Improving Patient Care - Semantic Scholar

Improving Patient Care Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge Christopher L. Roy, MD; Eric G. Poon, MD, MPH; Andrew S. Karson, MD, MPH; Zahra Ladak-Merchant, BDS, MPH; Robin E. Johnson, BA; Saverio M. Maviglia, MD, MSc; and Tejal K. Gandhi, MD, MPH

Background: Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on the epidemiology of test results pending at discharge or on physician awareness of these results. Objective: To determine the prevalence, characteristics, and physician awareness of potentially actionable laboratory and radiologic test results returning after hospital discharge. Design:

Cross-sectional study.

Setting:

Two tertiary care academic hospitals.

Patients:

2644 consecutive patients discharged from hospitalist services from February to June 2004.

Measurements:

Results:

A total of 1095 patients (41%) had 2033 test results return after discharge. Of these results, 191 (9.4% [95% CI, 8.0% to 11.0%]) were potentially actionable. Surveys were sent regarding 155 results, and 105 responses were returned. Of the 105 results in the surveys with responses, physicians had been unaware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to 50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%]) required urgent action. Inpatient physicians were dissatisfied with their systems for following up on test results returning after discharge.

Limitations:

The authors were unable to determine whether physicians’ lack of awareness of test results returning after discharge was associated with adverse outcomes.

The main outcomes were the prevalence and characteristics of potentially actionable test results returning after hospital discharge, awareness of these results by inpatient and primary care physicians, and satisfaction of inpatient physicians with current systems for follow-up on test results. The authors prospectively collected data on test results pending at the time of discharge and, as results returned after discharge, surveyed hospitalists, junior residents, and primary care physicians about those results that were potentially actionable according to a physicianreviewer.

Conclusions: Many patients are discharged from hospitals with test results still pending, and physicians are often unaware of potentially actionable test results returning after discharge. Further work is needed to design better follow-up systems for test results returning after hospital discharge.

G

the inpatient-to-outpatient transition has been shown to be associated with medical errors (7). Among these errors is a failure to follow up on the results of laboratory tests and radiologic studies that return after discharge. Although timely follow-up on test results has received attention from the Agency for Healthcare Research and Quality (8) and failure to follow up on results has been recognized by a large malpractice insurer (9) as accounting for one quarter of diagnosis-related malpractice cases, few studies have addressed follow-up on test results pending at hospital discharge. Moore and colleagues (7) studied test follow-up errors, which were defined as having a test result noted as pending at discharge in the inpatient medical

ood communication between inpatient and outpatient physicians at the transition from hospital to home is critical to patient safety. However, the amount and complexity of information that must be relayed at hospital discharge are often overwhelming. Unfortunately, when communication breaks down, patients are at risk: More than half of all preventable adverse events occurring soon after hospital discharge have been related to poor communication among providers (1). Recently, the challenges to high-quality transitions of care have been increasingly recognized (2), and several factors may be contributing to communication failures at discharge. Although the introduction of hospitalist programs across the United States has produced positive results (3– 5), the discontinuity of care inherent in the hospitalist model increases the likelihood of communication failures and makes thorough communication at discharge essential (6). Discontinuity is also an issue in teaching hospitals, where physicians-in-training may be responsible for some or all of the communication at discharge and, under new work-hour restrictions, may frequently change services or work in shifts. Whatever the cause, discontinuity of care at

Ann Intern Med. 2005;143:121-128. For author affiliations, see end of text.

www.annals.org

See also: Print Editors’ Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Web-Only Conversion of figures and tables into slides

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS. © 2005 American College of Physicians 121

Improving Patient Care

Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge

Context Poor communication between inpatient and outpatient providers precedes many preventable adverse events that occur shortly after discharge.

Contribution Forty-one percent of 2644 patients on the hospitalist services of 2 academic hospitals had pending laboratory or radiology results at discharge. Physician-reviewers deemed approximately 9% of these results potentially actionable. Physician surveys done 14 days after results were first available showed that physicians were unaware of many results and thought that about 13% of them required urgent action.

Cautions Findings may not apply to nonacademic or nonhospitalist settings.

