably across facilities.
Conclusions
Our study identified several scenarios that pose a higher risk for missed test results in EHR-based healthcare systems. In addition to implementing provider-level strategies to prevent missed test results, healthcare organisations should consider implementing monitoring systems to track missed test results.
... Patient safety can be compromised by a failure of referring physicians to acknowledge and act on radiology reports and other test results within an appropriate time frame [2][3][4]. A major challenge to radiologists is the communication of unexpected or acute significant findings to referring physicians, as most PACS and RIS systems do not have established robust systems in place to identify these reports and ensure that they are communicated to referring physicians in an expeditious manner. ...
An integral part of realizing the enormous potential of imaging in patient care is close communication between radiologists and referring physicians. One key element of this process is the communication of unexpected significant findings. The authors examined the performance of a PACS-based alert system in the appropriate communication of reports containing unexpected significant findings to referring physicians.
A PACS-integrated key word system was developed such that an e-mail was sent to the referring clinician if a radiologist detected a significant unexpected finding. The number, source, and outcome of chest radiographic unexpected findings over a 14-month period were analyzed. The time for response of the referring physician plus time for follow-up were also examined.
Key words were applied to 158 of the 39,665 chest radiographs (0.4%) obtained during the study period. The emergency department was the most frequent referral location (46.2%). Final diagnostic categories included malignancy (13.9%), benign lesion (49.4%), and no abnormality (20.2%). The average time to acknowledgment by clinicians of notification was 3.1 days, although 57.6% were acknowledged within 24 hours. The mean time interval to the next relevant radiologic investigation was 26 days among the 77.8% of findings that underwent radiologic follow-up.
The development of electronic alert systems, which are integrated into PACS, can aid greatly in report communication and eliminate the risk associated with unread reports that contain significant or unexpected findings.
... Patient safety can be compromised by a failure of referring physicians to acknowledge and act on radiology reports and other test results within an appropriate time frame [2][3][4]. A major challenge to radiologists is the communication of unexpected or acute significant findings to referring physicians, as most PACS and RIS systems do not have established robust systems in place to identify these reports and ensure that they are communicated to referring physicians in an expeditious manner. ...
Purpose
An integral part of realizing the enormous potential of imaging in patient care is close communication between radiologists and referring physicians. One key element of this process is the communication of unexpected significant findings. The authors examined the performance of a PACS-based alert system in the appropriate communication of reports containing unexpected significant findings to referring physicians.
Methods
A PACS-integrated key word system was developed such that an e-mail was sent to the referring clinician if a radiologist detected a significant unexpected finding. The number, source, and outcome of chest radiographic unexpected findings over a 14-month period were analyzed. The time for response of the referring physician plus time for follow-up were also examined.
Results
Key words were applied to 158 of the 39,665 chest radiographs (0.4%) obtained during the study period. The emergency department was the most frequent referral location (46.2%). Final diagnostic categories included malignancy (13.9%), benign lesion (49.4%), and no abnormality (20.2%). The average time to acknowledgment by clinicians of notification was 3.1 days, although 57.6% were acknowledged within 24 hours. The mean time interval to the next relevant radiologic investigation was 26 days among the 77.8% of findings that underwent radiologic follow-up.
Conclusions
The development of electronic alert systems, which are integrated into PACS, can aid greatly in report communication and eliminate the risk associated with unread reports that contain significant or unexpected findings.
... 10 Remarkably, despite this prevalence and cost, no empirical evidence exists to support the assertion that assurance behaviors reduce liability risk. In fact, the opposite may be true: a growing number of studies show that abnormal test results are frequently missed by ordering physicians, [11][12][13][14][15][16] and failure to follow up on results is a common cause of diagnostic error. 17 We believe that the high volume of testing likely plays an important role in missed results. ...
To assess medical students' and residents' experiences with defensive medicine, which is any deviation from sound medical practice due to a perceived threat of liability through either assurance or avoidance behaviors. Assurance behaviors include providing additional services of minimal clinical value. Avoidance behaviors include withholding services that are, or avoiding patients who are, perceived as high risk.
The authors conducted a cross-sectional survey of fourth-year medical students and third-year residents in 2010. Respondents rated how often malpractice liability concerns caused their teams to engage in four types of assurance and two types of avoidance behaviors using a four-point scale (never, rarely, sometimes, often). Respondents also rated how often their attending physicians explicitly recommended that liability concerns be taken into account when making clinical decisions.
Overall, 126 of 194 medical students (65%) and 76 of 141 residents (54%) completed the survey. Of the responding medical students, 116 (92%) reported sometimes or often encountering at least one assurance practice, and 43 (34%) reported encountering at least one avoidance practice. Of the responding residents, 73 (96%) reported encountering at least one assurance practice, and 33 (43%) reported encountering at least one avoidance practice. Overall, 50 of 121 medical students (41%) and 36 of 68 residents (53%) reported that their attending physicians sometimes or often explicitly taught them to take liability into account when making clinical decisions.
Medical trainees reported frequently encountering defensive medicine practices and often being taught to take malpractice liability into consideration during clinical decision making.
... 72 The Role of the Patient in Test Result Follow-up There have been suggestions that patients can play a role in detecting and preventing medical errors 73 and could therefore have an enhanced role in the test result follow-up process. [27][28][29] Direct notification of test results to patients could serve as a safety net for providers and empower patients to be partners in their care. 8,9 It is possible for electronic systems, linked to test result databases, to generate automatic letters, email or telephone messages to notify patients directly of positive and negative test results 9 or to allow patients' direct access to results via a patient portal. ...
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.
... In 2005, the Joint Commission underscored the importance of proper communication of critical lab results. 3,5,17 Their recommendations included the development of systems to ensure adequate follow-up of critical results in high-risk scenarios including the post-discharge period. 5 While many of the microbiology results do not fall into the "critical" category, we feel that these results should be considered for inclusion in hospital efforts to track post-discharge results. ...
Failure to follow up microbiology results pending at discharge can delay appropriate treatment, increasing the risk of patient harm and litigation. Limited data describe the frequency of postdischarge microbiology results requiring a treatment change.
To determine the incidence and predictors of postdischarge microbiology results requiring follow-up.
Cross-sectional.
