confronting diagnostic error-employer

CONFRONTING DIAGNOSTIC

ERRORHow the Right Diagnosis Is Key

to Quality Improvement and Lower Costs

Mark L. Graber, MD, FACP / Lew Levy, MD, FACP

EMPLOYER INSIGHTS SERIES

Every day, in spite of clinicians’ best intentions, patients receive inaccurate diagnoses, are prescribed incorrect treatments or are simply not diagnosed at all. These common errors contribute to unnecessary health

care costs, system inefficiency and employee dissatisfaction. To

help combat this, employers are seeking innovative approaches

to improving clinical quality and financial performance. Evidence

confirms that improved diagnostic accuracy contributes to achiev-

ing quality, controlling costs and increasing patient satisfaction.

CONFRONTING DIAGNOSTIC ERROR 1


IMPROVING DIAGNOSTIC ACCURACY AND ENSURING APPROPRIATE TREATMENT SUPPORTS

THE GOALS OF THE TRIPLE AIM: improving quality, containing costs and delivering a better

member experience.

Employers are always on the lookout for new and innovative approaches for employee benefits that improve

outcomes. Now, in combination with established approaches, such as evaluating hospital readmissions, medication errors, post-surgical complications and wrong-site surgeries, researchers are re-focusing on diagnostic accuracy to further support these efforts. And employers are beginning to take notice. “The combination of forces driving health care right now is energizing the discussion of diagnostic accuracy,” said Dr. Mark Graber, founder and

president of The Society to Improve Diagnosis in Medicine (SIDM).

On a national scale, health care experts are increasingly addressing the substantial impact of diagnostic error. SIDM is conducting research, promoting education and raising awareness to better understand the causes and remedies for diagnostic error. Additionally, the Institute of Medicine (IOM), as part of its Crossing the Quality Chasm series, will release a report in later 2015 on diagnostic error, placing it as a prominent part of the nation’s health care policy agenda.

BETTER MEMBER EXPERIENCE

Provide virtual access to world-renowned medical experts to confirm optimal clinical pathway

QUALITY IMPROVEMENT

Improve diagnostic and treatment accuracy through expert reviews of complex and critical care cases

COST CONTAINMENT

Minimize the costs of unnecessary hospitalizations, medications, treatments and surgeries

THE HIGH INCIDENCE AND HIGH COST OF DIAGNOSTIC ERRORS



The High Incidence—and High Cost—of Diagnostic Errors.

Diagnostic error is blamed for an estimated

40,000 to 80,000 deaths in the United States

each year.1 Diagnostic errors exact an enormous toll—both

human and financial. Not only are these errors devastating to patients

and their families, but too often they lead to patient harm, wasted

resources and malpractice litigation. IOM estimates that one out of

every three health care dollars spent is wasted, resulting in nearly

$1 trillion of wasted expenditures each year in the United States.2

Misdiagnosis is an important contributor to health care waste.


1 IN 20 primary care visits involve a preventable diagnostic

error; half of these errors are potentially harmful

PRIMARY CARE HEALTH CARE ORGANIZATIONS

10 PATIENTSare harmed every day in

clinics or ERs

1 DEATH occurs every month

in a typical health care organization

A research study led by Dr. Hardeep Singh at Baylor College of Medicine found that 1 in 20 patients experience a diagnostic error each year. Half of these cases cause patient harm. An analysis of diagnostic errors by location shows that only 16 percent are made in the chaotic, pressure-

filled environment of the emergency room. Over half occur in ambulatory care settings, and 28 percent happen in inpatient hospital settings.3

ERRORS OCCUR IN PRIMARY, INPATIENT AND OUTPATIENT CARE

Using several methods to study diagnostic errors reveals preventable harm occurs frequently

in all health care delivery systems.