Implications We need good integrated systems to assure follow-up of tests that are pending at discharge. –The Editors

record but not acknowledged in the outpatient chart. Using retrospective chart review, they found this type of error in the records of 8% of all discharged patients and 41% of all patients discharged with pending test results, but their study design did not allow them to determine 1) whether clinicians were aware of the results and did not document them or 2) the clinical consequences of these errors. To our knowledge, no other studies have prospectively examined the prevalence and characteristics of test results that return after discharge or physician awareness of them. We hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient physician to the outpatient physician and that some of these results might have important clinical consequences for patients. Accordingly, we sought to prospectively determine the prevalence and characteristics of these potentially actionable results, to determine how often physicians are unaware of these results, and to evaluate the satisfaction of inpatient physicians with current systems for following up on results returning after discharge.

medication and problem lists. These data are accessible at all inpatient and outpatient sites through the same electronic medical record. In addition, all physicians use the same e-mail system. Hospital A has 3 hospitalist inpatient teams that each consist of 1 hospitalist attending physician, 1 internal medicine resident, and 2 interns. At hospital A, the hospitalist attending physician is usually responsible for all communication to outpatient physicians at discharge, as well as for follow-up on all pending test results that return after discharge. Hospital B has 2 types of hospitalist services. One is nonhousestaff and is staffed only by hospitalist and nonhospitalist attending physicians; the nonhospitalist attending physicians care for their own patients on this service, but for the purposes of the study, we categorized them as inpatient physicians. The other hospitalist service at hospital B is a teaching service of 4 teams, each with 1 hospitalist attending physician, 1 junior resident, and 3 interns. On these teams at hospital B, the junior resident is responsible for communication at discharge and follow-up on all pending test results. During the study, 16 hospitalists were responsible for patient discharges at hospital A, 15 hospitalist and 93 nonhospitalist attending physicians were responsible for discharges on the nonhousestaff service at hospital B, and 54 junior residents were responsible for discharges on the teaching service at hospital B. Patient Selection and Identification of Results Returning after Discharge

Using the hospital computer systems, we prospectively identified 2644 consecutive patients discharged from February to June 2004. Shortly after each patient’s discharge, a research assistant entered into a database the patient’s identifying information, discharge diagnosis, and times and dates of hospital admission and discharge. He or she then tracked each patient’s pending test results by entering the patient on a “watch list” using a feature in a results-manFigure 1. Identifying results for physician review

METHODS We carried out our study on the general medicine hospitalist services at 2 academic tertiary care centers in Boston, Massachusetts (hospitals A and B). The human research committee for both hospitals reviewed and approved the study design. The hospitals belong to the same integrated care– delivery network and share a common electronic clinical data repository that includes test results, discharge orders and summaries, ambulatory notes, and 122 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2

www.annals.org


agement system called Results Manager. Results Manager is a computer application that is fully integrated into the electronic medical record and is able to cull pending and final test results from the clinical data repository and to prioritize them on the basis of type of result and degree of abnormality. It was originally developed to track test results in the outpatient setting, and it has been evaluated and tested extensively in that setting but has not been used for inpatients (10). Data Collection

We tracked test results with Results Manager for 14 days after patient discharge. A research assistant screened all laboratory and radiologic test results returning after discharge and excluded the results of tests done after discharge. Normal, near-normal, and stable results were excluded by using a predefined algorithm (Figure 1). If a result was abnormal, it was sent to 1 of 4 physician-reviewers who, using the electronic medical record, reviewed the discharge diagnosis; any related test results; and the discharge order, note, or summary (when available) to determine whether the result was potentially actionable. Any result mentioned in the discharge summary was excluded (these were most often final radiologic test results that did not differ from the preliminary results available to the inpatient team). At both hospitals, the discharge order (including discharge diagnoses, medications, and follow-up appointments) was entered into the electronic medical record on the day of discharge and therefore was always available at the time of physician review. Of the 671 results that we reviewed, 525 (78%) were for patients who also had a dictated or typed discharge summary available at the time of review. When discharge summaries are completed after hospital discharge, inpatient physicians have access to the electronic medical record, including any test results that were not available on the day of discharge. The physician-reviewers are board-certified internists; 2 are hospitalists, and 2 are primary care physicians. If a physician-reviewer was involved in the care of a patient who had a result that required review, that result was sent to one of the other 3 reviewers. After reviewing the discharge order, the discharge summary, and related test results, the physician-reviewer used clinical judgment to determine whether the result required clinical action on the basis of the available information. A result was considered potentially actionable if it could change the management of the patient by requiring a new treatment or diagnostic test (or repeated testing), modification or discontinuation of a treatment or diagnostic testing, scheduling of an earlier follow-up appointment, or referral of the patient to another physician or specialist. The reviewer rated the result as “definitely actionable,” “probably actionable,” “probably not actionable,” or “definitely not actionable.” The reviewer also rated the urgency of the required action according to how soon it should www.annals.org