Large academic hospital during 2007.
We evaluated blood, urine, sputum, and cerebrospinal fluid (CSF) cultures ordered for hospitalized patients. We identified cultures that returned postdischarge and determined which were clinically important and not treated by an antibiotic to which they were susceptible. We reviewed a random subset to assess the potential need for antibiotic change. Using logistic regression, we identified significant predictors of results requiring follow-up.
Of 77,349 inpatient culture results, 8668 (11%) returned postdischarge. Of these, 385 (4%) were clinically important and untreated at discharge. Among 94 manually reviewed cases, 53% potentially required a change in therapy. Urine cultures were more likely to potentially require therapy change than non-urine cultures (OR 2.8, 95% CI 1.1-7.2; P = 0.03). Also, 76% of 25 results from surgical services potentially required a therapy change, compared with 59% of 29 results from general medicine, 38% of 16 results from oncology, and 33% of 24 results from medical subspecialties. Overall, 2.4% of postdischarge cultures potentially necessitated an antibiotic change.
Many microbiology results return postdischarge and some necessitate a change in treatment. These results arise from many specialties, suggesting the need for a hospital-wide system to ensure effective communication of these results.
... 1 In another study, one-third of newly diagnosed osteoporosis patients received no recommendation to initiate therapy during the 6 months following their abnormal dual energy x-ray absorptiometry (DXA) scan. 6 A study of abnormal Pap smears from urban community health centers revealed that women who did not know the result or who did not understand that their result was abnormal were significantly less likely to have follow-up colposcopy. 7 Underserved, minority populations are more likely to have inadequate management of abnormal test results. ...
Inadequate follow-up of abnormal test results is a common safety problem in outpatient practice. However, it is unclear exactly where and how often failures occur in the results management process. Our goal was to determine where breakdowns occur by examining 4 high-risk abnormal test results in a group of 11 clinics of an urban community health center organization.
Using a chart audit, we counted failures in the management of abnormal results of 4 tests: Pap smears, mammograms, international normalized ratio (INR), and prostate-specific antigen (PSA). We assessed documentation that the result was filed in the chart; the provider signed and responded to the result; the patient was notified of the result; the appropriate follow-up occurred, and it occurred in a timely manner or there was explicit patient refusal of the recommended follow-up.
There were 344 abnormal test results (105 Pap smears, 82 mammograms, 61 INRs, and 96 PSAs). The highest rate of failures in the management process was at follow-up care; 34% of the abnormal results did not have documentation that appropriate follow-up had occurred (11% for mammography, 26% for INR, 45% for Pap smears, and 46% for PSA). All of the earlier steps were performed with far fewer failures. For patients receiving follow-up care, 49% of the time, follow-up care did not occur in a timely manner.
Most breakdowns in the testing process for these 4 abnormal tests were in the final step, documenting that appropriate follow-up care occurred. Office systems for managing abnormal results reporting and patient follow-up are needed to improve the safety and quality of care.
... 7,19 Yet, there are now robust data demonstrating that 1% to 10% of clinically important abnormal test results are missed by providers, with potential adverse consequences for patients' health. [4][5][6]8 This suggests that while providers believe that communication of test results is an important part of their jobs, they have difficulty communicating results consistently in busy clinical practices. Our finding that providers were less interested in the assistance of an automated result reporting process for abnormal test results (which are likely to require some sort of action and thus can least afford to be ''missed''), as opposed to normal results, creates an interesting paradox: providers appear more accepting of automation of the mundane task of notifying patients of their normal results when, in actuality, automating the reporting of abnormal results may be far more important to patients' welfare. ...
Missed test results are common in clinical practice and compromise patient safety. Direct reporting, whereby testing centers systematically notify both patients and providers of important test results, constitutes a potential solution, but provider acceptance is unknown.
To assess provider interest in direct reporting of selected test results and how interest varied across different tests.
Survey of primary care physicians at a tertiary care academic medical center.
Five-point Likert scores were used to gauge each physician's interest (1 = not at all interested to 5 = very interested) in scenarios pertaining to the direct reporting of 3 diagnostic tests of low (DXA scan), intermediate (genital herpes testing), and high (breast biopsy) "emotional impact" and whether interest varied with each test's result (normal vs abnormal). Physicians were also asked to cite specific advantages and disadvantages of direct reporting.
The response rate was 73% (148/202). Physician interest in direct reporting decreased progressively as scenarios shifted from low (DXA scan) to high (breast biopsy) emotional impact (P < .001); interest in direct reporting was also higher when results were normal rather than abnormal (P < .001). Common advantages of direct reporting cited by respondents were reductions in workload (selected by 75% of respondents) and reductions in missed diagnoses (38%). The most common concerns were that patients would become unnecessarily frightened (70%) and would seek unreliable information (65%).
Direct reporting of selected test results to patients is one system for insuring that important results are not missed, but implementation should consider the specific test in question, the test result, and provider preferences.
Background:
Delayed communication of radiographic findings is associated with poor patient outcomes and significant medicolegal risk. Radiologists verbally contact referring practitioners with urgent findings, though practitioner's expectations regarding notification has rarely been examined.
Aim:
To assess differences in preferred practice between radiologists and referring practitioners in the verbal communication of urgent radiology findings.
Methods:
For 33 clinical stems, respondents were asked if they would issue (radiologists) or expect to receive (referring practitioners) verbal notification of results or routine written communication only. Surveys were emailed to radiologists and referring practitioners of varying experience at a tertiary referral hospital in Melbourne, Victoria.
Results:
A total of 97 survey responses were received. 80 responses were from referring practitioners and 17 from radiologists. Referring practitioners were seen to slightly prefer verbal notification more often than issued by radiologists overall (61%; 95CI 57-66% verbal notification expected versus 58%; 95CI 52-64% issued). More senior referring practitioners with greater than 10 years' experience expected verbal notification more often (67%; 95CI 59-75%), and more senior radiologists issued verbal reports less often (54%; 95CI 39-69%). More junior referring practitioners, for example registrars or fellows, expected notification less often overall (59%; 95CI 43-76%). Subgroup analysis demonstrated statistically significant differences in notification preferences for certain clinical scenarios.
