Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, 8 met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published LMBP™ A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.
© 2018 Society of Hospital Medicine
Electronic Tools for Preparation of Discharge Summaries
Two studies 21,22 investigated tools to aid preparation of discharge summaries. Kantor et al.,21 rated fair, evaluated an EMR-generated list of TPAD, and O’Leary et al.,22 rated good, evaluated an electronic discharge summary template. The EMR-generated list resulted in an absolute increase of 25% in the proportion of TPAD documented and of 18% in the percentage of discharge summaries with complete information on TPAD. An electronic discharge summary template increased the percentage of discharge summaries with complete information on TPAD by 32.4%.22 O’Leary et al.22 was the only study that reported a negative effect of an intervention. The authors found a 10% (P = .04) reduction in the documentation of clinically significant laboratory results after implementation of the electronic discharge summary.
Electronic Notifications to Physicians
One good study, El-Kareh et al.,23 and one fair study, Dalal et al.,24 examined the impact of electronic notification of pending laboratory tests or test results to physicians. El-Kareh et al.23 also provided evidence on improved follow-up of test results. Physicians in intervention clusters were three times more likely (OR 3.2 95% CI 1.3-8.4) to have documented follow-up of test results than those in control clusters.23 The absolute increase in awareness of TPAD was 20%,23,24 among primary care physicians and 12%23 or 38%24 among inpatient attending physicians in the intervention clusters.
Notification of Patients or Parents
One study evaluated the impact of online parental access to the results of laboratory tests ordered during a child’s ED visit.25 The intervention indirectly increased physician awareness of the test results: 36 parents (12% of enrolled families) reported informing their physician of the test results. Therapy changed for seven children (5% of 141 whose parents retrieved the child’s test results and completed the follow-up survey).
DISCUSSION
Evidence Summary
We identified four interventions aimed at improving follow-up of TPAD and found suggestive evidence indicating that individual education for preparers of discharge summaries improved the quality of discharge summary documentation of TPAD; however, this type of evidence is below the level of evidence required by the LMBP™ to issue a recommendation. Site variations in the type and timing of interventions,20 small sample size,18 short follow-up,18,19 lack of detail on educational content,18-20 and differences in evaluated interventions limited the evidence quality. The long-term impact of educational interventions is also a concern. Oluma et al., for example, found that the benefits of education interventions were not sustained over time.26
Two studies21,22 evaluated aids to completing discharge summaries. The aids, which include a list of TPADs21 and an electronic template,22 resulted in a substantial increase in the completeness of the documentation of TPAD. Because of the differences in the interventions and the limited number of studies obtained, the evidence was rated as suggestive.
Suggestive evidence that automated e-mail notifications increased awareness of TPAD results by inpatient attending physicians and primary care providers was found. A limitation of this evidence is that both studies23,24 retrieved were conducted at the same institution; thus, the findings may not be generalizable to other institutions. Only one paper25 examined the impact of patient or parental access to laboratory tests results on the primary care physician’s awareness and follow-up of TPAD; as such, we consider the available evidence insufficient to evaluate the intervention.
Limitations
The evidence regarding interventions to improve follow-up of TPAD is limited. The interventions evaluated varied considerably in design and implementation. Most studies were conducted at a single medical center. Few studies had concurrent controls, and even fewer were randomized trials. Some studies included multiple interventions, thereby rendering the isolation of the impact of any single intervention difficult to accomplish.
Comparison to Other Literature
We found no other reviews of interventions to improve follow-up of TPAD. A review of interventions to improve information transfer found that computer-generated discharge summaries improved the timeliness and, less consistently, completeness of the summary.13 The authors of this review13 recommended computer-generated structured summaries that highlight the most pertinent information for follow-up care, as supported by a recent qualitative exploration of care coordination between hospitalists and primary care physicians.27
CONCLUSIONS
Successful follow-up of TPAD during care transition is a multistep process requiring identification and documentation of TPAD, notification of person responsible for follow-up, and their recognition and execution of the appropriate follow-up actions. We found suggestive evidence that individual education and tools, such as automated templates or abstraction, can improve documentation of TPADs and that automated alerts to the physician responsible for follow-up can improve awareness of TPAD results. The interventions were distinct; evidence from one intervention and outcome should be applied cautiously to other interventions and outcomes.