occur: within 1 hour, 8 hours, 24 hours, 72 hours, 1 week, or 1 month. Surveys

If the physician-reviewer defined a result as “definitely actionable” or “probably actionable,” either the inpatient physician or the primary care physician was surveyed by e-mail to determine whether he or she was aware of the result. At hospital A, the attending hospitalist was the inpatient physician surveyed; on the teaching service at hospital B, the junior resident was surveyed. On the nonhousestaff service at hospital B, the hospitalist or nonhospitalist attending physician was surveyed as the inpatient physician. The survey e-mail included the actual result and the patient’s name and discharge diagnosis. Inpatient physicians were surveyed 72 hours after a result became available in the electronic medical record, whereas primary care physicians were surveyed 14 days after a result was available, with the reasoning that most patients would have a postdischarge follow-up appointment within 14 days. Physicians who did not respond to the first survey e-mail received a second survey e-mail 3 days later. Because the inpatient physician could notify the primary care physician about a result after receiving the survey e-mail, we surveyed only the inpatient physician or the primary care physician about a given result. If the patient’s primary care physician could not be identified or was not accessible by e-mail, or if the patient was not discharged to home, we surveyed the inpatient physician instead. If the inpatient physician had clearly documented in the discharge summary that the primary care physician had been informed of the pending test result, we surveyed the primary care physician. Thirty-four percent of surveys were specifically assigned to either the inpatient physician or the primary care physician; the rest were randomly assigned. To preserve patient safety, we sent the survey e-mail to the inpatient physician without delay in all cases in which abnormal test results were considered urgent (requiring action within 72 hours). If no response was obtained or if the result was critical, the inpatient physician and primary care physician were paged immediately. The same survey was used for both inpatient physicians and primary care physicians. After being presented with the patient’s name, discharge diagnosis, and test result, physicians were asked whether they had been aware of the result before receiving the survey. If they answered “yes,” they were asked how they had become aware of it, whether they had known that the test had been ordered, whether the result had changed the patient’s diagnostic or therapeutic plan, how urgent the result was, and what action or actions they had taken because of the result. If they answered “no,” they were asked whether they had known that the test had been ordered, whether the result would change the patient’s diagnostic or therapeutic plan, how urgent the result was, and what action or actions they would take because of the result. 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 123



At the beginning of the study, we surveyed inpatient physicians about their satisfaction with their current system for following up on test results returning after discharge. Responses were rated on a Likert scale. We asked inpatient physicians how concerned they were about their ability to follow up on test results returning after discharge, about test results not being followed up on, about their knowledge of what test results are pending at discharge, and about their ability to communicate test results returning after discharge to primary care physicians. We also asked whether they believed that a computer system could help track these results and whether they were comfortable using the hospital’s electronic medical record. Outcomes

The primary outcomes of interest were the prevalence and characteristics of potentially actionable results returning after discharge, the awareness of these results on the part of inpatient and primary care physicians, and the satisfaction of inpatient physicians with their current system of tracking these results. Statistical Analysis

Some patients with results returning after discharge were discharged by the same inpatient physician. To account for the clustering of test results within discharging inpatient physicians, we used generalized estimating equaFigure 2. Identification of potentially actionable postdischarge results

Table 1. Survey Responses of 34 Inpatient Physicians and 28 Primary Care Physicians about Their Awareness of Potentially Actionable Postdischarge Results and Their Awareness of Tests Having Been Ordered* Type of Physician Responding

Responses, Physicians Who n Had Been Unaware of Result (95% CI), %

Inpatient (n ⫽ 34) 72 Primary care (n ⫽ 28) 33 All (n ⫽ 62) 105

70.0† (57.0–80.4) 45.8† (30.4–62.1) 61.6 (51.5–70.9)

Physicians Who Had Been Unaware That Test Had Been Ordered (95% CI), % 24.6‡ (14.2–39.2) 45.8‡ (29.5–63.0) 33.1 (23.4–44.4)