Conclusions:
Overall results show fair correlation between referrer's expectations of verbal notification and the provision of verbal notification by radiologists. However, there were discrepancies in the practice and preferences of more junior and senior practitioners, in addition to in certain clinical scenarios. This article is protected by copyright. All rights reserved.
Background
Missed or delayed follow-up of abnormal subcritical tests (tests that do not require immediate medical attention) can lead to poor patient outcomes. Safety-net health systems with limited resources and socially complex patients are vulnerable to safety gaps resulting from delayed management. Clinician perspectives to identify system challenges, vulnerable situations, and potential solutions were sought in focus groups.
Methods
Five semistructured focus groups were conducted in 2015 with purposefully sampled clinicians from radiology, hospital medicine, emergency medicine, risk management, and ambulatory care from an urban, academic, integrated, safety-net health system. Thematic analysis identified challenges of current management of abnormal subcritical tests, vulnerable situations, and solution characteristics. A total of 43 clinicians participated.
Results
Clinicians cited challenges in assigning responsibility for follow-up and identified tests pending at discharge and tests requiring delayed follow-up as vulnerable situations. The lack of tracking systems and missing contact information for patients and providers exacerbated these challenges. Proposed solution characteristics involved protocols to aid in assigning responsibility, reliable paths of communication, and systems to track the status of tests. Clinicians noted a strong desire for integration of the work flow and technology solutions into existing structures.
Conclusion
In an urban safety-net setting, clinicians recommended outlining clear chains of responsibility and communication in the management of subcritical test results, and employing simple, integrated technological solutions that allow for tracking and management of tests. Existing test management solutions should be adapted to work within safety-net systems, which often have fewer resources and more complex patients and may function in the absence of integrated technology systems.
Objective:
The purpose of this study was to determine whether a multistage tracking system could improve communication between health care providers, reducing the risk of delay in diagnosis related to inconsistent communication and tracking of radiology follow-up recommendations.
Materials and methods:
Unconditional recommendations for imaging follow-up of all diagnostic imaging modalities excluding mammography (n = 589) were entered into a database and tracked through a multistage tracking system for 13 months. Tracking interventions were performed for patients for whom completion of recommended follow-up imaging could not be identified 1 month after the recommendation due date. Postintervention compliance with the follow-up recommendation required examination completion or clinical closure (i.e., biopsy, limited life expectancy or death, or subspecialist referral).
Results:
Baseline radiology information system checks performed 1 month after the recommendation due date revealed timely completion of 43.1% of recommended imaging studies at our institution before intervention. Three separate tracking interventions were studied, showing effectiveness between 29.0% and 57.8%. The multistage tracking system increased the examination completion rate to 70.5% (a 52% increase) and reduced the rate of unknown follow-up compliance and the associated risk of delay in diagnosis to 13.9% (a 74% decrease). Examinations completed after tracking intervention generated revenue of 4.1 times greater than the labor cost.
Conclusion:
Performing sequential radiology recommendation tracking interventions can substantially reduce the rate of unknown follow-up compliance and add value to the health system. Unknown follow-up compliance is a risk factor for delay in diagnosis, a form of preventable medical error commonly identified in malpractice claims involving radiologists and office-based practitioners.
In this chapter we’ll see how the technical concepts discussed in Chapter 3 can be combined into a workable electronic health record system in the typical provider practice. I’ll use as examples some systems I consider to have state-of-the-art approaches to electronic records. As we discussed in Chapter 2, there are around 1,000 commercial electronic health record systems and I’m certainly not familiar with the substantial majority of them. I have selected carefully but that doesn’t mean they are the only – or even the best – products available, nor can I promise that they will be the best choice for any particular provider office.
Appendix 3: Details of research proposal and evaluation protocol
Our finding that 60% of incidental aortic dilations lacked evidence of recognition in the EMR by the clinical service within 3 months and that 18% were never documented should be considered in the context of studies of test result management. Studies conducted in multiple settings found that approximately 1% of elevated potassium levels, 2% of abnormal thyroid-stimulating hormone levels, and 23% of abnormal bone density CT scans were not recognized by providers according to medical record review (2–3, 11, 20). Alternatively, Roy and colleagues (4) found that clinicians overlooked approximately 60% of important abnormal test results that returned after patients were discharged from a large teaching hospital, whereas Choksi and colleagues (21) found that 2% of “significant unexpected” radiology findings in the Ann Arbor Veterans Affairs medical center would have been lost to follow-up if not for a safety-net system they had developed. The wide variation in the proportion of unrecognized test results being reported is probably related to several factors, including variation in the tests being considered, the definition of an abnormal result, and the quality and completeness of the medical records (and provider documentation) that were available for review.
Purpose:
The purpose of this paper is to outline considerations and steps taken to introduce electronic reporting and verification from systems design and multidisciplinary collaborations to gap analysis and devising solutions. It also evaluates carefully placed forcing functions' impact on verification rates.
Design/methodology/approach:
A multidisciplinary workgroup was formed to stop print and establish electronic reporting. The electronic verification's success was assessed by weekly activity analysis.
Findings:
Introducing a verification forcing function markedly improved verification activity. Thereafter, non-verified results stabilized at 7 percent up to 75 weeks post-implementation.
Practical implications:
This paper illustrates how results reporting and verification could be implemented in a tertiary hospital using a mixed electronic and paper record. Factors that were critical to success include stakeholder engagement and applying systems design that focussed on patient safety as a key priority. The electronic reporting system was augmented by strategically inserted forcing functions, clear clinical-responsibility lines and ancillary alert systems.
Originality/value:
The systems design method's value in managing non-critical but abnormal results appears to have been under-appreciated. This paper describes how systems design could be used to improve health information delivery and management.
This study describes the implementation and impact of an electronic test result acknowledgement (RA) system in the Mater Mothers' Hospital in Brisbane, Australia. The Verdi application electronically records clinicians' acknowledgement of the review of results. Hospital data (August 2011-August 2012) were extracted to measure clinicians' acknowledgement practices. There were 27 354 inpatient test results for 6855 patients. All test results were acknowledged. 60% (95% CI 59% to 61%) of laboratory and 44% (95% CI 40% to 48%) of imaging results were acknowledged within 24 h. The median time between report availability and acknowledgement was 18.1 h for laboratory and 1 day 18 h for imaging results. The median time from when a result was first viewed to its acknowledgement was 7 min for laboratory and 1 min for imaging results. The longest recorded time to acknowledgement was 38 days. Electronic RA provides a safety net to enhance test result management.
