Background

Timely follow-up of abnormal laboratory results is important for high-quality care. We sought to identify risk factors, facilitators, and barriers to timely follow-up of an abnormal estimated glomerular filtration rate (eGFR) for the diagnosis of chronic kidney disease.

Study Design

Mixed-methods study: retrospective electronic health record (EHR) analyses, physician interviews.

Setting & Participants

Large integrated health care delivery system. Quantitative analyses included 244,540 patients 21 years or older with incident abnormal eGFRs from January 1, 2010, to December 31, 2015, ordered by 7,164 providers. Qualitative analyses included 15 physician interviews.

Exposures

Patient-, physician-, and system-level factors.

Outcome

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 chronic kidney disease or kidney cancer.

Analytical Approach

Multivariable robust Poisson regression models accounting for clustering within provider were used to estimate risk ratios (RRs) and 95% CIs for lack of timely follow-up. Team coding was used to identify themes from physician interviews.

Results

58% of patients lacked timely follow-up of their incident abnormal eGFRs (ie, had a care gap). An abnormal creatinine result flag in the EHR was associated with better follow-up (RR for care gap, 0.65; 95% CI, 0.64-0.66). Patient online portal use and physician panel size were weakly associated with follow-up. Patients seen by providers behind on managing their EHR message box were at higher risk for care gaps. Physician interviews identified system-level (eg, panel size and assistance in managing laboratory results) and provider-level (eg, proficiency using EHR tools) factors that influence laboratory result management.

Limitations

Unable to capture intentional delays in follow-up testing.

Conclusions

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

中文翻译：

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大型综合医疗服务系统中GFR结果估计异常的随访：混合方法研究

背景

及时随访异常实验室结果对于高质量护理很重要。我们试图找出危险因素，促进因素和及时对异常估计的肾小球滤过率（eGFR）进行随访的障碍，以诊断慢性肾脏病。

学习规划

混合方法研究：回顾性电子健康记录（EHR）分析，医师访谈。

设置与参与者

大型综合医疗保健提供系统。从2010年1月1日到2015年12月31日，由7,164名医疗服务提供者订购了244,540例21岁以上的eGFR异常患者。定性分析包括15次医师访谈。

曝光量

患者，医师和系统级因素。

结果

及时随访事件异常的eGFR，定义为在60到150天内获得重复的eGFR，在表明肾功能正常的60天之前进行随访测试，或在慢性肾脏病或肾癌的60天之前进行诊断。

分析方法

使用多变量鲁棒Poisson回归模型解决提供商内部的聚类，可用于评估风险比（RRs）和95％CI，原因是缺乏及时的随访。团队编码用于从医师访谈中识别主题。

结果

58％的患者缺乏对其事件异常eGFR的及时随访（即存在护理差距）。EHR中肌酐结果异常标志与更好的随访相关（护理差距的RR为0.65； 95％CI为0.64-0.66）。病人在线门户网站的使用和医师小组规模与随访的相关性较弱。提供者在管理其EHR消息框后看到的患者出现医疗缺口的风险更高。医师访谈确定了影响实验室结果管理的系统级别（例如，小组规模和管理实验室结果的帮助）和提供者级别（例如，使用EHR工具的熟练程度）的因素。

局限性

无法捕获后续测试中的故意延迟。

结论

在基于EHR的综合医疗保健提供系统中，对异常结果的及时跟踪仍然具有挑战性。改善提供者EHR消息框管理和利用健康信息技术（例如，标记异常的eGFR结果），进行组织/人员变动（例如，增加护士在管理实验室结果中的作用）以及通过更好的患者门户网站促进患者参与的策略可能会有所改善测试跟进。