Lost to followup

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Gastrapathy

Gastrapathy

I’m just here so I don’t get fined
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Is it really lost to follow up if you just don't bother to contact patients with abnormal results? or is it just abandonment?
 
This story doesn’t make total sense to me. Are these simply FOBT performed at bedside such as in the ED or are these cases where they were actively surveilling for colon cancer.

To me this screams of the “you didn’t put the result in the POC book” so admin/JC says it wasn’t done. Or maybe they had some sort of “test yourself at home” thing going on.

I can’t imagine that there are 5,000 tests from 3 hospitals laying around that nobody read or did anything about....especially if they were POC tests. What else you going to do when your pulling the glove off your hand? Just ignore the fact it was just in someone’s rectum?


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Most FIT/FOBT are done at home and mailed back. These were positive tests resulted in AHLTA that were ignored. 7% of these patients will have had cancer and a delay in diagnosis. It’s really terrible.
 
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HighPriest said:
Is it really lost to follow up if you just don't bother to contact patients with abnormal results? or is it just abandonment?
Click to expand...

You’re right. These patients never knew they had a positive test. Although the “high reliability officer” is unaware of it, there can be no doubt that people died because of this. I’ve never been an expert witness for a plaintiff but i would for this.
 
They used no colonoscopy as their end point for the review. Isn't there an intervening step between +FOBT and colonoscopy? I'm asking because I do not know.

Regardless, if the GI departmenat at a major MTF doesn't have a specific SOP for FOBT f/u then someone really missed the mark there. Without it, if follow up and results discussion was never documented in the chart then it never happened. This is another example of proving that if policy isn't written down as an SOP then it isn't a policy. You can't trust 100% of your people to do the right thing so make sure policy is clear, understood and able to be used as a fall back when people or systems try to screw you.

I'm not completely against HRO because it is a tool to hold people to a higher standard and mitigate risk to lowest level possible. However, I do agree that having a healthcare model involving hundreds of MTF's that expects each of those hospitals to establish themselves as individual HRO's is impossible and to think it is effective is nonsense. We don't have enough good people to establish good policies at every hospital. Why are we all doing the same care just a little bit differently? This is the military. Find best practice models after having broad, multi-D review on a topic, create a policy and then apply it to everyone (all services, everywhere).

DHA, we need your obtrusive command and control. It hurts to say that.
 
It’s not the GI department. They don’t order the FOBT. The followup test for +FOBT is colonoscopy. There are no intervening steps. The PCP orders a FOBT and in this case, thousands of positives never made it to GI. Think of this like a positive mammogram that wasn’t referred for a US or Bx. And the statement that they aren’t aware of anyone who died and that they ignore positive tests all the time is just terrible. There are people who have died from colon cancer (7% of this group in all likelihood) because the vaunted military health system failed them so egregiously
 
Anyone who is against HRO doesn't truly understand what HRO is. The main problem with medicine, military and civilian, is they claim to be HRO while not actually putting ALL of the practices into place. This is why a lot of physicians are becoming anti-HRO: admin is telling them they are HRO, but putting all the blame on the doctors and nurses without making the administrative and leadership changes necessary to implement it properly. You get sick of the buzz word rhetoric.
 
Gastrapathy said:
It’s not the GI department. They don’t order the FOBT. The followup test for +FOBT is colonoscopy. There are no intervening steps. The PCP orders a FOBT and in this case, thousands of positives never made it to GI. Think of this like a positive mammogram that wasn’t referred for a US or Bx. And the statement that they aren’t aware of anyone who died and that they ignore positive tests all the time is just terrible. There are people who have died from colon cancer (7% of this group in all likelihood) because the vaunted military health system failed them so egregiously
Click to expand...

Now you expect me to understand colons AND breasts? I've gone cross-eyed.

One would think that if they were reviewing charts for a colonoscopy they also would have been looking for a colon cancer diagnosis or death certificate... I'm not trying to downplay it, but I imagine this fell somewhere in between the extremes of just simple failure to document lab result follow up and legitimate negligent death.
 
You can imagine whatever you want. They didn’t review charts. They sent a letter to people with previously ignored positive tests from years past and shoved their heads in the ground. Mortality starts increasing 3 months after a positive FIT if not acted upon. I’m not sure what “legitimate negligent death” means but I am an expert on this topic and I am certain that this was as bad as it sounds.
 
Gastrapathy said:
You can imagine whatever you want. They didn’t review charts. They sent a letter to people with previously ignored positive tests from years past and shoved their heads in the ground. Mortality starts increasing 3 months after a positive FIT if not acted upon. I’m not sure what “legitimate negligent death” means but I am an expert on this topic and I am certain that this was as bad as it sounds.
Click to expand...

Do we know that is true? The article just said there was no documentation. As objectively terrible as our EMR systems have been, I wonder if some, most, or all of those persons were notified but that it simply wasn't documented. Obviously non-documentation is a problem, but it's a different sort of problem than non-notification.
 
Gastrapathy said:
These were all people with positive tests who then didn’t have colonoscopies. It’s not a documentation issue.
Click to expand...

That's a bit of a bold statement drawing conclusions. I have probably had at least a dozen people with a positive FOBT who refused a colonoscopy. They only did the FOBT as a concession to me as they didn't want the colonoscopy in the first place.

