The Need for Closed-Loop Systems for Management of Abnormal Test Results

Timely Review and Communication of Histopathology Reports Following Appendicectomy: Insights from a Two-Cycle Clinical Audit

INTRODUCTION

Appendicectomy is the most frequent emergency general surgical procedure. Prior research highlights the importance of histopathology analysis after appendicectomy which is the practice in many countries including the United Kingdom (UK), aiming to prevent any oversight of vital findings and the avoidance of potential delays in patient care. Our primary objective was to audit the extent to which surgeons adhere to the NHS England patient safety guidelines from 2016 when it comes to timely reviewing and effectively communicating histopathology results to patients and/or their general practitioners following appendicectomy procedures. Our secondary objective was to amend practice, if deemed necessary, following the implementation of agreed-upon protocols, with the expected improvements being observable in the second cycle of the audit.

METHODS

In our two-cycle audit, we performed a retrospective analysis using online patient records from a single centre in the UK. The initial cycle involved cases of emergency appendectomies carried out consecutively for suspected appendicitis from April 2018 to June 2019. Following the clinical governance meeting and the implementation of recommendations, the second audit cycle covered cases between September 2020 and October 2020.

RESULTS

In the first cycle, among 418 laparoscopic appendectomies, 207 (49.52%) and 47 reports (11.24%) were reviewed within a 15-day and a 16-30-day window, respectively, following the online availability of histopathology results. Notably, 116 reports (27.75%) remained unreviewed by surgeons, and only 67 (16.02%) of these reports documented communication with patients and/or their general practitioners. In the second cycle, involving 49 patients, 38 reports (77.55%) were reviewed within the first 15 days, and 10 reports (20.4%) were reviewed between 16-30 days. Among these, 16 reports (32.65%) documented communication with patients and/or their general practitioners.

CONCLUSIONS

Our adherence to the aforementioned guidance was poor prior to this audit. This two-cycle audit highlighted the need for improvement in the timely review and communication of histopathology reports following appendectomy at our centre. The second cycle showed promising progress, suggesting that changes implemented between the cycles had a positive impact. Nevertheless, continuous efforts may be required to enhance and sustain adherence to these vital patient safety guidelines.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial

Importance

Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.

Objective

To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.

Design, Setting, and Participants

Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.

Intervention

Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.

Main Outcomes and Measures

The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.

Results

Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.

Conclusions and Relevance

A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03979495.

R, Lomo LC, Laudadio J, Markwood PS, Nielson KJ, Samedi V, Sampson B, Haspel RL, Zafar N, Montone KT, Childs J, White KL, Heher YK. The next phase in patient safety education: Towards a standardized, tools-based pathology patient safety curriculum: A call to action from the Association of Pathology Chairs' Residency Program Directors Section Training Residents in Patient Safety Workgroup

Patient safety education is a mandated Common Program Requirement of the Accreditation Council for Graduate Medical Education and for the Royal College of Physicians and Surgeons of Canada in all medical residency and fellowship programs. Although many hospitals and healthcare environments have general patient safety education tools for trainees, few to none focus on the unique training milieu of pathologists, including a mix of highly automated and manual error-prone processes, frequent multiplicity of events, and lack of direct patient relationships for error disclosure. We established a national Association of Pathology Chairs-Program Directors Section Workgroup focused on patient safety education for pathology trainees entitled Training Residents in Patient Safety (TRIPS). TRIPS included diverse representatives from across the United States, as well as representatives from pathology organizations including the American Board of Pathology, the American Society for Clinical Pathology, the United States and Canadian Academy of Pathology, the College of American Pathologists, and the Society to Improve Diagnosis in Medicine. Objectives of the workgroup included developing a standardized patient safety curriculum, designing teaching and assessment tools, and refining them with pilot sites. Here we report the establishment of TRIPS as well as data from national needs assessment of Program Directors across the country, who confirmed the need for a standardized patient safety curriculum.

Improving Results Management Processes in an Acute Hospital Using a Multi-Faceted Approach

BACKGROUND

Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results pose a significant problem to patient safety. A study team was formed to mitigate the clinical risks of poor results management, which was identified as a top clinical risk in our organisation, in order to make improvements to the results management process and to ensure the timely review, acknowledgement, and follow-up of test results.

METHODS

The institutional expectations of results management were set and published as a hospital policy, which was communicated to all clinical departments for compliance. Improvements to the electronic medical records system were made to facilitate the results acknowledgement process, and physicians were engaged to educate them on the importance of results management.

RESULTS

The study team observed a decrease in unacknowledged results from approximately 16,000 in March 2017 to 2673 in December 2020. The compliance rate for acknowledgement results increased from a monthly average of 83.7% (from March to December 2017) to a monthly average of 99.3% (in 2020). The risk score for results management decreased from 16 to 6.5, and was excluded from the organisation's top clinical risks.

CONCLUSION

This study showed the importance of both system improvements and culture changes that are required to improve the process of results management, and provides a step forward for the hospital to safeguard patient safety and mitigate clinical risk.

