Pediatric Offices Fail to Act on 1 in 10 Abnormal Test Results

Diagnostic errors (DEs) and missed opportunity for diagnosis (MOD), including the failure to act on abnormal laboratory test results in a timely manner, commonly occur in pediatric primary care offices, according to a study published online Aug. 10 in Academic Pediatrics. Approximately one in 10 abnormal laboratory results in pediatric primary care offices are not acted on appropriately or in a timely manner.

"While studies on reducing ambulatory diagnostic breakdowns in adults have emerged, little progress has been made in understanding or reducing ambulatory pediatric DEs," write the authors led by Michael Rinke, M.D., Ph.D., from Children's Hospital at Montefiore in the Bronx, N.Y. "Knowing that these DEs and MODs lead to long-term morbidity, it is crucial to pursue strategies to reduce their incidence."

Twenty-five primary care pediatric practices, participating in a national quality improvement collaborative (RedDE: Reducing Diagnostic Errors in Pediatric Primary Care), were randomized to collect five months of retrospective data (February through June 2015) on DEs or MODs regarding abnormal laboratory values, as well as elevated blood pressure and adolescent depression evaluation.

Specifically, five "subacute" laboratory tests were selected—abnormal hemoglobin and mean corpuscular volume (microcytic anemia), lead, or thyroid-stimulating hormone results, or a positive sexually transmitted infection (gonorrhea, chlamydia, syphilis, or HIV) or group A Streptococcus throat culture. These tests were chosen because they are frequently ordered in primary care pediatric practices and can lead to long-term harm if left unrecognized or untreated. Chart reviews assessed the number of patients who did not have an appropriate action documented after receiving any of these abnormal laboratory results, or patients who had an appropriate action documented but with an excessive delay.

The researchers found that for 33 children there was no timely chart documentation there was an abnormal laboratory value. For 11 percent of the 381 patients with abnormal laboratory values there was not an appropriate follow-up action in response to the abnormal test result documented in a timely manner. This rate was much lower than DEs associated with elevated blood pressure (54 percent) or MODs for evaluating adolescents with depression (62 percent).

The authors warn, though, that the extent of Des and MODs in pediatric practices, may actually be underestimated in their study.

"Practices that enrolled onto a quality improvement project to reduce DEs are likely not representative of all practices, given their expressed interest in DE improvement and their baseline characteristics," write Rinke and colleagues. "Almost 70 percent of our practices were university affiliated, and 40 percent had already worked 'a lot' on one of these errors."

Takeaway: Failure to act upon abnormal laboratory results is a common occurrence in pediatric, primary care practices.