Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial

Abstract

Purpose We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer. Methods We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months. Results We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58). Conclusion Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.

Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism

“…Third, we were similarly unable to have a second reviewer review a subset of records to confirm delays. However, inter-rater reliability for our chart review studies identifying similar types of delays has been quite high (kappas typically > 0.80), 24,35 adding confidence to our findings. Finally, data on clinical outcomes were not included or analyzed, limiting our ability to understand the clinical impact of care delays in these cases.…”

“…Trigger-positive patient records were reviewed by a physician using a manual data collection instrument developed based on previous work on trigger development and evaluation. 23,24,33 The reviewer (AA) used the review instrument to evaluate whether a delay was truly experienced by the patient, collect reasons for false-positive results, and determine patient and provider characteristics that potentially impacted delays. Characteristics included patient age; gender; race; presence of comorbidities including diabetes, hypertension, hyperlipidemia, obesity, and depression; type of provider seen when being tested for the TSH results (primary care provider [PCP] vs. specialist); who was primarily managing the patient's thyroid disease (PCP vs. an endocrinologist); what type of PCP the patient regularly saw (physician vs. nurse practitioner or physician's assistant); and whether the patient had previous PCP or endocrine visits.…”

“…23 EHR triggers can thus automatically identify medical records at risk for delayed follow-up of abnormal test results and facilitate timely follow-up action. 24 Thyroid-stimulating hormone (TSH) test results can often be missed or delayed for follow-up, 25 leading to suboptimal patient outcomes. Clinical guidelines recommend follow-up of abnormal TSH levels within 4-8 weeks after testing, with the goal of ensuring a euthyroid state using oral thyroxine (T4).…”

Communicating Findings of Delayed Diagnostic Evaluation to Primary Care Providers

“…Electronic algorithms designed to identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer were applied to the electronic health records (EHRs) of all patients seen by these PCPs from April 20, 2011, to July 19, 2012 (approximately 118,400 unique patients). Algorithms included "red-flag" findings to identify patients with possible cancer, clinical exclusion criteria to eliminate patients for whom further evaluation was not warranted, and expected follow-up criteria to eliminate patients who already had follow-up (see Table 1; additional details are described elsewhere 2,5,6 ). The electronic algorithms identified 1,256 patients with possible delays in diagnostic evaluation.…”

“…5 The communication strategy involved escalating steps, progressing from sending secure E-mails to making telephone calls to informing clinic directors if phone calls did not result in successful contact. In this analysis, we examine the effectiveness of these communication strategies to understand each method's effect on PCP responsiveness to communication.…”