The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged.
In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action.
The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics.
This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.
Purpose:
There is growing conflict in the literature describing the effect of delayed treatment on outcomes following radical prostatectomy. There is also evidence to suggest progression of low-risk prostate cancer to develop higher grades and volumes of prostate cancer during active surveillance. It is unknown as to what affect a delay in referral of those men with abnormal screened-PSA levels have on subsequent Gleason grade.
Methods:
We identified 350 men through our rapid access prostate clinic who underwent TRUS biopsy for abnormal age-related PSA and/or abnormal clinical examination. Clinicopathological findings were compared for those with positive versus negative TRUS biopsies, and for those with initial delays in referral (<12 months, 12-18 months, and >18 months). We used ANOVA and Student's t-tests amongst other statistical tools to examine significance of clinical findings.
Results:
Of the 350 men who underwent TRUS biopsy, those with a delay in referral of 12 months or more were significantly associated with higher PSA titers, clinically palpable disease and likelihood of diagnosis with prostate cancer. A delay of 18 months or more led to a significantly higher risk of being diagnosed with a leading grade 4 prostate cancer, which was further supported using PSA velocity as a diagnostic tool (change >0.4 ng/ml/year).
Conclusion:
We recommend that repeated asymptomatic abnormal age-related PSA readings and/or abnormal clinical examination in the screened population be referred without delay to a urologist for further assessment, enrolment into an active surveillance program or definitive subsequent treatment.
Mr B, a 60-year-old man with back pain, was not informed of an incidental finding of a renal mass suggestive of cancer on a magnetic resonance imaging scan. Failure and delays in test follow-up are a frequent problem in medicine, occurring in more than 5% of significantly abnormal ambulatory test results. Rather than simply blaming involved clinicians, systems for managing tests need to be reengineered using methods from reliability sciences. These begin with investigations into the systemic causes of the failures, then application of approaches such as heightened situational awareness, closed-loop systems, improved handoffs, just-in-time work, culture and practices of stopping to fix problems, forcing functions and simplification, enhanced visual cues, and cautious use of information technology and redundancy, all while avoiding suboptimization. Emerging test management systems and critical test follow-up recommendations illustrate how applying these principles can enhance this important aspect of patient safety.
The purpose of this study is to determine patients' preferences for how, from whom, and how soon they receive imaging results.
Hard copies of our survey were randomly distributed to patients at an academic medical center outpatient imaging facility for 9 weeks, during August through October 2008, to collect data regarding patient preferences for how they received results ("Method"), from whom ("Person"), and how quickly ("Speed").
A total of 129 (23%) of 557 patients (47.4% male; median age, 55 years) undergoing CT (62%) and MRI (38%) completed the survey. According to survey responses, results needed to be communicated within a few hours for an "acceptable" rating from 95% of patients. Thirty-one percent preferred to receive normal results by the fastest method, whereas 35% preferred to receive abnormal results by telephone. Patients did not show an overwhelming preference regarding which physician communicates the results. More than 25% of patients were indifferent as to who was giving the results and cared only about the speed of delivery. For normal results, 12% chose from the radiologist, 41% from the referring physician, 14% from both, and 33% from whoever is faster (p < 0.0001). For abnormal results, 6% chose from the radiologist, 41% from the referring physician, 27% from both, and 26% from whoever is faster (p < 0.0002).
Patients in our study wanted their results communicated much sooner than is currently practiced. Optimizing patient satisfaction may require a new communication model.
To evaluate the effectiveness of an electronic messaging system for accurately communicating important, but not emergent, abnormal radiology results to referring physicians.
The Institutional Review Board deemed this proposal a quality improvement project that did not require formal approval. The electronic messaging system permits radiologists to submit online requests to communicate important, but not emergent, abnormal findings and recommended follow-up to two communications facilitators, who contact referring health care providers by e-mail or telephone. Of 10,510 electronic communications during a 3-year period, a representative sample of 500 communications were selected for detailed analysis. To eliminate bias associated with increased experience with the system, every 20th communication during the 3 years that the messaging system had been functional was examined. Parameters studied included the rate of successful communications with referring physicians, the frequency of these being accomplished within the goal of 48 hours from the time of radiologist submission, and the results of an e-mail survey of physicians to assess their satisfaction with the system.
The radiologic abnormality was successfully communicated to the referring physician in every communication. Overall, a mean of 82.2% ± 3.3 (standard deviation) of communications were accomplished within the goal of 48 hours, with this goal being met in 93.7% ± 2.3 of communications submitted Monday through 3 pm on Thursday. Satisfaction among referring physicians was high (79.0% ± 3.8 satisfied; 5.0% ± 2.0 dissatisfied), especially among those with the most experience with the system.
The electronic messaging system communicated important, but not emergent, abnormal radiology results to referring physicians in a timely, accurate, and relatively inexpensive manner.
http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10101015/-/DC1.
Test result management is an integral aspect of quality clinical care and a crucial part of the ambulatory medicine workflow. Correct and timely communication of results to a provider is the necessary first step in ambulatory result management and has been identified as a weakness in many paper-based systems. While electronic health records (EHRs) hold promise for improving the reliability of result management, the complexities involved make this a challenging task. Experience with test result management is reported, four new categories of result management errors identified are outlined, and solutions developed during a 2-year deployment of a commercial EHR are described. Recommendations for improving test result management with EHRs are then given.
Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem.
We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up.
Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment.
Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.
Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference in 2008, attendees attended two focus groups dedicated to identification of strategies to lower the frequency of missed results. The recommendations were reviewed and summarized. Improved standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow up of test results, and systems re-engineering to improve the management and presentation of data. Focusing the initial interventions on the specific tests which have been identified as high risk for adverse impact on patient outcomes such as tests associated with a possible malignancy or acute coronary syndrome will likely have the most significant impact on clinical outcome and patient satisfaction with care.
Failing to inform a patient of an abnormal outpatient test result can be a serious error, but little is known about the frequency of such errors or the processes for managing results that may reduce errors.
