Web edition: June 22, 2009
None of us looks forward to getting bad news, especially when it comes to health. But being spared bad news because doctors were too distracted or disorganized to relay it is not only bad medicine, but potentially malpractice. A new study now finds that among some 23 primary-care practices that allowed their procedures to be reviewed, one in every 14 instances of “clinically significant abnormal test results” was never relayed to the patient.
Lawrence Casalino of Weill Cornell Medical College in New York City led the new investigation. His group contacted 98 different community-based primary care medical practices in the West and Midwest, asking for them to participate. Only 19 agreed. Two more university-based practices in both the Midwest and in the West were also included.
The researchers had their team randomly select 5,434 patients that had recently been seen by physicians belonging to these medical practices. Included patients had to be between the ages of 50 and 69 — old enough to likely be developing conditions that warranted testing (such as for high cholesterol, impaired blood-sugar control, prostate cancer or waning liver function), but not so old as to be ill enough to make certain of these findings relatively unimportant.
Patients’ records were reviewed for any of 10 types of blood tests and for three types of screening exams — mammography, Pap smears and occult blood assays of possible colon cancer. During a yearlong period, the participating practices had prescribed several thousand such tests.
Reviewers went over the findings of each test and identified some 1,889 instances where the results were seriously abnormal — enough so to warrant further testing, the patient’s referral to a specialist, or a prescription for medical treatment.
The researchers then combed the patients’ files for notations of any of 13 events that would suggest whether a patient had been told about his or her test results. It might be as straightforward as a note saying that the patient had been called with the results on some particular date. Or it could be documentation that a patient had been prescribed new meds consistent with the adverse test findings — even a referral to another doctor for some follow-up exam. The last two examples would infer that a patient had been told about the abnormal test results.
In all, some 182 instances pointed to no notification of bad test results. Their findings appear in the June 22 Archives of Internal Medicine.
After ruling out 20 cases as being equivocal or not meeting some particular cutoff criteria, the team was left with 162 cases where no notification had apparently been given. Each patient’s doctor was then sent a letter asking for clarification about whether or how notification had been given. Roughly half of these physicians sent back information, usually claiming that they had either failed to document that they had relayed word on the test findings or that the findings were not significant enough to bother contacting the patient.
In fact, Casolino says, the findings were bad enough in each case to require relaying to the patient. And even if a patient had been legitimately informed of their test data, any failure to document that is dangerous — at least as far as the physician is concerned, he notes. If there were any lawsuit challenging that a patient had been fully informed, the courts and insurers would immediately interpret that lack of documentation as physician negligence. I.e., malpractice.
Keep in mind, Casolino told me this afternoon, most medical practices that were contacted categorically refused to participate in the study. Many, he says, may have feared their records wouldn’t pass muster. Among those who did take part, some had an unblemished record of relaying worrisome test data. But at least one primary-care practice failed to inform its patients of bad news more than 25 percent of the time. Ouch!
I asked Casolino what got him interested in performing the new study. A close family member, he says, failed to get reports of test data indicating truly life-threatening problems. It was at that point that he decided it was worth checking out how often this might occur.
Turns out Casolino was a primary care physician for more than two decades. And he acknowledges that even he “had a very hard time staying on top of this.” It takes tremendous organization to make sure that test results don’t get lost on a desktop or some computer’s inbox, he notes.
But there are methods to reduce the chance that will happen. Chief among them: having rigid adherence to some housekeeping practices, such as routing all test results to the main physician on a case, making it standard policy to inform all patients of any and all findings — even normal ones, and asking patients to double check with the doctor if they don’t hear back with test data within a couple weeks or so.
Casolino’s group inquired of every doctor taking part in the new study about his or her recordkeeping for patient test data and found most had ad hoc systems that could easily allow some findings to slip through the cracks. As, it turns out, many results did. But overall, medical practices whose physicians reported having the most checks and balances in place also had the best track record of relaying important test data to their patients, the new study shows.
Oh, and what about electronic medical records? They’re no panacea, the new analysis found. Especially where doctors hadn’t made a full transition to electronic recordkeeping, test results were most often to get lost in these practices.
Finally, at least eight physicians had a habit of telling their patients not to worry if they didn’t hear back on test results because “No news is good news.” In fact, Casolino contends, no patient should accept that claim. “If you don’t hear back in two weeks, call your doctor’s office,” he says. Find out exactly what they learned. Your life, he says, could very well depend on it.
Casolino, L.P., et al. 2009. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine 169(June 22):1123.