When patients' test results are abnormal, their doctors failed to tell them the bad news more than 7% of the time, and in practices that used a combination of paper and electronic medical records, the failure rate was as high as 26%, according to a new report.
Some patients were given a false sense of security in that they were told if they didn't hear anything, the test result was fine. Some patients were told, "No news is good news."
"Failures to inform patients of clinically significant abnormal test results or to document that they have been informed appear to be relatively common, occurring in 1 of every 14 tests," the researchers wrote.
The study, by Lawrence Casalino, MD, of the Weill Cornell Medical College in New York, and colleagues in Chicago and Los Angeles, was published in the Archives of Internal Medicine yesterday. The researchers said theirs is the first to document a failure rate for a broad set of tests for a large and varied group of physician practices.
Medical records from 5,434 patients between the ages of 50 to 69 were examined from the files of nearly 200 volunteering primary care physicians in PPOs in the West and Midwest. The researchers discovered 1,889 abnormal results, but 135 of those findings were never conveyed to the patients.
The project selected only patients who had undergone any of 11 blood tests, such as cholesterol or hemoglobin, or three screening tests, such as mammography, Pap smear, or fecal occult blood. A failure to notify the patient was counted when the abnormal result was deemed clinically significant, in that the outcome could have indicated a lethal disease process.
For example, patients were not informed of results of total cholesterol levels as high as 318 mg/dL, a hemoglobin A1c as high as 18.9%, a potassium level as low as 2.6 mEq/L, or a hematocrit level as low as 28.6%.
The patient was said to not have been informed if there was no record of the patient being told, no follow-up referral, or any other documentation indicating disclosure within 90 days of the date the physician received the test result. In the case of high or low sodium or potassium level tests, the interval was 21 days.
Perhaps a surprising result from the study was that when an electronic medical record system was used in combination with a paper record system, it made the process worse. In the four practices that used both, the failure rate was 5.4%, 8.7%, 21.5%, and 26.2% (the last two were the worst scores in the study). Practices that used only paper records were almost as good as practices that had transitioned completely to an electronic medical record system.
"Diagnostic errors are the most frequent cause of malpractice claims in the United States," the authors wrote, adding that, "Failures to inform patients of abnormal results and failures to document that patients have been informed are common, and legally indefensible factors in malpractice claims."
One finding from this report that was astonishing is the high number of practices that the researchers said had no explicit rules for managing test results. "In most cases each physician devised his or her own method. In 8 practices, patients were told that 'no news is good news.' i.e. they should assume their results were normal."
The report said there are no generally agreed-upon guidelines to delineate practices to manage test results so that patients are always told. But, they said, these five rules might be used:
- All results are routed to the responsible physician
- The physician signs off on all results
- The practice informs patients of all results, normal and abnormal
- The practice documents that the patient has been informed
- Patients are told to call after a certain time interval if they have not been notified of their results.
The patient was counted as having been informed based on 13 types of evidence, such as a referral for a follow-up test. Additionally, the patient was informed if the physician responded to a subsequent questionnaire indicating the patient had been informed.
One might suggest that in some cases, such as patients who are too old and sick and perhaps unable to comprehend their results, the physician may have no need to tell the patient of a particular finding when more serious medical issues are present. However, the researchers got around that by including younger people below age 70 without existing known chronic diseases.
The researchers noted that while it is possible their report failed to recognize documentation that patients were informed, they added that this group of physicians volunteered for the study. A more random sample might find even greater failure rates.
The researchers also noted the lack of any incentive for physicians to notify patients about test results. "Failures to inform could be approached as a systems problem—a problem of organization and incentives—rather than as a failing of individual physicians," they wrote. In some practices the only way to see a test result is to search through every patient's records. In others, an electronic medical record routes test results to the responsible physician, and the system records the fact that the physician clicked on the results.
The authors summed up: "One approach to reducing failure rates would be to rely on the efforts of individual physicians and to exhort them to try harder to notify patients."
The report was funded by the California Healthcare Foundation.