Follow-up of Abnormal Metanephrine and Catecholamine Testing: Chasing Missed Neuroendocrine Tumors
Previous research has identified vulnerabilities in the follow-up of send-out test results that exceed the challenges with tests performed in-house. These include that send-out tests inherently have more steps and require more manual processes [8], and that these tests are more prone to delay, misinterpretation, and poor documentation. Reference laboratories usually provide non-structured reporting of results, often in the form of paper or PDF files. This can make it difficult for receiving hospitals or clinics to incorporate information into the electronic medical record or to build clinical reminders or alerts for ordering clinicians. Additionally, these data elements are often cryptic in that they provide reference values without necessarily setting parameters for abnormalities. This is a case in point with metanephrine and catecholamine testing, as the results are often variable and poorly reproducible and difficult for clinicians to interpret. There are different cutoffs for moderately elevated and critically elevated values, and how to proceed with patients with moderately elevated values is not clear and may require the expertise of subspecialists. Our study confirmed several issues surrounding vulnerabilities of send-out lab testing.
As a single-institution project with a small cohort of subjects, the generalizability of this project may be limited. However, some process-of-care vulnerabilities noted here are similar to those reported in previous research studies [8]. In addition, hospitals and clinics send specimens to a limited number of regional and national reference laboratories. The challenges that our clinicians encountered in managing these results are likely to be challenges in many other organizations. Also, while our study was limited to tests done to evaluate for pheochromocytoma, our findings are likely applicable to other reference laboratory tests.
Send-out labs continue to represent a major source of lost follow-up and potential patient harm. Creating systems with effective and timely alerts for providers will be useful in preventing missed follow-up. Our study found a lack of clear guidelines designating responsibility for pending lab results, which has been found across institutions in previous studies [8]. Since we conducted this project, our institution has reminded clinicians that discharging attendings are responsible for pending lab results at time of discharge and has developed an automated electronic method for delivering these results. Similar policy interventions at other institutions have shown promise [16]. We hope this will minimize the number of lab results, including those of send-out labs, which are not acted upon in a timely manner. However, other issues, including data interface with the electronic medical record and patients with abnormal results being lost to follow-up, remain barriers for our institution to address.
There are several immediate steps that could be taken by health care organizations and reference labs to reduce patient harm as a result of send-out labs that are not followed up. First, health care organizations can develop better integration between electronic records and lab processing for send-out labs, as well as more electronic alerts. This may help to notify ordering physicians after patients have been discharged and the case may not be front of mind. Reference labs should create robust electronic systems to transmit results as electronic data elements so that health care organizations can easily incorporate results into their electronic medical records, and develop notification systems that flag out-of-bound values. Secure online lab results for send-outs may shorten the delay in reporting. Additionally, creating clear policies establishing the responsible provider is crucial, as has been found by previous research by Singh and others [11,15].
In conclusion, send-out labs are vulnerable to lost follow-up. It is crucial for clinicians to be aware of all send-out lab results and to document their interpretation of abnormal results. Developing policies and systems to facilitate timely follow-up will help to reduce potential patient harm related to send-out labs.
Corresponding author: Richard Zamore, MD, MPH, Tufts Medical Center, 800 Washington St., Boston, MA 02111, rzamore@tuftsmedicalcenter.org.
Financial disclosures: None.