We conducted a retrospective medical record review of 5434 randomly selected patients aged 50 to 69 years in 19 community-based and 4 academic medical center primary care practices. Primary care practice physicians were surveyed about their processes for managing test results, and individual physicians were notified of apparent failures to inform and asked whether they had informed the patient. Blinded reviewers calculated a "process score" ranging from 0 to 5 for each practice using survey responses.
The rate of apparent failures to inform or to document informing the patient was 7.1% (135 failures divided by 1889 abnormal results), with a range of 0% to 26.2%. The mean process score was 3.8 (range, 0.9-5.0). In mixed-effects logistic regression, higher process scores were associated with lower failure rates (odds ratio, 0.68; P < .001). Use of a "partial electronic medical record" (paper-based progress notes and electronic test results or vice versa) was associated with higher failure rates compared with not having an electronic medical record (odds ratio, 1.92; P = .03) or with having an electronic medical record that included both progress notes and test results (odds ratio, 2.37; P = .007).
Failures to inform patients or to document informing patients of abnormal outpatient test results are common; use of simple processes for managing results is associated with lower failure rates.
The need for improving the timeliness of the communication of critical test results is reflected in a Joint Commission National Patient Safety Goal and is the basis for this special issue of the Journal.
Consecutive patients identified as having osteoporosis on screening dual-energy X-ray absorptiometry (DXA) scans were randomized to: (1) a patient activation intervention consisting of mailing patients their DXA scan results supplemented by a call from a nurse educator or (2) usual care. Three months after the DXA scan, patients were contacted to assess: (1) use of antiresorptive therapy, (2) osteoporosis specific knowledge, and (3) satisfaction with their osteoporosis-related care. A total of 1,035 consecutive patients were screened to identify 422 eligible patients. Of these, 56 patients met inclusion criteria and were subsequently randomized. At follow-up, use of antiresorptive agents was numerically more common in the intervention arm (62%) than the control arm (54%), but this difference was not statistically significant (p=0.58). Patients in the intervention group were more likely to report being notified of their DXA results in a timely fashion (p=0.03), but osteoporosis-specific knowledge was similar.
Objective: To summarize controlled trials examining the effect of calcium on bone density and fractures in postmenopausal women. Data Source: We searched MEDLINE and EMBASE up to 1998 and the Cochrane Controlled Register up to 2000, and we examined citations of relevant articles and proceedings of international meetings. We contacted osteoporosis investigators to identify additional studies, and primary authors for unpublished data. Study Selection: We included 15 trials (1806 patients) that randomized postmenopausal women to calcium supplementation or usual calcium intake in the diet and reported bone mineral density of the total body, vertebral spine, hip, or forearm, or recorded the number of fractures, and followed patients for at least 1 yr. Data Extraction: For each trial, three independent reviewers assessed the methodological quality and extracted data. Data Synthesis: We found calcium to be more effective than placebo in reducing rates of bone loss after two or more years of treatment. The pooled difference in percentage change from baseline was 2.05% [95% confidence interval (CI) 0.24-3.86] for total body bone density, 1.66% (95% CI 0.92-2.39) for the lumbar spine, 1.64% (95% CI 0.70-2.57) for the hip, and 1.91% (95% Cl 0.33-3.50) for the distal radius. The relative risk (RR) of fractures of the vertebrae was 0.77, with a wide CI (95% CI 0.54-1.09); the RR for nonvertebral fractures was 0.86 (95% CI 0.43-1.72). Conclusions: Calcium supplementation alone has a small positive effect on bone density. The data show a trend toward reduction in vertebral fractures, but do not meaningfully address the possible effect of calcium on reducing the incidence of nonvertebral fractures.
To examine physician use of stool guaiac testing in order to determine indications for testing, how the test was used, and the consequences of a particular test result.
Retrospective case series.
Large midwestern inpatient nursing home facility.
All patients with positive fecal occult blood tests (FOBT) and one-third of patients with negative FOBT.
In an 18-month period, 916 occult blood tests were performed on 339 patients (37% of the nursing home census). Patients over age 90 were as likely to receive FOBT as those under age 70. Fourteen percent of those tested had at least one positive test. Fifty-eight percent of the patients with positive tests underwent no additional diagnostic testing. No cause for the positive FOBT was found for 68% of patients receiving the test for routine screening. Physician estimates of how frequently they employed FOBT for these patients correlated very poorly with their actual practices (r = .17).
There is a high prevalence of positive results from FOBT among nursing home patients. In most cases, such results do not cause a change of therapy or result in additional workup. Lack of information on the role of FOBT in nursing home patients contributes to the great diversity in utilization of this test by nursing home physicians.
This section summarizes the results of the seven systematic reviews of osteoporosis therapies published in this series [calcium, vitamin D, hormone replacement therapy (HRT), alendronate, risedronate, raloxifene, and calcitonin] and systematic reviews of etidronate and fluoride we have published elsewhere. We highlight the methodological strengths and weaknesses of the individual studies, and summarize the effects of treatments on the risk of vertebral and nonvertebral fractures and on bone density, including effects in different patient subgroups. We provide an estimate of the expected impact of antiosteoporosis interventions in prevention and treatment populations using the number needed to treat (NNT) as a reference. In addition to the evidence, judgements about the relative weight that one places on weaker and stronger evidence, attitudes toward uncertainty, circumstances of patients' and societal values or preferences will, and should, play an important role in decision-making regarding anti-osteoporosis therapy.
Although osteoporotic fractures present an enormous health burden, it is not clear whether screening to identify high-risk persons is appropriate.
To examine evidence on the benefits and harms of screening postmenopausal women for osteoporosis.
MEDLINE (1966 to May 2001), HealthSTAR (1975 to May 2001), and Cochrane databases; reference lists; and experts.
English-language abstracts that included original data about postmenopausal women and osteoporosis and addressed the effectiveness of risk factor assessment, bone density tests, or treatment were included.
Selected information about patient population, interventions, clinical end points, and study design were extracted, and a set of criteria was applied to evaluate study quality.