HARM


Claims data compiled by CRICO/RMF, the risk management and medical malpractice company for Harvard-affiliated hospitals and health care organizations, show that of the diagnostic errors which occurred in the inpatient setting, the level of harm was considered “high” in 73 percent of the cases, with 46 percent of cases resulting in death. Similarly, in the ambulatory care setting, the severity of harm in 60 percent of cases was classified as “high,” and 28 percent of cases resulted in death.4

Multiple studies support these findings. Cognitive scientist Dr. Arthur Elstein, an expert in physician decision-making and behavior, calculates that 10 to 15 percent of all diagnoses are missed, wrong or delayed.5 Moreover, research shows that abnormalities in X-rays or pathology findings that were missed by a first review were detected by a second professional’s review 2 to 5 percent of the time.6,7 Standardized patient studies reveal that primary care physicians or internists misdiagnose 13 percent of cases where a chronic condition exists.8

SEVERITY OF ERROR DIAGNOSTIC ERROR OCCURRED

SEVERITY OF ERROR

INPATIENT (1,253 Cases) AMBULATORY (2,531 cases)

LEVELS OF HARM

OF CASES RESULTED IN DEATHS

OF CASES RESULTED IN DEATHS

LEVELS OF HARM

High

Medium

Low

High

Medium

Low

46%

73%60%

25%2% 5%

35%

28%

AMBULATORY

56%

INPATIENT

28%

ER

16%

DIAGNOSTIC ERROR LOCATIONS AND SEVERITIES

Diagnostic error occurs throughout the health care delivery system. When the errors occur,

the level of harm is often high and too frequently results in death.


Retrospective case reviews are crucial in determining the incidence of diagnostic error in medicine. In a study of women with and without breast cancer, radiologists disagreed 11 percent of the time on interpreting the mammogram, and half of the radiologists had less than an 80 percent sensitivity in detecting the abnormal studies.9 Autopsies, considered the gold standard in clinical diagnostics, provide another excellent opportunity to detect medical error. Although declining in use, historically they have revealed that 10 to 20 percent of the time there is a major discrepancy that, if addressed, would have changed the course of the patient’s treatment plan.10,11

Increasingly, individuals are aware of the problem of diagnostic error. A study from the Kaiser Family Foundation found that nearly one in three people indicated that they or somebody in their family had been affected by a preventable medical error, with 21 percent suffering a serious health consequence.12

Against the background of market transformation, experts are seeking new ways to advance the Triple Aim framework, which involves improving quality, containing costs, and delivering a better patient experience. The confluence of several market trends—the wider implementation of electronic health records (EHRs), the increasing importance of data-driven analytics, and the focus on actively involving patients in their health care—support clinical efforts to improve diagnostic accuracy.

NEARLY

ONE IN THREE MEMBERS INDICATED THAT THEY OR SOMEBODY IN THEIR FAMILY

HAD BEEN AFFECTED BY A PREVENTABLE MEDICAL ERROR

Retrospective case reviews are crucial in determining the

incidence of diagnostic error in medicine.

AN INNOVATIVE SOLUTION

TO ADDRESS DIAGNOSTIC

ERROR


An Innovative Solution to Address Diagnostic Error.

Independent second-opinion services, such as

the Best Doctors virtual solution, offer physicians

and employers an effective way to contain costs

and improve outcomes for complex and critical care medical

situations. Applicable across businesses of any size, the benefits of

a second-opinion consultation service include the following:

REDUCED AVERAGE SPEND, including reduced hospital stays and

readmissions, through avoidance

of unnecessary utilization

IMPROVED QUALITY

of care outcomes through changes in diagnosis and

management

BROADER ACCESS

to medical expertise - available to

all employees, regardless of geographic

location

POSITIVE INFLUENCE on quality ratings,

and member satisfaction

DIFFERENTIATED OFFERING in today’s

competitive employer

environment


10

The Best Doctors virtual solution addresses two important drivers of diagnostic errors. First,

the fragmented nature of medical information often means that a member’s full medical history is not available to the treating physician. If a member has multiple physicians who are using different EHRs or still relying on paper records, the treating physician will mostly likely not have access to a complete medical history. For each member, Best Doctors gathers all medical records and retests pathology slides at designated centers of excellence. Best Doctors then develops a comprehensive clinical summary of the member and sends it to an expert for review.

