Care Gaps in Patients with Incident Abnormal Test Results

To avoid errors in diagnosis and treatment, abnormal laboratory test results require timely follow-up. Increasing use of electronic health records (EHRs) can facilitate follow-up of abnormal results; however, studies have shown that EHRs alone do not contribute to improvements in care quality. Follow-up is similar in systems that do and do not depend on EHRs for electronically acknowledged and unacknowledged result alerts. Even with alerts labeled high priority, delays longer than 30 days can occur. In addition, the high volume or alerts and notifications sent to physicians may create new challenges for managing test results.

There are particular challenges associated with the diagnosis of chronic kidney disease (CKD) due to the recommended 90 days for retesting creatinine following an incident abnormal laboratory result to establish chronicity. Researchers, led by Kim N. Danforth, ScD, MPH, conducted a mixed-methods study designed to identify patient, provider, and system-level factors associated with care gaps in the follow-up of abnormal test results. The study utilized retrospective analyses of EHRs as well as physician interviews. Results were reported in the American Journal of Kidney Diseases [2019; 74(5):598-600].

The study was conducted within Kaiser Permanente Southern California (KPSC), an integrated healthcare delivery system that serves more than 4.5 million members in 230 medical offices. KPSC adopted EHRs in 2006 and approximately half of its members are registered for KPSC’s online patient portal.

The study used a convergent design with both quantitative and qualitative analyses. The retrospective cohort included KPSC members ≥21 years of age who had a creatinine laboratory result in the period 2010 to 2015 corresponding to an incident abnormal estimated glomerular filtration rate (eGFR). Abnormal eGFR was defined as <60 mL/min/1.73 m2 using the Modification of Diet in Renal Disease (MDRD) Study equation (eGFRMDRD). Incident cases were defined as those without abnormal eGFR results in the prior 2 years. Exclusion criteria were prior diagnosis of CKD or kidney cancer, or unknown or multiple race/ethnicity.

Primary care physicians (PCPs) selected for interviews were categorized by distribution of eGFR follow-up: (1) high-care-gap PCPs, ≥60% of patients with care gaps and (2) low-care-gap PCPs, <40% of patients with care gaps. The PCPs were unaware which care-gap group they belonged to.

The outcome of interest was timely follow-up of incident abnormal eGFRs, defined as repeat eGFR obtained within 60 to 150 days, follow-up testing before 60 days that indicated normal kidney function, or diagnosis before 60 days of CKD or kidney cancer.

The study included a total of 244,540 patients with an incident eGFRMDRD <60 mL/min/1.73 m2, ordered by 7164 providers. Of the total cohort, 141,630 (58%) did not receive timely follow-up. Retesting in 48% of patients with a care gap was late (151-365 days; n=68,057), 49% had no repeat creatinine test within a year (n=69,209), and 3% were retested early (30-59 days; n=4364). Of the patients with an incident eGFRMDRD <45 mL/min/1.73 m2 (n=21,888), 6139 (28%) experienced a care gap in follow-up. Of those, 2991 (49%) were retested late, 2290 (37%) had no repeat test within a year, and 858 (14%) were retested early

Across providers, care gaps in follow-up of incident abnormal eGFR results were common: 5925 (83%) had at least one patient with a care gap. Those who had no patients with care gaps were more likely to be non–full time, have small panel sizes, or were specialists.

Compared with patients with no care gap, those who had a care gap were younger, more likely to be women, more likely to be non-Hispanic white, and more likely to have a Charlson Comorbidity Index score of zero. They were less likely to have diabetes or hypertension or to be obese. Those with care gaps also tended to have higher eGFRs on their incident abnormal laboratory results, and an association between their test results and creatinine results flagged as abnormal was less likely: only 18.8% (n=26,570) of patients with a care gap had a creatinine result flagged as abnormal compared with 43.7% (n=44,991) of those without a care gap. When a physician other than the patient’s PCP ordered the test, care gaps in follow-up were less likely.

Multivariable analyses were conducted among three subcohorts: patients with incident eGFRMDRD <45 mL/min/1.73 m2 as well as those with eGFRs calculated using the CKD Epidemiology Collaboration (CKD-EPI) equation (eGFRCKD-EPI) <60 or <45 mL/min/1.73 m2. Results of the multivariable analyses were generally similar for the main cohort (eGFRMDRD <60 mL/min/1.73 m2) and the subcohort (eGFRMDRD <45 mL/min/1.73 m2). Care gaps were more common among women and non-Hispanic white patients, an association that was stronger using the eGFRMDRD <45 mL/min/1.73 m2 cutpoint. Patients who had higher eGFRs on the incident abnormal laboratory result were less likely to receive timely follow-up; this association was also stronger in the subcohort.

When the abnormal laboratory result was flagged in the EHR, there was an association between the flag and a reduced risk for a care gap (risk ratio [RR], 0.65 for eGFRMDRD <60 mL/min/1.73 m2; RR, 0.68 for eGFRCKD-EPI <60 mL/min/1.73 m2; and RR, 0.87 for eGFRCKD-EPI <45 mL/min/1.73 m2). When a provider other than the patient’s PCP ordered the laboratory test, the risk of a care gap was lower.

Patients registered for an online portal who checked results within 14 days were less likely to experience care gaps (RR, 0.90-0.98 across models). There were no differences between those who registered for an online portal and those who did not when results were not checked within 14 days.

Physician interviews revealed both system-level and provider-level factors that influence management of laboratory results. Factors identified included panel size and assistance in managing laboratory results and provider-level proficiency in using EHR tools.

The inability to capture intentional delays in follow-up testing was cited by the authors as a limitation to the study findings.

In conclusion, the researchers said, “Timely follow-up of abnormal results remains challenging in an EHR-based integrated healthcare delivery system. Strategies improving provider EHR message box management and leveraging health information technology (e.g., flagging abnormal eGFR results), making organizational/staffing changes (e.g., increasing the role of nurses in managing laboratory results), and boosting patient engagement through better patient portals may improve test follow-up.”

Takeaway Points

  1. A mixed-methods study that included retrospective electronic health record analysis and physician interviews sought to identify risk factors, facilitators, and barriers to timely follow-up of incident abnormal laboratory results.
  2. Lack of timely follow-up was evident in 58% of patients with incident abnormal estimated glomerular filtration rate testing, creating a gap in care.
  3. There were weak associations between timely follow-up and patient online portal use and physician panel size.