No trials of the effectiveness of screening have been published. Instruments developed to assess clinical risk factors for low bone density or fractures have moderate to high sensitivity and low specificity. Among different bone density tests measured at various sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry is the best predictor of hip fracture. Women with low bone density have approximately a 40% to 50% reduction in fracture risk when treated with bisphosphonates.
Population screening would be based on evidence that the risk for osteoporosis and fractures increases with age, that the short-term risk for fracture can be estimated by bone density tests and risk factors, and that fracture risk can be reduced with treatment. The role of risk factor assessment and different bone density techniques, frequency of screening, and identification of subgroups for which screening is most effective remain unclear.
Organized care management processes (CMPs) can improve health care quality for patients with chronic diseases. The Institute of Medicine of the National Academy of Sciences has called for public and private purchasers of health care to create incentives for physician organizations (POs) to use CMPs and for the government to assist POs in implementing information technology (IT) to facilitate CMP use. Research is lacking about the extent to which POs use CMPs or about the degree to which incentives, IT, or other factors are associated with their use.
To determine the extent to which POs with 20 or more physicians use CMPs and to identify key factors associated with CMP use for 4 chronic diseases (asthma, congestive heart failure, depression, and diabetes).
One thousand five hundred eighty-seven US POs (medical groups and independent practice associations) with 20 or more physicians were identified using 5 large databases. One thousand one hundred four of these POs (70%) agreed to participate in a telephone survey conducted between September 2000 and September 2001. Sixty-four responding POs were excluded because they did not treat any of the 4 diseases, leaving 1040 POs.
Extent of use of CMPs as calculated on the basis of a summary measure, a PO care management index (POCMI; range, 0-6) and factors associated with CMP use.
Physician organizations' mean use of CMPs was 5.1 of a possible 16; 50% used 4 or fewer. External incentives and clinical IT were most strongly associated with CMP use. Controlling for other factors, use of the 2 most strongly associated incentives-public recognition and better contracts for health care quality-was associated with use of 1.3 and 0.7 additional CMPs, respectively (P<.001 and P =.007). Each additional IT capability was associated with 0.37 additional CMPs (P<.001). However, 33% of POs reported no external incentives and 50% reported no clinical IT capability.
The use of CMPs varies greatly among POs, but it is low on average. Government and private purchasers of health care may increase CMP use by providing external incentives for improvement of health care quality to POs and by assisting them in improving their clinical IT capability.
Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies.
We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two.
Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting-enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events.
Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs.
Fecal occult blood testing (FOBT) screening can reduce colorectal cancer (CRC) mortality when patients with an abnormal result [FOBT(+)] undergo a complete diagnostic evaluation (colonoscopy or double-contrast barium enema with or without flexible sigmoidoscopy). The aim of this study was to determine common reasons for nonperformance of a complete diagnostic evaluation.
We identified 544 FOBT(+) patients, aged 50 yr or older, who had participated in a managed care organization-sponsored CRC screening program. The performance of a complete diagnostic evaluation was determined from a patient-specific follow-up form and managed care organization claims data. Physicians were asked to report whether patients submitted to a complete diagnostic evaluation. When an evaluation was not done, the physicians were also asked to state the reasons for nonperformance.
A total of 248 (46%) patients did not undergo a complete diagnostic evaluation. Physicians provided reasons for nonperformance for 50% (123/248). Factors accounting for nonperformance of a complete diagnostic evaluation were classified as follows: primary care physician decision (50%); specialist decision (28%); patient decision (17%); and other (practice-related) (5%). Many failures to complete an appropriate diagnostic evaluation were due to providers deciding to repeat the FOBT, perform a sigmoidoscopy, or not to proceed with any further testing.
Many patients with a positive FOBT do not receive a complete diagnostic evaluation. The reasons for nonperformance most frequently have to do with physician decision making. Many physician-related explanations do not conform to expert recommendations for appropriate follow-up.
Fecal occult blood testing (FOBT) screening can reduce colorectal cancer (CRC) mortality when patients with an abnormal result [FOBT(+)] undergo a complete diagnostic evaluation (colonoscopy or double-contrast barium enema with or without flexible sigmoidoscopy). The aim of this study was to determine common reasons for nonperformance of a complete diagnostic evaluation.Methods
We identified 544 FOBT(+) patients, aged 50 yr or older, who had participated in a managed care organization–sponsored CRC screening program. The performance of a complete diagnostic evaluation was determined from a patient-specific follow-up form and managed care organization claims data. Physicians were asked to report whether patients submitted to a complete diagnostic evaluation. When an evaluation was not done, the physicians were also asked to state the reasons for nonperformance.ResultsA total of 248 (46%) patients did not undergo a complete diagnostic evaluation. Physicians provided reasons for nonperformance for 50% (123/248). Factors accounting for nonperformance of a complete diagnostic evaluation were classified as follows: primary care physician decision (50%); specialist decision (28%); patient decision (17%); and other (practice-related) (5%). Many failures to complete an appropriate diagnostic evaluation were due to providers deciding to repeat the FOBT, perform a sigmoidoscopy, or not to proceed with any further testing.Conclusion
Many patients with a positive FOBT do not receive a complete diagnostic evaluation. The reasons for nonperformance most frequently have to do with physician decision making. Many physician-related explanations do not conform to expert recommendations for appropriate follow-up.
This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears.
The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews.
The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates).
Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.
In a sample of 30,195 randomly selected hospital records, we identified 1133 patients (3.7 percent) with disabling injuries caused by medical treatment. We report here an analysis of these adverse events and their relation to error, negligence, and disability.
Two physician-reviewers independently identified the adverse events and evaluated them with respect to negligence, errors in management, and extent of disability. One of the authors classified each event according to type of injury. We tested the significance of differences in rates of negligence and disability among categories with at least 30 adverse events.
Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent). Nearly half the adverse events (48 percent) were associated with an operation. Adverse events during surgery were less likely to be caused by negligence (17 percent) than nonsurgical ones (37 percent). The proportion of adverse events due to negligence was highest for diagnostic mishaps (75 percent), noninvasive therapeutic mishaps ("errors of omission") (77 percent), and events occurring in the emergency room (70 percent). Errors in management were identified for 58 percent of the adverse events, among which nearly half were attributed to negligence.