*Clustered univariate analyses. † P ⫽ 0.02. ‡ P ⫽ 0.06.

tions to calculate the prevalence of potentially actionable results and 95% confidence intervals. We used a similar approach to calculate rates of awareness of potentially actionable results among surveyed physicians. To ascertain the relationship between various subgroups and awareness rates, we built clustered multivariable regression models. Clustered analyses were done by using PROC GENMOD in SAS, version 8 (Cary, North Carolina). Surveys were administered by using Perseus SurveySolutions 6.0.148 (Perseus Development Corp., Braintree, Massachusetts). Role of the Funding Source

The funding source had no role in the design, analysis, or interpretation of the study or in the decision to submit the manuscript for publication.

RESULTS Postdischarge Results

Of the 2644 patients discharged from the hospitalist services during the study period, 1095 (41%) had a total of 2033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal (Figure 2). Of these 877 abnormal results, we excluded 206 because they were near-normal or stable compared with previous values. A physician reviewed the remaining 671 results (33% of the pending results), and 191 results (9.4% of the pending results [95% CI, 8.0% to 11.0%]) from 177 patients were considered potentially actionable on the basis of review of the discharge orders and summary. For these 191 results, we sent 155 surveys. In 31 cases, we could not identify the primary care physician, and in 5 cases, multiple results for the same patient were combined in 1 survey e-mail. Response Rates

We sent 155 surveys (98 to inpatient physicians and 57 to primary care physicians) and received 105 responses; 72 were from inpatient physicians (31 responses came from 11 hospitalists, 6 responses came from 5 nonhospitalist attending physicians, and 35 responses came from 18 junior residents), and 33 were from 28 primary care physicians. The response rate was 73% for inpatient physicians 124 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2

www.annals.org


and 58% for primary care physicians. The overall response rate was 68%. Physician Awareness of Results

Table 1 shows awareness by inpatient and primary care physicians of 1) potentially actionable test results and 2) a test having been ordered. Of the 105 results for which 62 physicians returned surveys, physicians had been unaware of 65 (unawareness rate, 61.6% [CI, 51.5% to 70.9%]). Inpatient physicians were less likely than primary care physicians to be aware of results (bivariate odds ratio, 0.36 [CI, 0.15 to 0.86]; P ⫽ 0.02). Surveyed physicians had been unaware that a test had been ordered in the case of 31 of 105 results (awareness rate, 33.0% [CI, 23.4% to 44.4%]). When we examined awareness of results in various subgroups, comparing hospital A with hospital B, housestaff teams with nonhousestaff teams, and teams on which the inpatient physician responsible for the discharge communication was an attending physician with teams on which the inpatient physician responsible for the discharge communication was a resident, we found no significant differences on either bivariate or multivariate analyses. However, awareness that the test had been ordered was significantly higher among surveyed physicians when the


inpatient physician responsible for discharge communication was a resident (bivariate odds ratio, 8.0 [CI, 1.9 to 33.4]; P ⫽ 0.004). Of the 40 results of which surveyed physicians had been aware before receiving the survey e-mail, they had learned of 28 by reviewing the electronic medical record, had been notified of 5 by housestaff or a medical student, had been notified of 4 by another physician, and had been notified of 3 by laboratory or radiology personnel. Actionability, Urgency, and Nature of Results

Of the 105 potentially actionable results for which surveys were returned, surveyed physicians “strongly agreed” or “agreed” with the physician-reviewer that 35 results (33.3% [CI, 24.7% to 43.1%]) were actionable, changing the diagnostic or therapeutic plan for the patient, and that 15 results (14.2% [CI, 8.7% to 22.5%]) required urgent action. Of the 65 potentially actionable results of which physicians were not aware, surveyed physicians “strongly agreed” or “agreed” that 24 results (37.1% [CI, 25.7% to 50.2%]) were actionable, changing the diagnostic or therapeutic plan for the patient, and that 8 results (12.6% [CI, 6.4% to 23.3%]) required urgent action. Table 2 shows a sample of urgent actionable results of which surveyed physicians were not aware. Of the 8 results that

Table 2. Examples of Actionable Results of Which Surveyed Physicians Had Been Unaware Discharge Diagnosis Actionable results requiring urgent action Diabetic ketoacidosis, septic thrombophlebitis

