Communication gap: MDs fail to follow-up in 1/3 of imaging exams

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 - Missing puzzle piece

Failure to follow-up test results for ambulatory patients represents an urgent concern and occurs in up to 35.7 percent of radiology tests, according to a review of medical literature published in the October issue of Journal of General Internal Medicine.

Solving the issue, however, will not be simple, and authors Joanne L. Callen, PhD, of the University of New South Wales in Sydney, and colleagues suggest that a multifaceted approach will be required.

“There are significant safety issues in the management of laboratory and radiology test results for ambulatory patients,” wrote the authors. “Studies show that factors associated with failure to follow-up test results in ambulatory settings are complex and often it is a combination of elements, systems, people, organizational factors and work practices interacting that leads to important results being missed.”

Results of the study were based on a systematic review of evidence in English-language medical literature published from 1995 to 2010. Medline, CINAHL, Embase, Inspec and the Cochrane Database were all mined as data sources, with a total of 768 articles screened by the authors.

The authors searched for studies which documented quantitative evidence of the number of tests not followed-up in outpatient clinics, academic medical or community health centers or primary care practices. Nineteen studies ultimately met the inclusion criteria.

A wide variation in the extent of tests not followed-up existed, according to Callen and colleagues. Studies reported failed follow-up rates as low as 1 percent and as high as 35.7 percent for radiology tests. Laboratory tests fared even worse, with failed follow-up rates ranging from 6.8 percent to 62 percent.

The impact of failing to follow-up on ambulatory tests was very serious in some cases, with four studies reporting missed cancer diagnoses as a result, according to the authors. Other negative outcomes included missed abnormal serum potassium levels related to hyperkalemia and adverse drug events.

The authors noted there are multiple causes of failed follow-up, including:

  • Scarcity of governing principles for test management;
  • Absence of integrated information systems for test management;
  • The multidisciplinary nature of test management processes; and
  • The role of the patient in test result follow-up.

One study found that if policies and procedures were in place, along with an electronic alert notification for abnormal radiology results, the follow-up rate could be improved, but even this strategy could not eliminate missed results completely, explained the authors.

“Although studies of evidence regarding the link between EHRs and ambulatory quality of care have shown mixed results, a number have shown that information and communication technology can play an important role in ensuring a safer and more systematic test management process,” wrote the authors.

Technology isn’t the sole savior, as the authors pointed out that even in systems where the physician electronically acknowledges they’ve opened an alert message, it doesn’t indicate they read and acted on the results.

Directly notifying patients of results is another practice innovation cited by the authors to aid in ensuring follow-up, but here, too, lie some potential pitfalls. Abnormal results could alarm patients unnecessarily and practices might not be able to handle the increased patient communication load. It also potentially invites malpractice risks.

“Solutions which acknowledge the inter-dependence between physicians, nurses, and radiology/laboratory staff are important to ensure the safe communication of abnormal test results,” wrote Callen et al. They concluded that an effective multi-pronged follow-up strategy includes clear policies related to result notification, integrated communication technologies, and consideration of the multidisciplinary nature of the process as well as the role of the patient.