Although the prevention of many adverse events must await improvements in medical knowledge, the high proportion that are due to management errors suggests that many others are potentially preventable now. Reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
Although adverse events (AEs) are not uncommon in hospitalized patients, they are by no means inevitable. A review of records from a population-based study in New York revealed that nearly 4% of hospitalized patients suffered AEs. Two-thirds of those events were considered to be caused by errors in management, most of which were not because of negligence. A large part of the reason preventable AEs occur is that today's medical care is extremely complex, involving a variety of personnel, equipment, and procedures. By seeking to eliminate errors in the system of providing care and raising the awareness of health care providers about the potential for AEs, programs can be established to address and possibly remedy this serious problem.
To investigate physician practices in the handling of patients' test results from the time the test was ordered until the time any required follow-up was completed.
Survey of 161 attending physicians and 101 residents in family practice and internal medicine practicing at a large urban teaching hospital and 21 suburban primary care practices in Southeastern Michigan. The survey included questions about physician demographics, and whether physicians have methods for ensuring that (1) the results of all tests ordered are received, (2) all patients are notified of results, (3) all patient notification is documented, and (4) all required follow-up is done. Physicians were also asked to self-rate the reliability of their methods and the importance of various steps in the handling of patients' test results.
The response rate was 79% for both attending physicians and residents. Approximately 17% to 32% of physicians reported having no reliable method to make sure that the results of all tests ordered are received. One third of physicians do not always notify patients of abnormal results. The most common reasons reported for not notifying patients were that the results were trivial and that the patient was expected to return to the clinic soon. Residents were significantly less likely to document notifying patients of abnormal results (P < .001). Only 23% of physicians reported having a reliable method for identifying patients overdue for follow-up.
Lack of methods to ensure that the results of tests ordered were received, dependence on follow-up visits to inform patients of results, and lack of documentation were relatively common among physicians surveyed. These could lead to an increased risk of malpractice litigation and suboptimal patient care.
Osteoporotic fractures are a significant public health problem, resulting in substantial morbidity and mortality. Previous estimates of the economic burden of osteoporosis, however, have not fully accounted for the costs associated with treatment of nonhip fractures, minority populations, or men. Accordingly, the 1995 total direct medical expenditures for the treatment of osteoporotic fractures were estimated for all persons aged 45 years or older in the United States by age group, sex, race, type of fracture, and site of service (inpatient hospital, nursing home, and outpatient). Osteoporosis attribution probabilities were used to estimate the proportion of health service utilization and expenditures for fractures that resulted from osteoporosis. Health care expenditures attributable to osteoporotic fractures in 1995 were estimated at 10.3 billion (75.1%) was for the treatment of white women, 0.7 billion (5.3%) for nonwhite women, and 8.6 billion (62.4%) was spent for inpatient care, 1.3 billion (9.4%) for outpatient services. Importantly, fractures at skeletal sites other than the hip accounted for 36.9% of the total attributed health care expenditures nationally. The contribution of nonhip fractures to the substantial morbidity and expenditures associated with osteoporosis has been underestimated by previous researchers.
Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings.
We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost.
After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient.
By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.
Patients whose test results are abnormal cannot make health behavior changes until the final phase of the laboratory testing process, patient notification, has been completed. Patients whose results are normal are often not notified at all. Few studies have examined the problematic aspects of patient notification, a crucial step in a complex and expensive process.
To determine patient preferences for receiving laboratory test results.
Patient survey by telephone.
Forty-nine patients with hypercholesterolemia who had had a lipoprotein profile performed within the previous 6 months were asked whether or not they had been informed of the test result, how they were informed, how satisfied they were with the process, and how they would prefer to be notified of results. All patients attended a clinic in suburban Detroit. Questions were read from a prepared script.
The majority of patients (94%) preferred to receive notification of all test results: both abnormal results accompanied by recommendations for health management changes, and normal results. Preferences for type of notification included mail (59%), phone (16%), office visit (12%), other or multiple response (6%).
Notification of both normal and abnormal results is of great importance to patients. Further studies are needed to determine what form of notification is most effective and which method is most satisfactory to patients.
The true utility of quality measurement lies in its ability to inspire quality improvement, with resultant enhancements in the processes and outcomes of care. Because quality measurement is expensive, it is difficult to justify using measures that are not likely to lead to important improvements in health. Many current measures of chronic disease technical quality, however, have one or more pitfalls that prevent them from motivating quality improvement reactions. These pitfalls include that: (1) measured processes of care lack strong links to outcomes; (2) actionable processes of care are not measured; (3) measures do not target those at highest risk; (4) measures do not allow for patient exceptions; and (5) intermediate outcome measures are not severity adjusted. To exemplify recent advancements and current pitfalls in chronic disease quality measurement, we examine the evolution of quality measures for diabetes mellitus and discuss the limitations of many currently used diabetes mellitus care measures. We then propose more clinically meaningful "tightly linked" measures that examine clinical processes directly linked to outcomes, target populations with specific diagnoses or intermediate disease outcomes that contribute to risk for poor downstream health outcomes, and explicitly incorporate exceptions. We believe that using more tightly linked measures in quality assessment will identify important quality of care problems and is more likely to produce improved outcomes for those with chronic diseases.
The goal of this study was to evaluate the difference in patient satisfaction, timeliness of reporting, patient recollection of recommendations, and patient anxiety before and after passage of the Mammography Quality Standards Reauthorization Act of 1998, which requires written notification of all mammographic results.
We used a telephone survey with sampling that was stratified to reflect patients with normal and abnormal findings who had screening and diagnostic mammograms. Patients with visits before the mandate became effective (April 1999, n = 298) and after (January 2000, n = 316) were interviewed about the average time to receive results, satisfaction with communication about results, anxiety, and perceived follow-up recommendations. Multiple logistic regression was used to test the association of time period with patient dissatisfaction, controlling for age, anxiety level (considerable or extreme vs none or moderate), examination type (screening vs diagnostic), and examination result (normal vs abnormal findings).
No significant difference was found between periods in anxiety about results or agreement with documented radiology recommendations, but we found a substantial increase in the number of screening patients who reported timely receipt of results. Significantly fewer patients were dissatisfied with mammographic results communication after the mandate (multivariable odds ratio = 0.46, p = 0.006). Screening examination patients and patients who reported considerable or extreme anxiety about test results were more likely to be dissatisfied in both periods.
