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LR32 / Better patient - doctor communication in the follow-up of abnormal mammograms will improve the quality of care and reduce the failures and delays in diagnosis

Slovakia




Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Communication and documentation
Patient safety theme the SCP/clinical risk management practice is aimed at
The study “Communication Factors in the Follow-up of Abnormal Mammograms” is focusing on the factors that are significantly associated with appropriate short term follow up of Abnormal Mammograms. The evidence that follow-up of test results is not always done in a comprehensive and timely manner comes mainly from the field of malpractice litigation. Appropriate follow-up, proper documentation and good patient - doctor communication of abnormal test results is for the future results of care essential. Women with these abnormalities should either receive repeat mammogram within 6 month, or be referred for surgical evaluation
Objective of the CRM practice
The evidence that follow-up of test results is not always done in a comprehensive and timely manner comes mainly from the field of malpractice litigation. Analysis of malpractice cases shows that about one-quarter of dignosis related malpractice cases can be attributed to failures in the follow-up system. These ommissions are by definition avoidable and may represent the type of error that could be reduced by high-performance follow-up systems. Identification of the communication factors most closely associated with the delivery of appropriate follow-up care can suggest ways to design systems to ensure the delivery of this care. In order to understand the communication factors involved in the delivery of appropriate follow-up care for abnormal test results, we examined a particular type of abnormal test result for which follow-up care can be particularly challenging to deliver. The quality of the communication likely influences the quality of follow-up care for abnormal mammograms requiring short-term follow-up.
Short description of the CRM practice, including any references for further information
Documentation of the follow–up plan by physician and understanding of the follow-up plan by the patient are important factors that are correlated with receipt of appropriate follow-up care for these women. Interventions designed to improve the quality of results follow-up in the outpatient setting should address these issues in patient-doctor communication. The quality of the communication likely influences the quality of follow-up care for abnormal mammograms requiring short-term follow-up. Appropriate follow-up of abnormal test results requires multiple steps, as the physician needs to review the results, transmit them to the patient, discuss the appropriate plan with the patient, and help the patient to execute the followup plan. Integral to all these steps is a clear line of communication between the physician and patient. Good patient-doctor communication has long been recognized as a cornerstone for good-quality medical care. [page 316, 1] Failure to diagnose or delay in diagnosis has become the fastest growing area of malpractice litigation, and in some clinical areas, the highest prevalence malpractice claim . [page 316, 1] Reference from ( [4] Kravitz RL, Rolph JE, Petersen L. Omission-related malpractice claims and the limits of defensive medicine.) Furthermore, analysis of malpractice cases shows that about one-quarter of diagnosis-related malpractice cases can be attributed to failures in the follow-up system. These omissions are by definition avoidable and may represent the type of error that could be reduced by high performance follow-up systems. [page 316, 1] - references [5] According to the American College of Radiology, 3% of mammograms performed in the United States are read as “marginally abnormal” for which short-term follow-up imaging in 3 to 6 months is required. According to the American College of Radiology, 3% of mammograms performed in the United States are read as “marginally abnormal” for which short-term follow-up imaging in 3 to 6 months is required. While most of the women with this type of mammography results are not eventually diagnosed with breast cancer, 0.5% to 3% unfortunately are. [page 316, 1] - References [,6,7, 8]
Innovator of the SCP, country of origin
Country of origin : United States of America - 10 academically affiliated ambulatory medical practices in the Boston Metropolitan Area
Involved health care staff
Health care professionals from 10 academically affiliated ambulatory medical practices in the Boston Metropolitan Area (1 of 10 participating general internal medicine practices in the greater Boston area).
