Follow-up of Abnormal Metanephrine and Catecholamine Testing: Chasing Missed Neuroendocrine Tumors

Results

During the 3-year look-back period, 451 send-out tests for 332 patients were ordered for serum metanephrines, serum catecholamines, urine catecholamines, or metanephrines. Fifty-five tests affecting 46 patients returned with either moderately or critically elevated values, while 396 results affecting 286 patients returned within the reference range. Five patients had critically elevated values and 41 patients had moderately elevated values. Fifteen were inpatients when the tests were ordered and 31 were outpatients.

In 15 out of 46 abnormal cases, there was no documentation in the electronic medical record that the responsible physician was aware of the result (Figure). Of the 31 cases with follow-up documentation, 26 were moderately elevated and 5 were critically elevated. All 15 cases with no follow-up documentation had moderately elevated levels. Of these 15 cases, 6 were outpatients and 9 were inpatients.

In the survey of the responsible physicians in the 15 cases with no follow-up, all 15 physicians responded. Six were aware of the abnormal result and 9 were not (Figure). Five of the 6 cases in which the physician was aware were outpatients. Eight of the 9 cases in which the physician was not aware were inpatients. In 4 of 15 abnormal cases with no follow-up, the patient was seen at a follow-up appointment but the lab results were not addressed. In 3 of 15 abnormal cases with no follow-up, the patient did not return for a planned follow-up appointment. In 3 of 15 abnormal cases with no follow-up, the physician was aware and addressed the results, but did not document that the results were addressed (all 3 were outpatient cases). In 3 of 15 abnormal cases with no follow-up, lab results for inpatients were pending at time of discharge and there was no documentation of pending results in the designated space for this in the discharge summary. In 2 of 15 abnormal cases with no follow-up, the patient was followed by a primary care physician outside of our institution. In 7 cases, the patient had multiple subspecialists involved in their care. All undocumented abnormal levels were addressed by our institution, either by contacting the patient or primary care physician, or by determining that the abnormality was not clinically relevant.

Discussion

We identified cases in which patients had abnormal results on tests used to diagnose neuroendocrine tumors such as pheochromocytoma over a 3-year period and sought evidence that a responsible clinician had followed up on the abnormal results. In one-third of abnormal test results, we found no documentation in the medical record that the responsible clinician was aware of the result or had communicated it to another clinician or the patient. This occurred most often in cases in which metanephrine and/or catecholamine levels were pending at the time of hospital discharge, and when a patient who was discharged from the hospital or seen in clinic did not return for a scheduled follow-up appointment. When we followed up with the responsible physician, only 6 in 15 were aware of the abnormal results and had either concluded that they were not clinically significant or had addressed the issue without completing documentation.

The results reveal several themes. One common circumstance for inpatients was when lab results were pending at time of discharge and there was no documentation of the pending results in the designated space for this in the discharge summary. Attending physicians were frequently unaware either that these tests had been ordered or that they were pending at time of discharge. This was usually due to some combination of lack of appropriate discharge documentation by trainees, or lack of communication between trainees and attendings. In addition, patients who had metanephrine and/or catecholamine testing typically had multiple comorbidities and subspecialist providers, resulting in confusion over which provider was responsible for results. This illustrates, as previous studies have shown, that transitions of care are a point of vulnerability in addressing lab abnormalities [1,10].