May 2020, Volume XXXIV, Number 2
A dose of insight
early 84% of adults and 93% of children will have contact with a health care professional each year in the United States. (See https://tinyurl.com/mp-stats.) These patients and their caregivers are ultimately asking for two things—an accurate diagnosis and an appropriate treatment plan. While arriving at a timely and accurate diagnosis for every single patient may not always be possible, it is always the goal.
Diagnostic accuracy is far from simple. In fact, diagnosis-related events are the single largest root cause of malpractice claims. Health care providers can benefit from fresh perspectives, data-driven insights, and new ways of thinking about everyday activities.
A fresh approach to claims data
Our conclusions from analysis of claims data are not absolute findings, but hypotheses: signals from the past about where vulnerabilities existed and may still be at play.
Typically, a fully investigated liability claim will contain valuable information, such as allegations of primary and secondary causes, patient health and demographic information, injury severity, physician specialty, risk management issues, location of the alleged error, human and financial costs, and expert reviews and opinions. We use this information to create evidence-based recommendations to mitigate risk.
Leading causes of claims
Diagnosis-related events result in indemnity payments just slightly higher than the next five highest categories combined. Our study found that 53% of diagnosis-related claims include risk management issues involving poor clinical decision-making; 54% are high-severity cases, with 36% resulting in death; and 36% stem from outpatient (office setting) locations.
Rethinking the diagnostic process
It’s estimated that 10–20% of all medical diagnoses are inaccurate (see https://tinyurl.com/mp-accuracy). Thirty-three percent of diagnostic-related claims and 26% of associated indemnity payments allege that a breakdown in decision-making occurred during the patient’s H&P (patient/family history and physical examination).
The four discrete phases of testing (ordering, performance, receipt/transmittal, and interpretation) trigger 52% of diagnosis-related claims and 55% of indemnity payments.
It’s estimated that 10–20% of all medical diagnoses are inaccurate.
Nine percent of the diagnosis-related claims we examined were attributed to referral management.
Allegations involving inadequate physician follow-up with the patient accounted for 5% of claims and 7% of indemnity paid.
Missed and delayed diagnosis of cancer
Among malpractice claims that allege a diagnostic failure, the largest number involve a missed or delayed diagnosis of cancer. The top four cancers involved in such claims have always been breast, lung, colorectal, and prostate, though the exact order periodically shuffles.
In the case of breast and lung cancers:
In the case of colorectal, lung, prostate, and oral cancers:
General medicine practitioners are the focus of most allegations involving these cancers. They are pulled into these cases largely because of their role as the overall manager of the patient’s care.
In 2016, the highest number of new cancer cases among men were cancers of the prostate, lung and bronchus, and colon and rectum, while the largest number of new cancers in women were cancers of the breast, lung and bronchus, and colon and rectum—the exact top four cancers involved in allegations of diagnosis-related failure, and the same cancers that are on the rise in the United States (see https://tinyurl.com/mp-cancer-stats).
The role of radiology in cancer diagnosis
More than half of diagnosis-related claims involve an allegation that something went wrong during one of the testing steps, specifically diagnoses involving radiology and the presence of cancer. The vast majority of breast- and lung- cancer claims allege that the radiologist was the specialist most accountable.
Quality improvement processes that provide honest feedback to radiologists on the accuracy of their reads may not be as robust as they ought to be, which may lead radiologists to conclude their accuracy rate is higher than it is. Also, when radiologists are unsure of their interpretation, there may not be decision support tools in place or an avenue to obtain a second opinion without embarrassment or retribution. Further, ongoing education on common and unusual diagnostic pitfalls may be lacking.
Teleradiology provides a valuable service for facilities that cannot support an in-house radiologist around the clock, but it can also contribute to missed diagnoses if film and transmission quality are suboptimal.