Chest pain, rapid atrial fibrillation

Situation at Discharge

Postdischarge Test Result

Patient discharged to rehabilitation receiving vancomycin for septic thrombophlebitis with methicillin-resistant Staphylococcus aureus Patient treated for rapid atrial fibrillation

Blood culture grew Clostridium perfringens during vancomycin treatment

Pulmonary emboli

Patient receiving levofloxacin for urinary tract infection

Duodenal ulcer

Patient discharged without antibiotic therapy Patient received nafcillin for facial cellulitis and abscess

Facial cellulitis, intravenous drug use

Actionable results not requiring urgent action Gastritis

Low back pain, urinary incontinence, elevated liver function test results, and hypercalcemia Angioedema due to lisinopril

Alcohol withdrawal, seizures

Alcoholic hepatitis

www.annals.org

Patient admitted with epigastric pain presumed to be due to gastritis and discharged receiving proton-pump inhibitors but not antibiotics Patient admitted with low back pain and urinary incontinence Patient intubated for angioedema and discharged without antibiotic treatment Patient admitted with seizures and alcohol withdrawal

Patient had elevated aminotransferase levels thought to be due to heavy alcohol use

Thyroid-stimulating hormone level was ⬍0.01 ␮IU/mL (normal range, 0.40– 5.0 ␮IU/mL), consistent with a new diagnosis of hyperthyroidism Urine culture grew ⬎100 000 colonies of Klebsiella pneumoniae resistant to levofloxacin Urine culture grew ⬎100 000 colonies of Pseudomonas aeruginosa Wound culture grew methicillin-resistant Staphylococcus aureus

Result on serologic test for Helicobacter pylori was positive

Ferritin level (18 ␮g/L) consistent with iron deficiency Final chest radiograph was consistent with possible early pneumonia Computed tomographic scan of the chest, obtained in the emergency department to rule out pulmonary embolus, was positive for lung nodules; follow-up was recommended Hepatitis C viral load was 4 680 920 IU/mL

19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 125



Table 3. Actions That Would Be Taken by Surveyed Physicians

Satisfaction among Inpatient Physicians

upon Learning of a Postdischarge Result

We assessed the satisfaction of inpatient physicians with their current ability to follow up on results returning after discharge. Of 44 inpatient physicians surveyed (including hospitalists and junior residents), 34 responded (77% response rate). Of these 34 responders, 74% were concerned about their ability to follow up on test results, 85% were concerned about results not being followed up on, 65% were concerned about what tests are pending at discharge, and 54% were concerned about their ability to communicate these results to primary care physicians. All respondents agreed that computer systems could help track these results, and 64% said that they were comfortable using the hospital’s electronic medical record.

Action

All Physicians, n

Inpatient Physicians, n

Primary Care Physicians, n

Notify primary care physician Order further testing or treatment Refer patient to primary care physician or other physician Inform patient Inform extended care facility Review medical record None

21

20

1*

5

1

4

8

4

4

5 1

2 1

3 0

2 25

2 22

0 3

*The primary care physician who gave this response was not the patient’s actual primary care physician but was seeing the patient during follow-up.

required urgent action, 6 were microbiological test results (blood, urine, and wound cultures) that necessitated the starting or changing of antibiotic therapy. One patient who had been admitted to the hospital with new atrial fibrillation had an undetectable thyroid-stimulating hormone level consistent with a new diagnosis of hyperthyroidism. Actionable but nonurgent results included 3 incidental findings of a pulmonary nodule or nodules or opacities on chest radiography or computed tomography that required follow-up, 5 positive serologic test results for Helicobacter pylori in patients with gastrointestinal bleeding or dyspepsia, a very high hepatitis C viral load in a patient admitted to the hospital with presumed alcoholic hepatitis, and a finding of iron deficiency. There were significantly more “definitely actionable” than “probably actionable” ratings by physician-reviewers among the 105 results for which surveys were returned than among the 86 potentially actionable results for which surveys were not returned or not sent (42% compared with 27%; P ⫽ 0.046). Actions Taken

Surveyed physicians were asked what action or actions they would take as a result of the survey e-mail; the data for results of which physicians had been unaware are summarized in Table 3. Physicians could choose more than 1 action. Twenty-one physicians said that they would notify the patient’s primary care physician, 8 said that they would refer the patient to his or her primary care physician or another physician, 5 said that they would order further testing or treatment, 5 said that they would inform the patient of the result, 2 said that they would review the medical record, and 1 said that he or she would notify the patient’s extended care facility. None said that he or she would refer the patient to the emergency department or hospital, and 25 said that they would take no action. 126 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2