By standardizing results notification, the Mammography Quality Standards Reauthorization Act improved patient satisfaction and reporting timeliness among screening examination patients, but did little to improve anxiety or recollection of recommendations. Future quality improvement efforts should focus on improving patients' understanding of follow-up recommendations.
This study estimates the cost of osteoporosis in California, including health care services and the value of lives lost prematurely to the disease. Costs are estimated for diagnoses of "osteoporosis" and for the proportion of spine, forearm, hip and other fractures that are caused by the disease. The additional costs resulting from a secondary diagnosis of osteoporosis are also included. Osteoporosis accounted for over 4 million in lost productivity resulting from premature death. Most of the cost results from hip fractures and other fractures. In fact, only 15% of costs are for people with a diagnosis of "osteoporosis" per se, and, of this group, most of the costs are associated with a secondary, not a primary diagnosis. The disease is largely a diagnosis of older white women: three-quarters of the hospitalization costs are incurred by women, 80% of those hospitalized are white, and three-quarters are over age 65 years. As would be expected, Medicare pays for most of the hospital care -- almost three-fourths of the total. Nursing home care represents the largest cost for people with osteoporosis, accounting for 59% of the money spent treating the disease.
Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined.
Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use.
Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record-based measures but would have required about 50% fewer chart reviews.
Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.
Risk factors for medical errors remain poorly understood. We performed a case-control study of retained foreign bodies in surgical patients in order to identify risk factors for this type of error.
We reviewed the medical records associated with all claims or incident reports of a retained surgical sponge or instrument filed between 1985 and 2001 with a large malpractice insurer representing one third of the physicians in Massachusetts. For each case, we identified an average of four randomly selected controls who underwent the same type of operation during the same six-month period.
Our study included 54 patients with a total of 61 retained foreign bodies (of which 69 percent were sponges and 31 percent instruments) and 235 control patients. Thirty-seven of the patients with retained foreign bodies (69 percent) required reoperation, and one died. Patients with retained foreign bodies were more likely than controls to have had emergency surgery (33 percent vs. 7 percent, P<0.001) or an unexpected change in surgical procedure (34 percent vs. 9 percent, P<0.001). Patients with retained foreign bodies also had a higher mean body-mass index and were less likely to have had counts of sponges and instruments performed. In multivariate analysis, factors associated with a significantly increased risk of retention of a foreign body were emergency surgery (risk ratio, 8.8 [95 percent confidence interval, 2.4 to 31.9]), unplanned change in the operation (risk ratio, 4.1 [95 percent confidence interval, 1.4 to 12.4]), and body-mass index (risk ratio for each one-unit increment, 1.1 [95 percent confidence interval, 1.0 to 1.2]).
The risk of retention of a foreign body after surgery significantly increases in emergencies, with unplanned changes in procedure, and with higher body-mass index. Case--control analysis of medical-malpractice claims may identify and quantify risk factors for specific types of errors.
Prior research has demonstrated that clinicians often fail to review and act upon outpatient test results in a timely and appropriate manner. To address this patient safety and quality of care issue, Partners Healthcare has developed a browser-based, provider-centric, comprehensive results management application to help clinic physicians review and act upon test results in a safe, reliable, and efficient manner. The application, called the Results Manager, incorporates extensive decision support features to classify the degree of abnormality for each result, presents guidelines to help clinicians manage abnormal results, allows clinicians to generate result letters to patients with predefined, context-sensitive templates and prompts physicians to set reminders for future testing. In this paper, we outline the design process and functionality of Results Manager. We also discuss its underlying architectural design, which revolves around a clinical event monitor and a rules engine, and the methodological challenges encountered in designing this application.
To identify the communication factors that are significantly associated with appropriate short-term follow-up of abnormal mammograms.
Prospective longitudinal study involving medical record review and patient survey.
Ten academically affiliated ambulatory medical practices in the Boston metropolitan area.
One hundred twenty-six women with abnormal mammograms requiring short-term (6 months) follow-up imaging.
Proportion of women in the study who received appropriate follow-up care.
Eighty-one (64%) of the women with abnormal mammograms requiring short-term follow-up imaging received the appropriate follow-up care. After adjusting for patients' age and insurance status, 2 communication factors were found to be independently associated with the delivery of appropriate follow-up care: 1). physicians' documentation of a follow-up plan in the medical record (adjusted odds ratio, 2.79; 95% confidence interval, 1.11 to 6.98; P =.029); and 2). patients' understanding of the need for follow-up (adjusted odds ratio, 3.86; 95% confidence interval, 1.50 to 9.96; P =.006). None of the patients' clinical or psychological characteristics were associated with the delivery of appropriate follow-up care.
Follow-up care for women with abnormal mammograms requiring short-term follow-up imaging is suboptimal. Documentation of the follow-up plan by the physician and understanding of the follow-up plan by the patient are important factors that are correlated with the receipt of appropriate follow-up care for these women. Interventions designed to improve the quality of result follow-up in the outpatient setting should address these issues in patient-doctor communication.
Evidence suggests that patients diagnosed with osteoporosis are often undertreated. One potential solution to undertreatment is to enhance patient involvement in their osteoporosis care (a.k.a. patient activation) by having the dual-energy X-ray absorptiometry (DXA) center directly provide patients with their test results and educational material. However, little is known about patient interest in such an intervention. Consecutive patients presenting to an academic medical center DXA scanning unit were given a questionnaire to assess their preferences for being informed of their test results and interest in receiving their results plus educational material by mail from the testing center. Two hundred and two (202) of 206 (98%) of patients agreed to complete the survey. Fifty-one percent of participants preferred receiving their results by mail directly from the DXA center, followed by phone call (28%) and office visit (11%). Overall, 90% of patients reported interest in receiving results and educational material by mail. Younger patients were more interested in receiving their results by mail when compared with older patients, but this difference did not reach statistical significance (odds ratio [OR] = 2.40: 95% confidence interval [CI]: 0.91-6.31, p = 0.14). Patients undergoing DXA scanning were interested in receiving their scan results and educational material directly from the testing center. This might represent an effective intervention for improving care of patients with osteoporosis.