Why Test Results Are Still Getting “Lost” to Follow-up: a Qualitative Study of Implementation Gaps

Zimolzak, Andrew J.; Shahid, Umber; Giardina, Traber Davis; Memon, Sahar A; Mushtaq, Umair; Zubkoff, Lisa; Murphy, Daniel R.; Bradford, Andrea; Singh, Hardeep

doi:10.1007/s11606-021-06772-y

Cited by 14 publications

(5 citation statements)

References 45 publications

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“…The current study was designed to examine the additive effect of EHR reminders, direct patient outreach, and patient navigation. The EHR reminders alone did not improve follow-up proportions and highlight the limited ability of passive reminders among patients who are overdue for follow-up . The lack of additive benefit of patient navigation beyond that of reminder letters and phone calls may reflect the relatively modest remote navigation approach that was implemented; only 315 patients (9.1%) in the EHR reminders, outreach, and navigation group were screened for social determinants of health .…”

Section: Discussionmentioning

confidence: 94%

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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ImportanceRealizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.ObjectiveTo test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.Design, Setting, and ParticipantsPragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.InterventionAutomated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.Main Outcomes and MeasuresThe primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.ResultsAmong 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P &lt; .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.Conclusions and RelevanceA multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.Trial RegistrationClinicalTrials.gov Identifier: NCT03979495

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Section: Discussionmentioning

confidence: 94%

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

Atlas,

Tosteson,

Wright

et al. 2023

JAMA

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“…Recent literature shows that follow-up of test results is still a major health threat to patients. Lack of proper implementation of solutions and policies is identified as a cause 23 …”

Section: Discussionmentioning

confidence: 99%

“…Lack of proper implementation of solutions and policies is identified as a cause. 23 For investigating the nature, cause and impact of errors in the laboratory testing process different types of data sources can be used. In addition to voluntary incident reports, as we did, one could use databases with medical claims or major safety incidents, or medical chart review.…”

Section: Human Wrong Diagnosis Unidentifiablementioning

confidence: 99%

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error: A Voluntary Incident Report Analysis

van Moll,

Egberts,

Wagner

et al. 2023

J Patient Saf

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Objectives Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process. Methods We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017–2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error. Results Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%). Conclusions Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.

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“…As indicated in the National Academies of Sciences, Engineering, and Medicine's Report-Improving Diagnosis in Health Care-diagnostic testing is a key part of the information gathering process within the diagnostic process [12]. Failure to follow up on key pieces of information gathered in this process (ie, abnormal test results) can lead to diagnosis and treatment delays [13,14]. To combat this problem, the health care system operated by the United States Department of Veterans Affairs (VA) requires that test results requiring no action to be communicated to patients within 14 days after availability and results requiring an action to be communicated within 7 days (based on Veterans Health Administration Directive 1088).…”

Section: Application To a Health Services Problem: Case Studymentioning

confidence: 99%

Electronic Co-design (ECO-design) Workshop for Increasing Clinician Participation in the Design of Health Services Interventions: Participatory Design Approach

Savoy¹,

Patel²,

Shahid³

et al. 2022

JMIR Hum Factors

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Background Participation from clinician stakeholders can improve the design and implementation of health care interventions. Participatory design methods, especially co-design methods, comprise stakeholder-led design activities that are time-consuming. Competing work demands and increasing workloads make clinicians’ commitments to typical participatory methods even harder. The COVID-19 pandemic further exacerbated barriers to clinician participation in such interventions. Objective The aim of this study was to explore a web-based participatory design approach to conduct economical, electronic co-design (ECO-design) workshops with primary care clinicians. Methods We adapted traditional in-person co-design workshops to web-based delivery and adapted co-design workshop series to fit within a single 1-hour session. We applied the ECO-design workshop approach to codevelop feedback interventions regarding abnormal test result follow-up in primary care. We conducted ECO-design workshops with primary care clinicians at a medical center in Southern Texas, using videoconferencing software. Each workshop focused on one of three types of feedback interventions: conversation guide, email template, and dashboard prototype. We paired electronic materials and software features to facilitate participant interactions, prototyping, and data collection. The workshop protocol included four main activities: problem identification, solution generation, prototyping, and debriefing. Two facilitators were assigned to each workshop and one researcher resolved technical problems. After the workshops, our research team met to debrief and evaluate workshops. Results A total of 28 primary care clinicians participated in our ECO-design workshops. We completed 4 parallel workshops, each with 5-10 participants. We conducted traditional analyses and generated a clinician persona (ie, representative description) and user interface prototypes. We also formulated recommendations for future ECO-design workshop recruitment, technology, facilitation, and data collection. Overall, our adapted workshops successfully enabled primary care clinicians to participate without increasing their workload, even during a pandemic. Conclusions ECO-design workshops are viable, economical alternatives to traditional approaches. This approach fills a need for efficient methods to involve busy clinicians in the design of health care interventions.

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Why Test Results Are Still Getting “Lost” to Follow-up: a Qualitative Study of Implementation Gaps

Cited by 14 publications

References 45 publications

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error: A Voluntary Incident Report Analysis

Electronic Co-design (ECO-design) Workshop for Increasing Clinician Participation in the Design of Health Services Interventions: Participatory Design Approach

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