THE TOP EXPERTS FOR A PARTICULAR MEDICAL SCENARIO MAY NOT BE

AVAILABLE AT A LOCATION REASONABLY CLOSE

TO THE MEMBER.

The best experts for a particular medical scenario may not be available at a location reasonably close to the member. This can be particularly devastating for members with acute or catastrophic care needs. Because Best Doctors engages top physicians and specialists worldwide, the member and treating physician benefit from the knowledge of medical professionals who have the specific expertise and

experience to evaluate the case and make actionable treatment recommendations. “We provide state-of-the-art recommendations to the member and the treating team based on the best medical science available today,” said Dr. Levy. “Treating physicians appreciate the thoroughness and attention to detail we provide in the evaluation of their patient’s case.”

“Treating physicians appreciate the

thoroughness and attention to detail we

provide in the evaluation of their patient’s case.”

Dr. Lewis Levy, Senior Vice President of

Medical Affairs and Chief Quality Officer,

Best Doctors


Best Doctors’ Independent, Virtual Second-Opinion Service – How It Works Typically, members initiate a case with a simple phone call or website visit, or they may be referred by other vendors, with whom Best Doctors integrates. As a first step, a Best Doctors clinician engages the member to obtain a thorough clinical history. Next, Best Doctors gathers all relevant medical documentation—including hospital charts, medical records and notes from physician office visits, as well as imaging, lab and pathology results. Pathology is retested to confirm results.

This information is compiled into an all-inclusive, academically rigorous clinical summary. The physician who develops this clinical summary also assesses the case and develops 15 to 20 specific questions for the expert who will ultimately conduct the second-opinion review. The clinical summary gives the independent expert all of the relevant cinical information for the comprehensive review.

The Best Doctors process is modified for urgent, acute and catastrophic cases. When these cases are referred to Best Doctors, a clinician is immediately sent to the hospital to

STARTAccess world-class medical experts

Conduct expert review and develop reportFor Critical Care, delivered within 72 hoursReview and QA

expert response

Deliver results and recommendations to

member, family, and local treating team

Member initiates contact with

Best Doctors, or is referred by

employer

Collect all medical recordsFor Critical Care,

collected within 24-48 hours of initial contact

Analyze clinical information

Create comprehensive clinical summary

BEST DOCTORS PROCESS

The virtual second-opinion service is a proven approach with actionable treatment

recommendations.


facilitate complete understanding of the urgent case. The appropriate critical care experts are quickly activated to provide ongoing real-time clinical guidance in partnership with the local treating team. Often, these experts are providing valuable insights within 24 to 48 hours of hospitalization.

BEST DOCTORS MAINTAINS A DATABASE OF 53,000 EXPERTS,

SELECTED THROUGH A PEER-NOMINATION PROCESS.

Best Doctors maintains a database of 53,000 experts, selected through a peer-nomination process utilizing a Gallup-endorsed methodology. These experts represent roughly the top five percent of the medical profession. Best Doctors selects the most appropriate specialist to review each case based on the area(s) of expertise required. Once the specialist has completed their review, the report is sent back to Best Doctors for internal review and quality control. In the last step of the process, Best Doctors communicates the independent second opinion results to the member and all treating physicians involved with the member’s care.

Summary

Once considered a topic too unwieldy to define and study, diagnostic error is now taking center stage in discus-sions of member safety. Employers now have an opportunity to help end medical uncertainty and give their employee populations the peace of mind that comes with obtaining the right diagnosis and treatment.

Best Doctors offers a best-in-class solution for providing an independent, virtual second-opinion service. Their ability to solve for the fragmentation in health care by providing the treat-ing physician with a comprehensive and holistic review of the member’s case history can completely alter the course of treatment. The true value of Best Doctors, however, comes from their understanding of the top expert community; these specialists provide cutting-edge knowledge in support of and in collaboration with the local treating team.

