Right Test, Right Patient, Right Time…Wrong Interpretation?

Providing accurate test results is a critical function of the clinical laboratory—but our responsibility doesn’t end there. Clinicians depend on the laboratory to provide vital interpretive comments to give meaning to these results. However, there is a fine line between providing helpful information to the end user versus contributing to information overload. Moreover, the end user is no longer only the physician, but extends to other healthcare providers and even to patients themselves who increasingly access their results via patient portals.

A Monday morning interactive short course developed with the Royal College of Pathologists of Australasia (RCPA) Quality Assurance Program (QAP) grappled with this issue, linking the quality of interpretive comments directly to patient outcomes and patient satisfaction.

Now that we have improved analytical test results, we need to improve the pre and post analysis, noted Samuel Vasikaran, MD. “If we don’t interpret test results right then the effect of testing won’t be correct,” he said.

Vasikaran explained that most junior doctors feel they only have moderate or limited confidence in requesting and interpreting results. A recent survey at his institution, the Royal Perth Hospital showed that most junior doctors and general practitioners would like more help with test interpretation. Furthermore, studies have demonstrated that well written interpretive comments improved test utilization and patient outcome.

Vasikaran recommends that laboratorians only add comments to a test result if the results are unexpected, influence decisions on management or treatment, or if the test is fairly esoteric. Ideally, the laboratory should individualize comments in the context of the patient’s clinical condition and in conjunction with other test results or clinical parameters. Unfortunately, this is not always feasible.

An interactive survey of the audience showed that 100% of attendees provide some type of interpretive comments to their test results, but 57% had no mechanism to assess the quality of the comments they provide. Until recently, laboratorians did not have mechanisms available for peer reviewed quality assessment (QA) and support for continuous professional education. The RCPA QAP developed its assessment as a solution to enable individuals to objectively examine their practice and approach the assessment as a quality activity, while functioning as a component of a larger QA scheme. The assessment also contains a strong educational component, making it more than just a traditional exam or checklist item.

Graham Jones, DPhil, MBBS, highlighted the lessons learned from the RCPA QAP external quality assessments, one of which focuses on improving deficiencies in the quality of comments in patient reports.   Jones walked the audience through several examples of case interpretations which illustrated the difficulty in proper interpretations. According to Jones, desirable comments may include: absence or presence of abnormality; possible clinical implications and/or diagnosis; degree or severity of abnormality; and suggested follow-up or specialist referral. Undesirable comments may include restating the obvious (“normal” or “elevated”); suggesting obvious clinical interventions (check blood pressure, conduct physical exam); restating the clinical question if known; and suggesting any invasive interventions, such as a biopsy.

Both Jones and Vasikaran predicted that in the future, participating in external QA schemes for interpretive comments will largely become more of a contractual obligation rather than a professional one. They also emphasized that the visibility of the laboratory depends primarily on the results and interpretive comments laboratorians provide to physicians and patients.