DISCUSSION In this study of hospitalist services at 2 major tertiary care centers, we found that almost half of discharged patients had pending laboratory and radiologic test results and that 9% of these results were potentially clinically actionable. Surveyed physicians were unaware of almost two thirds of these potentially actionable results; more than a third of these would change the patient’s diagnostic or therapeutic plan, and 12.6% required urgent action. The most common results requiring urgent action were results of microbiological tests necessitating initiation or change of antibiotic treatment. Many nonurgent actionable results were from radiologic studies (for example, incidental pulmonary nodules) or serologic tests (for example, H. pylori titers). Inpatient and primary care physicians often did not know what tests had been ordered and had results pending at discharge, perhaps reflecting the ordering of tests by several team members and physicians-in-training. Finally, most inpatient physicians were dissatisfied with their current ability to follow up on results returning after discharge, and they agreed that computer systems could make this follow-up easier. Among 2644 patients discharged over the 5-month study period, we discovered only 15 results returning after discharge that were considered urgent by clinicians (the clinicians were unaware of 8 of these) and 35 results returning after discharge that changed the patient’s diagnostic or therapeutic plan (the clinicians were unaware of 24 of these). Despite these small numbers, the implications for patient safety remain impressive: Almost half of all discharged patients had pending test results, 6% of these patients had results considered potentially actionable by a physician-reviewer, and physician awareness of these results was low. Failure to follow up on certain results (for example, the results of blood cultures) could have catastrophic consequences, but even results that do not require urgent action (such as discovery of a pulmonary nodule or iron deficiency) could have important consequences if overlooked. Given the high volume of results returning after discharge and the potential for patient harm if even a few www.annals.org


results are overlooked, a highly reliable system for ensuring follow-up seems warranted. The limitations of our study notwithstanding, if we extrapolate our findings, an error rate of 0.9 per 100 patient discharges, or about 10-2 (24 missed actionable results among 2644 patient discharges), would fall far short of a target error rate of 10-6 set in other high-risk industries (11) and would translate into 270 missed actionable results in a hospital with 30 000 discharges per year. Our findings have special implications for teaching hospitals. When responding to our survey e-mails, both primary care and inpatient physicians were often unaware that a test had been ordered. It is not surprising that a primary care physician would not know of every test ordered during a hospitalization for which he or she is not the attending physician of record, but the fact that an inpatient physician is not aware of an ordered test suggests that another team member (perhaps an intern or resident) wrote the order without the inpatient physician’s knowledge. Of note, on teams on which the discharging physician was a resident compared with teams on which the discharging physician was not a resident, awareness that a test was ordered was higher (although awareness of the test result was not). In teaching hospitals where multiple team members are involved in ordering tests, systems must be in place to ensure that the persons responsible for test follow-up are aware of all tests that have been ordered and have results pending at discharge. In addition, as we found, many tests ordered in the inpatient setting that still have results pending at discharge are irrelevant to the patient’s care. Therefore, while we should strive for fail-safe communication, we should also be circumspect about ordering tests in the inpatient setting. Dissatisfaction with systems of follow-up on abnormal test results has been documented in primary care (12, 13), and we saw similar findings among inpatient physicians. The discharge summary remains the standard means for communicating information about pending test results, but it may not be reliable; in some studies, discharge summaries are available for only 12% to 33% of follow-up visits (14 –16). Nonselective mailing to physicians of all inpatient laboratory and radiologic test results risks losing important abnormal results among normal ones and is an ineffective way to communicate results requiring urgent action. Electronic results-management systems are being evaluated to solve the problem of timely and reliable test follow-up in the outpatient setting (10), and such technology may be useful to hospitalists in tracking results returning after discharge. Such systems could highlight important results and filter out normal results to avoid overwhelming busy clinicians. Our survey shows that our inpatient physicians would be eager to adopt such systems, and a second phase of this study will examine the effect of an electronic results-management system on physician awareness of results returning after discharge. Our study results should be interpreted in light of www.annals.org


