The Role of Laboratory Tests in Transitions of Care and Readmissions

Transitions of care occur when patients transition from one healthcare setting to another. For example, when a patient is discharged from hospital to home or when a patient is transferred from hospital to a skilled nursing facility. These transition periods are complex and if not well planned and coordinated can lead to adverse events.

One study documented 11 percent of patients discharged from a hospital subsequently had either adverse drug events or experienced serious or life-threatening injuries because of improperly conducted transitions of care.¹ Another study estimated 80 percent of serious medical errors involve poor transition of care.²

Not only is patient safety at risk due to transitions of care, but there are also grave financial implications for hospitals. Poorly handled transitions of care play a significant role in hospital readmissions³ and represent $15-$20 billion in healthcare costs.⁴ As a response to cost associated with readmissions, in 2013 the Center for Medicare and Medicaid Services (CMS) began penalizing hospital reimbursement for hospitals with excess readmissions.⁵ In 2023, hospitals can be penalized up to 3 percent on all CMS payments for excess readmissions. Many hospitals have thin operating margins of less than 2 percent⁶; therefore, a 3 percent CMS payment penalty can be financially devastating.

Laboratory testing has an impact on transitions of care and readmissions. Studies have identified tests pending at time of discharge (TPADs) impact follow-up care—and 41 to 100 percent of patients discharged from the hospital have TPADs.⁷ Additionally, 40 to 60 percent of TPADs influence clinical care; 46 percent of patients with TPADS are subsequently readmitted, and 66 percent of surveyed healthcare providers stated preventable medical errors occurred due to TPADs.⁷

While adversely contributing to readmissions with negative implications in respect to clinical and financial outcomes, TPADs are also a focus of the National Quality Foundation (NQF). The NQF is a non-profit institute founded by CMS to develop quality metrics and is responsible for the generation and maintaining the list of “Never Events,” also referred to as “sentinel events.”⁸ Recently a new sentinel event was added to the list of previously existing events: “Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.”⁹ Between detrimental clinical impact, financial implications, and possibility of sentinel events, strategies addressing TPADs are critical.

Lack of awareness costs the system

In a 2019 analysis performed by the author at a large academic hospital in U.S., 28,776 tests were pending at the time of discharge with a total cost of $702,624. While many tests were subsequently resulted within 72 hours of discharge, 20,391 were resulted after 72 hours. A previous study demonstrated only 38 percent of discharging physicians reported awareness of TPAD results after 72 hours.¹⁰ Based on these results it can be estimated that discharging physicians at the hospital were unaware of approximately 12,642 test results as they became available post-discharge. Furthermore, an additional study demonstrated only 12 percent of TPADs are documented in discharge summaries.⁷ Applying this percentage to the same large academic hospital it can be estimated that of the 28,776 TPADs in the 12-month period, only 3,453 were likely reported in discharge summaries. It is in these scenarios where TPADs can negatively impact transitions of care and lead to unnecessary readmissions since physicians following discharged patients may be unaware of important test results impacting patient care. In the academic hospital in this example, review of the previous five years of CMS data showed the hospital had been penalized over $1.3 million dollars for excess readmission.

Strategies can improve communication, outcomes

Various strategies exist to potentially reduce the overall number of TPADs and improve documentation of TPADs within discharge summaries. While physician, nurse, and case management education are critical to raise awareness of the importance of TPADs and their impact on transitions of care, other tools also exist. One possible strategy is the use of discharge summary templates to ensure TPADs are included in all discharge summaries.⁷ Templates could allow discharging physicians to import a list of TPADs rather than relying free text entries only to populate discharge summaries. Similar methods have long been used for pharmacy medication reconciliation at time of discharge and can be adapted to document laboratory TPADs. In this respect, “laboratory test reconciliation” should be standard practice at discharge. Also, email notifications to discharging physicians when test results become available post-discharge are useful¹¹ to ensure results are communicated to outpatient physicians. Another tactic is providing physicians with an easier way to identify TPADs in the electronic medical record (EMR) at discharge. The laboratory resulting page of the EMR from the large academic hospital previously discussed displayed result filters for tests with results, for cytology/pathology and microbiology results, but no filter for tests without results. An additional filter to identify tests without results would be a useful way for physicians to easily identify TPADs and add them to the discharge summary. While these tools and strategies can assist in reducing undocumented TPADs, an ongoing audit of select discharge summaries is beneficial to monitor TPAD documentation compliance and gauge the effectiveness of interventions and education.