From a documentation standpoint, I will typically email people their test results. If there are no issues I do not do a t-con that I sent them their results. And, if I'm being honest, I probably don't ALWAYS do a t-con for concerning results either, but I don't sign it in AHLTA until I have emailed or called the person. Perhaps I need to ensure that I do though.

Just because a patient was notified, doesn't always mean they follow through either.
 
@Cooperd0g consent for a FOBT should include the plan if positive. Otherwise you are doing it for metrics rather than patient benefit. And yes, documenting a refusal is definitely standard of care and also just being a doctor. Frankly, if you can’t be bothered to document that they declined, I doubt you tried very hard to talk them into it. You certainly didn’t bring them into clinic and discuss. But that response pretty much proves the point.

These are thousands of patients who were failed by doctors in the MHS. The way this has been defended here is sad. You are AD, ask the folks at Navy Marine Corps Public Health Center to send you the report. But then, if you can’t be bothered to document a conversation where a patient has a 7% risk of dying from undiagnosed cancer, I’m not sure what to say.

The VA gets more than 90% of their FITs in for colonoscopy. The MHS gets less than 60%. Tell me again how that’s the patient’s fault
 
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Gastrapathy said:
Frankly, if you can’t be bothered to document that they declined, I doubt you tried very hard to talk them into it.
Click to expand...
Agree with this 100%.

I can’t help but agree that even if you did tell all of those patients that they had a positive FOBT, some would have refused colonoscopy. But certainly not all. Probably not most. Likely only a small percentage if you actually told them that they have a 7% chance of having colon cancer.

The point is: arguing that some people just refuse a colonoscopy doesn’t excuse the fact that none of them had one.

And if you’re not documenting that, then I have to assume that you didn’t see those patients in clinic. You have an encounter note open in front of you. You’re a provider, so I am assuming that you know why you ordered a FOBT to begin with, and you know what the risks are if it’s positive. So if those assumptions are true, and you close that note and don’t indicate that the patient verbally released liability by declining a test, you’re a fool. If those assumptions are false and you don’t know why you ordered the test or what it means, then you are worse than a fool (or maybe you’re an ENT or Ortho doc).

The problem with any defense of this situation is that you’re trying to argue that this terrible thing is slightly less terrible than the worst case scenario, and that is ultimately a moot point, init?

It is possible that they tried to follow up with all of these patient via phone, and they didn’t open an encounter when they did it (which is equally as foolish but certainly more probable). But that also doesn’t excuse the situation and it doesn’t explain why -none- of them got scoped.

$#!t, man, I don’t want some pervy GI doc playing with my bum, but if I have a 7% chance of @$$ cancer, glove up.
 
@HighPriest there was no followup. And even worse, when they identified that this had happened, they made a half hearted effort to fix it by sending a single letter. When they said that they weren’t aware of any deaths, that’s because they made sure not to really look.

when you are this much worse than the VA system...
 
Gastrapathy said:
@Cooperd0g consent for a FOBT should include the plan if positive. Otherwise you are doing it for metrics rather than patient benefit. And yes, documenting a refusal is definitely standard of care and also just being a doctor. Frankly, if you can’t be bothered to document that they declined, I doubt you tried very hard to talk them into it. You certainly didn’t bring them into clinic and discuss. But that response pretty much proves the point.

These are thousands of patients who were failed by doctors in the MHS. The way this has been defended here is sad. You are AD, ask the folks at Navy Marine Corps Public Health Center to send you the report. But then, if you can’t be bothered to document a conversation where a patient has a 7% risk of dying from undiagnosed cancer, I’m not sure what to say.

The VA gets more than 90% of their FITs in for colonoscopy. The MHS gets less than 60%. Tell me again how that’s the patient’s fault
Click to expand...

You are right; and I can't say that the 30% disparity is the patient's fault. But with regard to me, I think I didn't phrase my statement properly. I always document concerning results and that they have been passes along with a plan. I don't ALWAYS document every lab out of "normal" parameters - someone has trace protein in their urine I have them do a repeat. I don't necessarily do a full appointment or t-con regarding the initial trace protein unless they don't get the repeat done or the repeat shows the same thing.

If I had a person refuse colonoscopy in favor of a FOBT you bet your ass I document that. And I definitely document if they refuse the colonoscopy after a positive FOBT.
 
If I have a biopsy that shows FLUS in a thyroid, I call the patient (or my nurse does), every call gets a timed, dated note even if the patient doesn’t answer the phone. They get a follow up scheduled. We leave messages to contact us on voicemail if we can, and we document when we left that message and what it stated. Every time. And frankly, the patient is more likely to die driving to the hospital than they are from thyroid cancer. But the standard of care is to make every effort to follow up on results - especially positive results. (And no, not normally with normal results).
So if I’m not documenting that I told the patient what’s up, I’m documenting that I tried really hard.
You simply can’t tout the military medical system if you don’t hold it to the same standard as the civilian system (or higher). I think everyone agrees with that. And in that case, this is inexcusable regardless of the cause or way in which it occurred.
 
This goes back to HRO principles. It looks like @HighPriest has some good systems in place. Clearly we don’t in the military as a whole.
 
Agree that regardless of what happened it is inexcusable. Having all of the details would help us have a more relevant discussion.

For something like this example it is very easy and appropriate for all hospitals within DOD to have the same way positive results are given to patients and documented.

Without implementing such easy policies we will never be HRO
 
Does FP still do flex sigs?
 
I remember surgery doing colonoscopies at starship.
 
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