Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

Objectives: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care.

Materials And Methods: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees.

Background: A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure.

Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits.

Importance: Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality.

Objectives: To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors.

Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care.

Background: Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer.

Objective: Identify loop closure rates and vulnerable process points for patients with rectal bleeding.

Design: Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices-an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020.

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

Ideally, urgent dermatology referrals for evaluation of a lesion concerning for skin cancer should be triaged and processed with appropriate urgency by primary care and dermatology, respectively. We performed a retrospective single-institution study by conducting chart reviews of all dermatology referrals designated by primary care as urgent for evaluation of a lesion concerning for skin cancer. We identified 320 referrals placed between January 1 and December 31, 2018.

Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance.

Importance: Following up on recommendations from radiologic findings is important for patient care, but frequently there are failures to carry out these recommendations. The lack of reliable systems to characterize and track completion of actionable radiology report recommendations poses an important patient safety challenge.

Objectives: To characterize actionable radiology recommendations and, using this taxonomy, track and understand rates of loop closure for radiology recommendations in a primary care setting.

Variation in Breast Cancer Risk Model Estimates Among Women in Their 40s Seen in Primary Care.

The Gail, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick breast cancer risk prediction models are recommended for use in primary care. Calculating breast cancer risk is particularly important for women in their 40s when deciding on mammography, with some guidelines recommending screening for those with 5-year risk similar to women age 50 (≥1.1%).

Systems engineering analysis of diagnostic referral closed-loop processes.

Background: Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes.

Objective: Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case.

A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s.

Introduction: Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk.

Study Design: Pretest-Posttest trial.

Nondiagnostic Fine-Needle Aspiration Biopsy of Thyroid Nodules: Outcomes and Determinants.

Nondiagnostic results are common following fine-needle aspiration biopsy (FNAB) of thyroid nodules, but recommendations for the management of these patients vary. We sought to determine the outcomes and predictors of nondiagnostic FNABs in a single-center cohort of patients undergoing thyroid nodule evaluation. We identified all first time ultrasound-guided FNABs performed between May 2007 and June 2013 at the Beth Israel Deaconess Medical Center Thyroid Nodule Clinic and examined demographic data, follow-up ultrasounds, repeated FNABs, and histopathologic findings.

Building a Quality Management System for a Thyroid Nodule Clinic.

Background: There are few published quality metrics relevant to fine-needle aspirations (FNA) of the thyroid and endocrinology. With the development of a Thyroid Nodule Clinic within an academic practice, the Division of Endocrinology, in collaboration with the Department of Medicine Quality Improvement Team, established a system to monitor the results and follow-up of thyroid biopsies to ensure patient safety and to prevent adverse clinical outcomes attributable to delayed or incomplete follow-up.

Methods: All FNA performed are identified using billing data from the Thyroid Nodule Clinic.

The Effects of Resident Peer- and Self-Chart Review on Outpatient Laboratory Result Follow-up.

Purpose: Performing and teaching appropriate follow-up of outpatient laboratory results (LRs) is a challenge. The authors tested peer-review among residents as a potentially valuable intervention.

Method: Investigators assigned residents to perform self-review (n = 27), peer-review (n = 21), or self- + peer-review (n = 30) of outpatient charts.

Incidentally detected lung nodules: clinical predictors of adherence to Fleischner Society surveillance guidelines.

Objective: The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance.

Materials And Methods: A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up.

Measuring patient and family experiences of health care for children.

Background: The Institute of Medicine considers patient centeredness a core dimension of quality. Several patient/family surveys exist to assess pediatric health care. The Children's Health Insurance Program Reauthorization Act mandates strengthening quality measurement for children, including for patient/family experience of care.

Review of quality measures of the most integrated health care settings for children and the need for improved measures: recommendations for initial core measurement set for CHIPRA.

Objective: To identify, assess, and make recommendations for inclusion of measures that assess the domain of "most integrated health care setting," with a specific focus on measures of the medical home, one particular mechanism for integrating care, to identify gaps in measurement; and to make recommendations for new measure development.

Methods: We developed a conceptual framework for care integration and reviewed literature on measures assessing the presence and quality of the medical home to determine their validity, reliability, and feasibility as a proxy for care integration.

Results: We identified 2 broad approaches to assessing the extent to which patients receive care that fulfills the aims of the medical home: 1) organizational assessment of practice systems and processes thought associated with achieving these desired aims (viz, the National Committee for Quality Assurance Physician Practice Connections-Patient Centered Medical Home measure and the Medical Home Index, and 2) direct assessment by patients/families of their experience of care in targeted dimensions.