A new study that shows one in 20 U.S. adults may be misdiagnosed during an outpatient visit is helping focus renewed attention on the often-overlooked arena of outpatient safety.
The study, which appeared in the journal BMJ Quality & Safety, found that about 12 million adults could be misdiagnosed annually in the outpatient setting.1 Significantly, about half of these errors have the potential to harm patients, the study states.2
The report is the latest to suggest that misdiagnosis and other outpatient errors are a major problem in the U.S. health system. A 2011 study of malpractice awards revealed that more than 40% of the payouts stemmed from care provided in the outpatient environment.3
Jay Anders, MD, chief medical officer for McKesson Business Performance Services (BPS), said the risk of misdiagnosis and other problems is rising as more care shifts to outpatient facilities and physician offices.
“There is so many more office visits than admissions, so the opportunity to make a mistake is markedly greater,” Anders said. “In addition, physicians have a very limited amount of time with the patient, and that increases the possibility of misdiagnosis.”
Fortunately, Anders said, a combination of decision support tools at the point of care, better provider-to-provider data sharing, greater use of physician extenders and improved patient engagement strategies can help alleviate the risks associated with outpatient care.
Outpatient care dwarfs hospitalizations in the U.S., with more than 900 million physician office visits annually, versus 35 million hospital discharges.4 Yet despite the massive volume, most patient safety initiatives and research to date has focused on the inpatient environment. Only about 10% of patient-safety studies between 2005 and 2010 were performed in an outpatient setting, according to Tejal Gandhi, MD, a board-certified internist, associate professor at Harvard Medical School and an expert on patient safety.5
In a 2010 article in the New England Journal of Medicine, Gandhi and co-author Thomas H. Lee, MD, noted that outpatient settings are vulnerable to errors in part because of the challenges associated with information transfer between providers, particularly in cases involving complex medical conditions. In addition, outpatient practices typically lack the infrastructure and expertise needed to address quality and safety improvement. Also absent are the staffing ratios and other accreditation requirements present in the hospital setting.
Finally, Gandhi and Lee wrote, the “signal-to-noise ratio” is much lower in outpatient settings. “In ambulatory care, a physician may see 100 patients with chest pain before seeing one with an actual myocardial infarction.6
Decision Support Essential
McKesson’s Anders noted that evidence-based decision support systems that provide physicians with diagnosis-related information at the point of care have become increasing sophisticated and user-friendly over the past several years. The systems provide a range of capabilities, he said, from preventative recommendations to order sets for specific diagnoses.
“You can’t diagnose what you don’t think of, so these systems offer important reminders to make sure that all possibilities are considered,” Anders said. He added that decision-support solutions will become increasingly necessary as the body of medical knowledge continues to expand. The number of genomic-based tests, for example, has soared more than 10-fold in just the past three years, from approximately 2,500 to more than 30,000 today, he said.
Along with fast, easy-to-access decision support, streamlined communications between providers is another important tool for combating misdiagnosis. Anders said that while the U.S. remains a long way from universal health information exchange, large, multi-group practices and some health systems are making rapid progress toward seamless, real-time patient information transfer.
Similarly, the rise of population health management applications should help physicians more easily identify patients with complex health needs, thus allowing the doctors to focus more time and attention on their care. Conversely, less demanding patient requirements can be delegated to physician extenders to free up physician time.
Strategies designed to improve patient engagement, a vital but long-overlooked aspect of all care, also are becoming increasingly prominent and effective, Anders said. A growing number of mobile applications, for example, can help patients monitor chronic conditions, such as diabetes and heart disease. At the same time, higher insurance deductibles are creating financial incentives for patients to become better stewards of their own care.
A Fragmented Environment
Gandhi of Harvard Medical School and co-author Lee wrote that, broadly speaking, “the greatest immediate challenge in addressing these safety issues is that of creating a culture of safety in the outpatient setting, which is so often fragmented and disorganized and lacking clear leadership.7”
“In contrast, many hospitals have made large investments in patient-safety teams, safety `walk-arounds,’ safety reporting systems, root-cause analysis and culture surveys,” she wrote. “Ambulatory practices need some version of these investments – but few have made them yet.”8
Despite the challenges, Anders said he is optimistic that care provided away from the hospital can be improved dramatically.
“In the last three to five years, we’ve seen dramatic improvements in the technologies that work,” he said. “So we’re getting better and better at giving the physician what they need in any given situation. At the same time, there is a growing acknowledgement of the importance of outpatient safety, so we will see more and more individuals and organizations focusing energy, attention and resources on the issue.”
1 Karen Weintraub, “1 in 20 adult outpatients misdiagnosed, study reports,” Boston Globe, April 16, 2014, http://www.bostonglobe.com/lifestyle/health-wellness/2014/04/16/adult-outpatients-misdiagnosed-new-study-reports/nVQ18BMjvTbkoCi0aRfwLO/story.html
3 Michelle Andrews, “Mistakes In Outpatient Care Raising Concerns,” Kaiser Health News, June 28, 2011, http://www.kaiserhealthnews.org/features/insuring-your-health/michelle-andrews-on-errors-in-outpatient-care.aspx
4 Tejal K. Gandhi, Thomas H. Lee, “Patient Safety Beyond the Hospital,” The New England Journal of Medicine, September 9, 2010 http://www.nejm.org/doi/full/10.1056/NEJMp1003294