A recent study published in JAMA Network Open reveals that a quality improvement collaborative, known as the Virtual Breakthrough Series (VBTS), did not significantly improve the follow-up rates for abnormal test results suggestive of lung or colorectal cancer across 12 Department of Veterans Affairs (VA) medical centers. The stepped-wedge cluster-randomized clinical trial, conducted between February 2020 and March 2022, aimed to enhance the follow-up of critical test results but yielded largely null findings.
The study, led by Lisa Zubkoff and colleagues, involved 11 teams implementing 47 unique interventions to reduce missed test results. These interventions included increasing patients’ access to test results via portals (91% of sites), preventing clinician EHR notification fatigue (55%), and monitoring for breakdowns in test results review and communication (45%). Despite these efforts, the primary outcome—change in the follow-up rate of abnormal test results from the preintervention phase to the action phase—showed no significant difference.
The estimated mean difference between the preintervention and action phases was -0.78 percentage points (95% CI, -6.88 to 5.31) for colorectal cancer e-triggers and 0.36 percentage points (95% CI, -5.19 to 5.90) for lung cancer e-triggers. These results indicate that the VBTS intervention did not have a significant impact on improving follow-up rates for these critical tests.
Exploratory Analysis Reveals Potential Benefits for Low-Performing Sites
An exploratory analysis, however, suggested that the VBTS may offer benefits for sites with low baseline performance. Specifically, the site with the lowest follow-up rate at baseline increased its follow-up rate from 27.8% in the preintervention phase to 55.6% in the action phase. This suggests that while the intervention may not be universally effective, it could be valuable for organizations struggling with test result follow-up.
Study Design and Methods
The study utilized a stepped-wedge cluster-randomized design, with 12 VA medical centers randomized into three cohorts. Each cohort progressed through three phases: preintervention, action, and continuous improvement. The VBTS intervention included instruction on reducing rates of missed test results, a change package with evidence-based strategies, a workbook for participants, and electronic trigger (e-trigger) algorithms to identify patients with potentially missed test results.
The primary outcome was the change in the follow-up rate of abnormal test results from the preintervention phase to the action phase. Secondary outcomes included effects across cohorts and the intervention’s effect on sites with the highest and lowest preintervention follow-up rates.
Limitations and Implications
The authors acknowledge several limitations, including the potential for selection bias due to voluntary participation and the impact of the COVID-19 pandemic on staff reassignments and study delays. Despite these limitations, the study highlights the challenges in translating multifaceted interventions into clinical practice.
"In this SW-CRCT, although teams successfully implemented changes designed to reduce missed test results, the VBTS did not result in significant change in missed test results, except among low-performing sites," the authors concluded. "These findings suggest that the VBTS approach may be most helpful for organizations with low rates of test results follow-up."