Sometimes a sound diagnosis and an optimal outcome comes down to the writing and communication skills of the radiologist and/or the ability of the ordering provider to interpret information. Radiology reports that contain many possibilities but no definitive diagnostic information can be confusing, and do not aid in developing a care plan. This problem is further compounded when the report includes disclaimers and multiple recommendations without a sound basis to implement them.
Diagnostic accuracy: cardiac and vascular issues
Cardiac and vascular issues represent 8% of diagnosis-related claims. Taken together, heart problem (non-MI), myocardial infarction (MI), and thrombosis/clot/emboli were involved in 12% of diagnosis-related claims. These issues were almost as frequent (12% vs.13%) in our study as infections (pneumonia, sepsis, MRSA, sinusitis, etc.) and were more frequent than fractures/dislocations (a historically common condition in diagnosis-related claims).
Heart and vascular issues can be difficult to diagnose because symptoms can vary from patient to patient and can mimic symptoms for other common ailments. Because these issues are so often fatal, it’s important that diagnostic testing be thorough and timely and that practitioners obtain a complete patient and family history.
Helping physicians and patients to do better, together
Below are important questions to consider in helping physicians and patients work together in the quest for diagnostic accuracy.
Arriving at a timely and accurate diagnosis for every single patient may not always be possible.
Inpatient vs. outpatient settings
Our claims data show that 35% of diagnostic errors occur in physician offices and clinics. It is difficult to determine the exact cause(s) for this finding. It could be that, unlike hospitals, office settings often do not have personnel dedicated to auditing compliance with published practice guidelines. Even if physician offices do review this information, the volume of data may not be large enough to be considered a credible basis for treatment decisions.
In addition, peer review may not be as robust in a small practice. All the providers may be similarly trained and approach diagnoses the same way; every provider in the practice may not feel comfortable offering alternatives to another provider; and there are typically no expert resources within an office practice that can provide guidance.
Finally, the practice may not have access to clinical decision support tools that can assist in diagnosing and developing the appropriate treatment during the first patient encounter.
The emergency department and its role in diagnostic risk
The emergency department (ED) and urgent care facilities, as a category, represent the location type with the second-highest incidence of diagnostic-related claims (24% of claims and 17% of indemnity paid).
These physicians typically have no ongoing relationship with most patients, some of whom arrive unable to speak for themselves and with no reliable historian accompanying them. ED providers have to make immediate and often lifesaving decisions with little or no information, often with rapid and impersonal patient hand-offs.
About 48% of diagnostic-related ED closed claims included allegations of patient evaluation, followed by 26% that alleged issues with ordering tests. More than 50% of diagnostic-related ED claims showed the highest level of severity, a category that includes death. Key risk management issues in order of priority involved clinical decision-making (53%), clinical systems (13%), and communication (8%).
Health insurance companies and their impact on diagnosis
Our insured providers continue to express concern over health insurers’ approval processes for tests and procedures. They report that the approvals are not consistent, often delay the diagnostic process, and, at times, appear arbitrary. Most practitioners do not quarrel with national practice guidelines for a particular diagnosis if they are supported by credible data, but are frustrated by approvals that require several interim steps that can add complexity and confusion.
The following recommendations apply broadly to the phenomena of diagnostic errors:
The magnitude of responsibility for diagnosis is staggering, and the issue of diagnostic inaccuracy is no small matter. Diagnostic inaccuracies may have grave results, but it’s important to acknowledge that doctors are getting it right more often than not.
This article includes general risk management guidelines for information purposes. It is not intended, and should not be taken, as legal or medical advice.
Robert Hanscom, JD, is vice president of business analytics at Coverys.
Maryann Small, MBA, is director of data governance and business analytics at Coverys.
Publisher’s note: This article is an excerpt from a Coverys report. Unless otherwise indicated, statistics and information are based on Coverys’ analysis of 10,168 closed malpractice claims across a five-year period (2013-2017). A more full report on diagnostic accuracy from the authors, with extensive supporting data, is at https://tinyurl.com/mp-coverys.
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