It is a win for members who now know that their diagnosis and treatment plan is the right one. It is a win for treating physicians who appreciate having access to the expertise of the leaders in specific disciplines. And it is a win for employers who are addressing the multiple objectives of improved quality of care and enhanced employee satisfaction.

Clinical History52-year-old female was diagnosed with metastatic cervical cancer

Biopsy of the mass demonstrated cancer, and imaging showed multiple masses in the pelvis and abdomen, including in the colon and liver

Member was treated with radiation to her pelvis and chemotherapy for cervical cancer

Follow-up imaging did not demonstrate a good response to chemotherapy, and the member engaged Best Doctors for recommendations about her diagnosis and optimal treatment regimen

Clinical Impact• Expert performed specialized testing (immunohistochemistry)

on the biopsy specimen that had not been done at the treatinginstitution; this testing definitively diagnosed colon cancer, notcervical cancer

• Second expert confirmed the diagnosis of colon cancerthat had spread to the cervix and changed the treatmentto optimally treat the member’s colon cancer

Outcome• Member quickly sought care with a colon cancer specialist

and started treatment with the expert-recommendedchemotherapy regimen

• Treatment is going well and has been effective

Financial Impact• $42,000 cost savings

• Cost avoidance by averting cancer progression andcomplications by providing the appropriate cancer therapy

BEST DOCTORS MEMBER STORY:

Correct Cancer Diagnosis Leads to Optimal Treatment

MEMBER TESTIMONIAL“I am tremendously appreciative that Best Doctors spent so much time on my case.”

Best Doctors Experts

Marisa Nucci, MD - Associate Professor of Pathology, Harvard Medical School

Dennis Ahnen, MD - Medical Oncologist and Professor of Medicine, University of Colorado Denver School of Medicine

Clinical HistoryPreviously healthy 50-year old male was found to have worsening kidney function

Kidney biopsy led to a diagnosis of AL amyloidosis, a rare disease that occurs when a substance called amyloid builds up in the organs

Initial pathology review suggested that the source of amyloid was buildup of antibodies (called AL amyloidosis) produced by abnormal white blood cells

Bone marrow transplant was recommended by the treating team to eradicate the abnormal white blood cells and halt production of AL amyloid

MEMBER TESTIMONIAL“I’m so thankful for Best Doctors, and the service made a difference in my life.”

Clinical Impact• Biopsy specimen was sent and expert noted a very unusual

distribution of amyloid in the kidney and challenged the diagnosisof AL amyloidosis; he recommended mass spectrometry touncover the true identity of the abnormal protein

• Mass spectrometry was used to precisely identify the culpritprotein as apolipoprotein A-IV, which has never before beendescribed as causing amyloidosis in the kidney

• Best Doctors expert pathologists changed the diagnosis to adifferent type of amyloidosis, one that is caused by a geneticdefect and not by abnormal white blood cells

• The expert changed treatment, advising against a bonemarrow transplant, since it would not have any effect on themember’s amyloidosis

• Since the slow buildup of amyloid from the apolipoproteinA-IV defect had likely been going on for many years and wasprogressing only very slowly, the member could be observedsafely without any risky or costly interventions

Outcome• Plans for stem cell (bone marrow) transplant were cancelled

• The member and treating physicians are extremely gratefulthat this high-risk and ineffective treatment was avoided

Financial Impact• $250,000 cost savings

• Cost avoidance by preventing bone marrow transplant andfollow-up treatments

BEST DOCTORS MEMBER STORY:

Expert Pathology Review Results in Correct Diagnosis and Treatment

Best Doctors Experts

Helmut G. Rennke, MD - Director, Renal Pathology, Brigham and Women’s Hospital; Professor, Harvard Medical School

Sanjeev Sethi, MD, PhD - Anatomic Pathology, Mayo Clinic College of Medicine

Bijay P. Nair, MD, MPH - Assistant Professor of Medicine, Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences; Central Arkansas Radiation Therapy Institute (CARTI), Internal Medicine, Hematology, and Medical Oncology

REFERENCES1. Leape LL. Counting deaths due to medical errors. JAMA. 2002;288:2404–05.