several limitations. First, although the surveys were confidential, they were not anonymous, and physicians may have been reluctant to report lack of awareness of test results for reasons of liability. Thus, our response rate was relatively low, especially among primary care physicians, and our results may have been subject to responder bias; it is not clear whether survey respondents would have been more or less likely than nonrespondents to be aware of results returning after discharge. However, we found that surveys that received a response had a higher percentage of results rated as “definitely actionable” by the physicianreviewer, suggesting that surveyed physicians were more likely to respond to results with more clinical importance. Second, surveyed physicians agreed with our physician-reviewers that a potentially actionable result required clinical action in only about one third of cases. From our data, we are unable to determine the reason for this disagreement. We suspect that the physician-reviewers used a broader definition of “actionable,” including results that did not require immediate attention but required action nonetheless, and were basing their assessments on the medical record alone, whereas the surveyed physicians may have used a narrower definition of “actionable” and had more knowledge of the clinical context. Third, we did not formally test agreement among physician-reviewers on actionability. Fourth, we could not determine whether unawareness of a test result was associated with adverse outcomes for patients or whether physicians would have eventually learned of a given result themselves. However, we believe that we allowed sufficient time for physicians to learn about results (72 hours for inpatient physicians and 14 days for primary care physicians). Finally, our study was done in 2 academic tertiary care centers with hospitalists, housestaff, a shared electronic medical record, and computerized provider order entry, and our findings may not be generalizable to institutions without these characteristics. In fact, few hospitals currently have a shared electronic medical record that both outpatient and inpatient physicians can access (17). Without such a system, awareness of potentially actionable results returning after discharge would probably be lower still. We conclude that patients are frequently discharged from hospitals with test results still pending, that physicians are often unaware of potentially important test results returning after discharge, and that some of these results require urgent action. Future studies should focus on systems to ensure fail-safe communication of and follow-up on test results returned after hospital discharge. From Brigham and Women’s Hospital and Massachusetts General Hospital, Boston, Massachusetts. Acknowledgments: The authors thank Mr. Justin Golden and Mr.

Martin Spera. Grant Support: By a grant from the Harvard Risk Management Foundation, Cambridge, Massachusetts. 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 127



Potential Conflicts of Interest: None disclosed. Requests for Single Reprints: Christopher L. Roy, MD, Brigham and

Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail, [email protected]. Current author addresses are available at www.annals.org.

References 1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354] 2. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141:533-6. [PMID: 15466770] 3. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-94. [PMID: 11798371] 4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:86674. [PMID: 12458986] 5. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002; 137:859-65. [PMID: 12458985] 6. Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111:36S-39S. [PMID: 11790367] 7. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern

128 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2

Med. 2003;18:646-51. [PMID: 12911647] 8. Agency for Healthcare Research and Quality. Patient fact sheet: 20 tips to help prevent medical error. Accessed at http://www.ahrq.govconsumer/20tips .htm on 25 February 2005. 9. Harvard Risk Management Foundation. Reducing office practice risks. Forum. 2000;20:2. 10. Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform. 2003;36:80-91. [PMID: 14552849] 11. Institute for Healthcare Improvement. Improving the Reliability of Health Care. Innovation Series. Cambridge, MA: Institute for Healthcare Improvement; 2004. 12. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. “I wish I had seen this test result earlier!”: Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-8. [PMID: 15534158] 13. Murff HJ, Gandhi TK, Karson AK, Mort EA, Poon EG, Wang SJ, et al. Primary care attitudes concerning follow-up of abnormal test results and ambulatory decision support systems. Int J Med Informatics. 2003;71:137-49. [PMID: 14519406] 14. van Walraven C, Seth R, Laupacis A. Dissemination of discharge summaries. Not reaching follow-up physicians. Can Fam Physician. 2002;48:737-42. [PMID: 12046369] 15. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17:186-92. [PMID: 11929504] 16. Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111:15S20S. [PMID: 11790363] 17. Poon EG, Kaushal R, Jha AK, Christino M, Honour MM, Fernandopulle R, et al. Assessing the level of healthcare information technology adoption in the United States: a 2003 snapshot of the Boston and Denver markets. Medinfo. 2004(CD):1815 [Abstract].

www.annals.org

Current Author Addresses: Drs. Roy and Maviglia: Brigham and

Women’s Hospital, 75 Francis Street, Boston, MA 02115. Drs. Poon and Gandhi, Ms. Ladak-Merchant, and Ms. Johnson: Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120.

www.annals.org

Dr. Karson: Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.

19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 W-31