When Abnormal Lab Tests Fall Through the Cracks

Last winter, we reviewed a study by Hardeep Singh and colleagues which revealed that office-based physicians affiliated with the DeBakey VA in Houston failed to act on 8% of the clinically significant abnormal lab test results they received. More than 25% of these results triggered a new diagnosis for the involved patient. In a shocking 42% of these instances, the diagnosis was cancer.

Others have confirmed Singh’s findings. In a study of 23 physician practices on the West coast for example, Lawrence Casilano’s group found that on average, physicians didn’t inform patients about abnormal test results 7% of the time. Some practices in that study failed to do so nearly 20% of the time.

One cause of the problem is the enormous volume of test results physicians must manage, even as they work through the myriad distractions associated with their jobs. A 6 year-old study of Boston-based primary care practices found for example, that physicians reviewed about 900 test results each week.

And that was 6 years ago. To the extent that physicians handle even more test results now, or that their work environment has become more chaotic since then, the risk increases that abnormal lab findings will fall through the cracks.

“There is such a huge volume of test results,” Gordon Schiff, an associate director of the Center for Patient Safety at Brigham and Women’s Hospital told AMedNews. “It’s a Sisyphean task. You’re never caught up. As soon as you roll the ball back to the top of the mountain, it rolls back down again.”

But there’s another, more subtle reason why abnormal test results can be overlooked. Physicians working in complex health care organizations may not be sure who is responsible for the follow-up. Is it the primary care doctor, the sub-specialist who ordered the test, or perhaps a nurse practitioner or an office manager?

Attacking the Problem
The latter problem can be solved if providers institute policies governing test result follow-up. In fact, in a recent paper Singh has put forward recommendations for this purpose.

Singh’s “Eight Recommendations for Policies for Communicating Abnormal Test Results” appear in the May issue of the Joint Commission Journal on Quality and Patient Safety. According to Singh, providers should:

_- Specify what makes a test result “significantly abnormal,” how quickly such tests need to be acted upon, and how this information gets relayed to the physician?

  • Specify which physician on the care team is responsible for follow-up.
  • Specify who should be contacted with the abnormal results.
  • Specify when it is OK for a physician to be notified electronically or by fax, and when a call is necessary.
  • Specify an acceptable length of time between when a critical test is ordered and when the result is reported to the physician.
  • Understand in advance how patients prefer to be notified about abnormal results.
  • Solicit feedback on test-results communication performance from all staff.
  • Make someone responsible for monitoring and evaluating test-results communication procedures._

Does This Constitute an Adequate Solution?
Fundamentally, Singh’s recommendations boil down to making sure someone is accountable for getting information to patients: “If you order it, you own it.” That’s an excellent place to begin, but these recommendations can be augmented to further assure abnormal test results do not fall through the cracks.

First, it is wise to assure that physicians document when they review lab tests and the actions they take in response to abnormal results. The audit trail so created will inform QI projects by determining whether breakdowns in physician-patient communication occur before or after the physician supposedly becomes aware of an abnormal result.

It is also prudent to involve patients. Secure physician-patient electronic communication systems can notify physicians that their patients have not opened the message after certain period of time, for example. Such notifications can prompt a fax, a direct call or minimally, a second electronic message.

Beyond this, patients should be advised against thinking “no news is good news” when it comes to their test results. They should know to call the office if they haven’t heard within a certain period of time.

Glenn Laffel, MD, PhD
Sr. VP Clinical Affairs
Practice Fusion EMR