2. Institute of Medicine of the National Academies. Best Care at Lower Cost: The Pathto Continuously Learning Health Care in America. Washington, DC: The NationalAcademies Press; September 6, 2012.

3. Singh H, Meyer AND, Thomas, EJ. The frequency of diagnostic errors in outpatientcare: estimations from three large observational studies involving US adultpopulations. BMJ Qual Saf. 2014; 0:1-5.

4. Siegal D. Analysis of Diagnosis-Related Medical Malpractice Claims. CRICO. CBSLearning Collaborative presentation. 2014.

5. Elstein A. Clinical reasoning in medicine. In: Higgs J, ed. Clinical reasoning in thehealth professions. Oxford, England: Butterworth-Heinemann Ltd. 1995;49–59.

6. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine—analysis of 583physician-reported errors. Arch Int Med. 2009;169:1881–87.

7. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses inthe ambulatory setting: a study of closed malpractice claims. Ann Intern Med.2006;145:488–96.

8. Peabody JW, Luck J, Jain S, et al. Assessing the accuracy of administrative data inhealth information systems. MedCare. 2004;42:1066–72.

9. Beam CA, Layde PM, Sullivan DC. Variability in the interpretation of screeningmammograms by US radiologists. Findings from a national sample. Arch Intern Med.1996;156:209–13.

10. Shojania K, Burton E, McDonald K, et al. The autopsy as an outcome andperformance measure; Evidence report/Technology assessment #58 (Preparedby the University of California at San Francisco-Stanford Evidence-based PracticeCenter under Contract No. 290–97–0013). AHRQ Publication No03-E002. Rockville,MD: Agency for Healthcare Research and Quality, 2002.

11. Sonderegger-Iseli K, Burger S, Muntwyler J, et al. Diagnostic errors in three medicaleras: a necropsy study. Lancet. 2000;355:2027–31.

12. The Kaiser Family Foundation, Agency for Healthcare Research and Quality,Harvard School of Public Health. National Survey on Consumers’ Experiences WithPatient Safety and Quality Information. October 2004. http://kff.org/health-costs/poll-finding/national-survey-on-consumers-experiences-with-patient/. AccessedAugust 1, 2014.

R

Mark L. Graber, MD, FACPSenior Fellow, RTI InternationalProfessor Emeritus, SUNY Stony Brook School of MedicineFounder and President, Society to Improve Diagnosis in Medicine

Dr. Mark Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at the State University of New York at Stony Brook. Dr. Graber is a national leader in the field of patient safety and in 2002 originated Patient Safety Awareness Week, an event now recognized internationally. He is also a pioneer in efforts to address diagnostic errors in medicine. In 2011 he founded the Society to Improve Diagnosis in Medicine), and this year Dr. Graber launched a new journal, Diagnosis, devoted to improving the quality and safety of diagnosis and reducing diagnostic error.

Dr. Graber graduated from Stanford University School of Medicine and completed residency training at Mount Zion Hospital in San Francisco as well as a fellowship in nephrology at Boston University School of Medicine.

Lew Levy, MD, FACP Senior Vice President of Medical Affairs and Chief Quality Officer, Best DoctorsInternist, Harvard Vanguard Medical Associates Instructor, Harvard Medical School

Dr. Lew Levy is the Senior Vice President of Medical Affairs and Chief Quality Officer at Best Doctors. He provides medical leadership to the clinical operations team to deliver the highest quality clinical information on diagnosis and treatment to members and their treating physicians. He has over 25 years of clinical experience as an internist at Harvard Vanguard Medical Associates in Boston. Dr. Levy also has an extensive teaching career as a preceptor in the Internal Medicine Residency Program at Brigham and Women’s Hospital and is an instructor at Harvard Medical School. He continues to practice primary care internal medicine and has participated in pioneer ACO, HMO and FFS arrangements.

Dr. Levy earned his medical degree from the University of Rochester School of Medicine and Dentistry and completed his residency in internal medicine at the Graduate Hospital of the University of Pennsylvania.

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