BACKGROUND: Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings.
METHODS: We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost.
RESULTS: After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient.
CONCLUSIONS: By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.
Failure to notify patients of abnormal laboratory test results or to ensure appropriate follow-up can result in inferior patient care and potential malpractice liability.1-5 Failure to document physician review and communication of test results to patients can make defense of a malpractice claim more difficult. Our review of the English-language literature identified only a few studies related to the management and reporting of laboratory test results in primary care.6-10
Boohaker and colleagues9 proposed that there are 4 basic steps involved in managing laboratory test results: tracking tests until results are received; notifying patients of the results; documenting that the notification occurred; and assuring that recommended follow-up occurs for abnormal test results. They surveyed 161 attending physicians and 101 internal medicine and family practice residents at the Henry Ford Hospital in Detroit and 21 suburban primary care practices in southeast Michigan for information on the perceived importance of each step, how each of the steps was handled, and the perceived reliability of the methods used. The percentages of respondents with fair or poor methods or no method for tracking test results were: 17% for blood studies, 27% for Papanicolaou tests, 29% for mammograms, and 32% for X-rays. Approximately 50% felt that it was moderately or extremely important to notify all patients of normal test results. However, only 28% said that they accomplished this. Thirty-six percent admitted that they do not always succeed in notifying patients of abnormal test results. Often this was because patients were expected to return to the clinic soon, or the results were considered trivial. However, patient unavailability, physician forgetfulness, and time constraints were contributing factors as well. Only 55% reported that they always document patient notification of laboratory results. Another 30% said they did so most of the time. Seventy-five percent had a fair or poor method or no method for tracking patients to see if they received recommended follow-up of abnormal test results. A patient survey was conducted in the Internal Medicine Teaching Clinic at Henry Ford Hospital. Seventy-nine percent of patients surveyed wanted to be notified of all test results, whether normal or abnormal.
No one has identified and published a unified method that accomplishes each of the 4 steps effectively and efficiently. We attempted to do so by tapping the collective wisdom of clinician members of the Oklahoma Physicians Resource/Research Network (OKPRN), a network of practicing family physicians throughout Oklahoma.
Methods
Our study was conducted between August 1998 and April 1999. We sent a questionnaire to all 24 physician members of OKPRN. The questions were designed to obtain information about methods being used to address the 4 steps in the process articulated by Boohaker and coworkers9 and their perceived effectiveness. Two clinicians reporting effective methods for a particular step were then chosen for further analysis, with an attempt to choose practices with different methods. Four different physicians’ practices were audited, with several physicians reporting effective methods for more than 1 step. A single research assistant was sent to each practice to perform the audits. During this visit, a 5-minute open-ended interview was also conducted with the physician or the physician’s staff to more precisely describe the method used for the management step being evaluated.
Step 1: Test Tracking
Twenty patients who had been seen by the physician 2 to 6 weeks earlier, who had laboratory tests ordered during that visit, and whose charts were available were chosen at random by the research assistant ([Table 1]). Each patient’s records were reviewed, as was the logbook or tracking device used, following the sequence of procedures described by the physician. All deviations from the procedure were documented.