Methods: Attendings and PCPs were randomized to automatically receive finalized TPADs via network email for patients discharged from general medicine and cardiology services during the study period. TPADs of patients discharged between 6/20/11 to 5/31/12 were included if the attending and PCP were randomized to concordant study arms. TPADs of patients discharged were excluded if the attending and PCP were randomized to discordant study arms. Normal and near-normal TPADs were excluded using a previously established screening protocol. Two board-certified internists independently determined whether remaining TPADs were actionable by reviewing the discharge summary. Two different board-certified internists independently reviewed the electronic health record (EHR) to identify documentation of acknowledgment and actions taken regarding the actionable TPADs during the 3-month period after the index discharge. All discrepancies were adjudicated by reviewer pairs. We performed Chi-squared tests to compare our outcomes, the rates of documented acknowledgment and action for actionable TPADs, clustering by attending and adjusting for covariates. We compared time to documented acknowledgment in a priori sub-group analyses.
Results: Of 12,999 TPADs (Figure 1) available during the study period, 3378 TPADs were sampled based on our randomization schema. Of these, 2554 TPADs were excluded based on our screening protocol. Of the remaining 824 TPADs, 253 TPADs were determined to be actionable and underwent subsequent chart review. Of these 253 actionable TPADs, 150 TPADs (representing 123 patients discharged by 53 attendings) and 103 TPADs (representing 90 patients discharged by 44 attendings) were assigned to intervention and usual care arms, respectively (Table 1). The rates of documented acknowledgment (Table 2) in the intervention and usual care arms were 61% and 59%, respectively (adjusted p=0.85). The rates of documented action (Table 2) were 57% and 54% in the intervention and usual care arms, respectively (adjusted p=0.79). In our subgroup analysis, the median days to documented acknowledgment were 9 and 14 days in the intervention and usual care arms, respectively (p=0.07).
Conclusions: Although we did not observe significant improvement in the rate of documented acknowledgement and action in the EHR when attendings and PCP were automatically notified of actionable TPADs, a trend towards decreased time to acknowledgment favoring the intervention is encouraging. The relatively high percentage of actionable TPADs without any documentation of acknowledgment (~40%) in the EHR represents an ongoing patient safety concern.