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
United States of America: Boston Metropolitan Area - 5 hospital-based practices, 1 university health service, 1 large group-model HMO, 2 neighborhood health centers in disadvantaged communities, and 1 suburban group practice. They were diverse in location, structure, and the degree of academic affiliation, and include The study was approved by the institutional review board at each institution. [page 317, 1]- In order to determine the appropriateness of care for this population, during the study was used: the Guideline for the management of common breast problems published in 1995 by the Harward Risk Management Foundation. (This guideline is similar to the guideline which was published by the American College of Obstetrics and Gynecology, largely based on the results of follow - up study performed by Sickles EA who followed 7 484 women with this abnormality using follow – up mamograms at 6 months, 1 years, 2 years, and 3 years.) [page 317, 1] references [3]
Summary of evidence for effectiveness, including references
Proportion of women in the study who received appropriate follow-up care: One hundred twenty-six women with abnormal mammograms requiring short-term (6 months) follow-up imaging. Eighty-one (64%) of the women with abnormal mammograms requiring short-term follow-up imaging received the appropriate follow-up care. After adjusting for patients’ age and insurance status, 2 communication factors were found to be independently associated with the delivery of appropriate follow-up care: 1. physicians’ documentation of a follow-up plan in the medical record (adjusted odds ratio, 2.79; 95% confidence interval, 1.11 to 6.98; P= .029); and 2. Patients’ understanding of the need for follow-up (adjusted odds ratio, 3.86; 95% confidence interval, 1.50 to 9.96; P = .006). None of the patients’ clinical or psychological characteristics were associated with the delivery of appropriate follow-up care. In contrast, several patient-doctor communication factors were found to be associated with appropriate follow- up in the partially adjusted analyses (P < .1). [page 316, 1], 3. In the study were screened 8 892 mammogram at the 10 sites. One hundred eighty-one women had the index abnormality for this study without meeting any of the exclusion criteria. One hundred fifty-nine (88%) of these abnormalities were detected on screening mammograms, whereas 22 (12%) were detected on mammograms done as part of a work-up for a breast complaint. Of these 181 women, 126 (70%) participated in the baseline telephone survey. The analysis is based on this cohort of 126 women. [page 317, 1] 4. Women who reported being told that follow-up was needed were significantly more likely to receive the appropriate follow-up care (OR = 4.32; P = .004). [page 320, 1], 5. Most of the knowledge regarding patient safety was derived from impatient data , there is a growing literature suggesting that medical errors are at least an equally significant problem in the outpatient setting [page 316, 1]
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
The study was a part of a larger study to examine the quality of follow-up care women received at primary care clinics for common breast problems. Women were recruited from 1 of 10 participating general internal medicine practices in the greater Boston area. [page 317, 1] They were diverse in location, structure, and the degree of academic affiliation, and include 5 hospital-based practices, 1 university health service, 1 large group-model HMO, 2 neighborhood health centers in disadvantaged communities, and 1 suburban group practice. The study was approved by the institutional review board at each institution. [page 317, 1]
Summary of available information on feasibility, including references
In summary: follow-up of abnormal results represents a challenge in the outpatient setting, where follow-up actions often have to be performed in the future. Up to one-third of women with abnormal mammograms requiring short-term follow-up do not receive the appropriate follow-up care. The health care system needs to adopt better strategies to ensure that appropriate follow-up of abnormal tests occurs. The authors believes that these strategies need to address how patients and physicians communicate with each other about abnormal test results. They suggests that further research is needed to determine whether better result management systems can reduce the present quality gap. [page 322, 1]
Existing implementation tools, including references
As patient involvement: appropriate patient - doctor communication of follow – up care for women with abnormal mammograms, that require short-term follow-up. Active and good patient – physician communication about the abnormal mammogram test results is essential for the follow-up care. The physician must explain to the women the implications of the result and the rationale for the short term repeat imaging.. Follow-up care for these types of mammograms typically occurs in the future, when neither the patient nor the doctor may be focused on the problem. The quality of patient –docotr communication likely influences the quality of follow-up care for abnormal mammograms requiring short - term follow-up. [page 317, 1] Intervention designed to improve the quality of result follow-up in the outpatient setting should address to the communication factors in patient –doctor communication an important role.
Potential for/description of patient involvement in the CRM practice, including references
Unfortunately, current practice environments may not allow physicians sufficient time to spend on patient education, and not surprisingly, a gap often exists between what patients actually understand and what healthcare professionals expect them to. Strategies advocated by health literacy experts, which include asking patients to describe their understanding after information is delivered to them, may be helpful. Providing some memory aid, such as written instructions may also prove useful. Other strategies may include the deployment of advanced patient-doctor communication systems that allow physicians and patients to discuss with each other test results and follow-up plans via secured e-mail and to set electronic reminders to ensure the follow-up plan is carried out.
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Communication Factors in the Follow-up of Abnormal Mammograms -Eric G. Poon, MD, MPH, Jennifer S. Haas, MD, MPSH, Ann Louise Puopolo, RN, BSN, Tejal K. Gandhi, MD, MPH, Elisabeth Burdick, MA, David W. Bates, MD, MSc, Troyen A. Brennan, MD, JD, MPHJGEN INTERN MED 2004; 19:316 -323 Division of General Medicine and Primary Care, Department of Medicine (EGP, JSH, ALP, TKG, EB, DWB, TAB), Brigham and Women’s Hospital; and Department of Health Policy and Management (DWB, TAB), Harvard School of Public Health, Boston, Mass.[2] Fisher G, Petters MD Munro, Goldman EB Adverse events im primary care identified from a management databeáse. [3] Guideline for the management of common breast problems published in 1995 by the Harvard Risk Management Foundation in its quarterly Newsletter (12) Committee on Gynecologic Practice ACOG committee opinion Follow up of abnormal screening mammography. [4] Kravitz RL, Rolph JE, Petersen L. Omission-related malpractice claims and the limits of defensive medicine. Med Care Res Rev. 1997;54:456–71.[5] Leape LL Error in medicine [6] Lacquement MA, Mitchell D, Hollingsworth AB. Positive predictive value of the Breast Imaging Reporting and Data System. J Am Coll Surg. 1999;189:34–40.[7] Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The breast imaging reporting and data system. Positive predictive value of mammographic features and final assessment categories. Am J Roentgenol. 1998;171:35–40.[8]. Sickles EA. Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up protocol? Radiology. 1999;213:11–4.
Reviewer
MUDr. Eugen Nagy
Organisation
Health Care Surveillance Authority, Slovakia
Any additional information on the CRM (e.g. implementation barriers and drivers)
There is no specified text here
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