Identifying the mechanisms that contribute to safe and effective electronic test result management systems- a multisite qualitative study

OBJECTIVE

Suboptimal design of health information technology (IT) systems can lead to the introduction of errors in the diagnostic process. We aimed to identify mechanisms that can affect the safety and effectiveness of these systems in hospital settings thus contributing to the building of an explicit and replicable understanding of the variables that can affect the functioning of IT systems.

MATERIALS AND METHODS

This qualitative study drew from observations and semistructured interviews from a purposive sample of 46 participants (26 emergency department and 20 laboratory and medical imaging staff) across 3 Australian hospitals. Iterative, inductive coding of the data led to the development of higher-level themes based on relationships between codes.

RESULTS

Two overarching themes emerged: (1) usability and safety of the electronic test result management system; and (2) system redesign considerations about who is meant to follow up, when and how. The usability and safety of digital systems and the way these systems deal with accountability processes are triggered by mechanisms that are contextually dependent.

DISCUSSION

Our findings highlighted the multitransactional nature of the test result management process involving numerous healthcare professionals across different settings. This communication requires integration of the systems utilized by different departments and transparency of the test result follow-up process to facilitate clear lines of responsibility and accountability.

CONCLUSION

Identifying mechanisms that shape the functionality and sustainability of electronic result management can offer a valuable appreciation of key elements that need to be accounted for, and the circumstances in which they need to operate effectively.

Multilevel Follow-up of Cancer Screening (mFOCUS): Protocol for a multilevel intervention to improve the follow-up of abnormal cancer screening test results

INTRODUCTION

While substantial attention is focused on the delivery of routine preventive cancer screening, less attention has been paid to systematically ensuring that there is timely follow-up of abnormal screening test results. Barriers to completion of timely follow-up occur at the patient, provider, care team and system levels.

METHODS

In this pragmatic cluster randomized controlled trial, primary care sites in three networks are randomized to one of four arms: (1) standard care, (2) "visit-based" reminders that appear in a patient's electronic health record (EHR) when it is accessed by either patient or providers (3) visit based reminders with population health outreach, and (4) visit based reminders, population health outreach, and patient navigation with systematic screening and referral to address social barriers to care. Eligible patients in participating practices are those overdue for follow-up of an abnormal results on breast, cervical, colorectal and lung cancer screening tests.

RESULTS

The primary outcome is whether an individual receives follow-up, specific to the organ type and screening abnormality, within 120 days of becoming eligible for the trial. Secondary outcomes assess the effect of intervention components on the patient and provider experience of obtaining follow-up care and the delivery of the intervention components.

CONCLUSIONS

This trial will provide evidence for the role of a multilevel intervention on improving the follow-up of abnormal cancer screening test results. We will also specifically assess the relative impact of the components of the intervention, compared to standard care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03979495.

Prevalence of clinically significant incidental findings by whole-body fludeoxyglucose F 18 positron emission tomography/computed tomography scanning in moderate-to-severe psoriasis patients participating in clinical trials

BACKGROUND

There has been an increase in the number of psoriasis treatments being investigated in clinical trials. Patients may have undiagnosed issues at the start of a study which may become identified during follow-up as incident medicinal conditions. The prevalence of incidental findings in patients with moderate-to-severe psoriasis presenting for clinical trials is unknown.

OBJECTIVE

Determine the prevalence of incidentalomas and rate of malignancy identified by fludeoxyglucose F 18 (FDG) positron emission tomography/computed tomography (PET/CT) imaging in clinical trial patients with moderate-to-severe psoriasis.

METHODS

A cross-sectional secondary analysis of patients with moderate-to-severe psoriasis who underwent FDG PET/CT scans at the baseline visit, before randomization, for 3 phase 4 clinical trials on vascular inflammation in psoriasis. Only patients without active infection, malignancy, or uncontrolled comorbidities were eligible for the clinical trials.

RESULTS

A total of 259 healthy patients with moderate-to-severe psoriasis underwent an FDG PET/CT scan as part of the study procedures. In all, 31 patients (11.97%) (95% confidence interval [CI], 8.28-16.56) had clinically significant incidentalomas on the baseline FDG PET/CT scan. Univariate logistic regression demonstrated that with every increase of 10 years of age, there was an approximate 30% increased risk of discovery of an incidentaloma (odds ratio, 1.30; 95% CI, 1.01-1.68). Of those patients with findings suggestive of malignancy (n = 28), 6 were confirmed to have cancer, resulting in a 2.31% (95% CI, 0.9-5.0) prevalence of malignancy. The positive predictive value of a true cancer was 31.58% (range, 21%-54%).

LIMITATIONS

Generalizability and lost to follow-up.

CONCLUSION

Incidentalomas on FDG PET/CT imaging are common in otherwise healthy, asymptomatic patients with moderate-to-severe psoriasis in clinical trials. Our results can help inform interpretation of clinical trial safety data and emphasize the importance of compliance with cancer screening recommendations.