The revolving door of resident continuity practice: identifying gaps in transitions of care.

Background: It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving.

Objective: To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance.

Design: Retrospective chart review

Subjects: We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care.

Main Measures: We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up.

Key Results: These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation.

Conclusions: This study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.