Aside from ensuring proper documentation of TPADs, another issue is whether physicians know at the time of test order entry during a hospital admission what the turnaround time (TAT) of the test is and if it will be resulted pre- or post-discharge. This can be particularly important for reference testing which has a high likelihood of becoming a TPAD due to longer TAT. If a physician knows the TAT prior to ordering the test, it may prompt them to not order the test or select an alternate test or methodology providing results prior to discharge. At the very least, the ordering physician would know which tests would be likely to become TPADs. For this reason, some hospitals have started embedding reference test TAT directly into test names in the physician order entry system. For example, reference tests such as “Factor V Leiden” can be renamed “Factor V Leiden (REF, 5d)” to alert the ordering provider of TAT and the possibility of generating a TPAD. Being aware of an extended TAT may also prompt the ordering provider to consider deferring the testing altogether until the patient is in the outpatient setting since the results will not impact decision making during the inpatient hospital stay.

The laboratory plays a critical role

While not necessarily aware of the exact number of TPADs from any given facility, many laboratory professionals are aware of, or suspicious of, numerous TPADs occurring in their own facilities. Studies clearly document the relationship between TPADs and potential impact on transitions of care and readmissions. When attempting to address transitions of care and readmissions, many hospitals may not consider the important role the laboratory plays. Given the longer TATs of some laboratory tests and the constant push to reduce inpatient length of stay leading to faster discharges, clinically important TPADs will always exist and must be addressed. By assisting in identifying TPADs and formulating strategies to improve TPAD awareness and inclusion on discharge summaries, laboratories can impact transitions of care benefiting patient quality care and assisting in reduction of readmissions. This demonstrates the value of the laboratory in the overall delivery of healthcare and the impact of test results regardless of care setting. With financial challenges faced by many healthcare systems and the impact on patient care, addressing laboratory TPADs is critical.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005 Apr;20(4):317-23. doi: 10.1111/j.1525-1497.2005.30390.x. PMID: 15857487; PMCID: PMC1490089.
2. Solet DJ, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 2005;80:1094-9
3. Mansukhani RP, Bridgeman MB, Candelario D, Eckert LJ. Exploring transitional care: evidence-based strategies for improving provider communication and reducing readmissions. P T. 2015 Oct;40(10):690-4. PMID: 26535025; PMCID: PMC4606859.
4. (n.d.). Hospital Discharge and readmission. Uptodate.com. Retrieved July 28, 2023, from https://www.uptodate.com/contents/hospital-discharge-and-readmission
5. (n.d.). Hospital Readmissions Reduction Program. CMS.gov. Retrieved July 28, 2023, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
6. (n.d.). Operating margins stabilize, but not-for profit hospitals still vulnerable. Modernhealthcare.com. Retrieved July 28, 2023, from https://www.modernhealthcare.com/providers/operating-margins-stabilize-not-profit-hospitals-still-vulnerable
7. Darragh PJ, Bodley T, Orchanian-Cheff A, Shojania KG, Kwan JL, Cram P. A systematic review of interventions to follow-up test results pending at discharge. J Gen Intern Med. 2018 May;33(5):750-758. doi: 10.1007/s11606-017-4290-9. Epub 2018 Jan 19. PMID: 29352419; PMCID: PMC5910344.
8. (n.d.). National quality forum. Qualityforum.org. Retrieved July 28, 2023, from https://www.qualityforum.org/Home.aspx
9. (n.d.). National quality forum list of SRE’s. Qualityforum.org. Retrieved July 28, 2023, from https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx#sre4
10. Cadwallader J, Asirwa C, Li X, Kesterson J, Tierney WM, Were MC. Using computerized provider order entry to enforce documentation of tests with pending results at hospital discharge. Appl Clin Inform 2012; 3(2): 154–163.
11. Dalal AK, Roy CL, Poon EG, et al. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am Med Inform Assoc 2014;21(3):473-80.