Diseases that are high priority for diagnostic improvement include relatively rare conditions that have high misdiagnosis rates such as spinal abscess.
New research estimates diagnostic error and misdiagnosis-related harm rates for 15 of the top diseases in the United States.
In a landmark 2015 report, "Improving Diagnosis in Healthcare," the National Academy of Medicine found that most Americans are likely to experience at least one diagnostic error, with some errors having "devastating consequences." The co-authors of the new research focus on the "Big Three" U.S. diseases: vascular events, infection, and cancer. They previously identified that the five most frequent diseases in each "Big Three" category account for nearly half of all serious harms from diagnostic errors.
"Diagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates," the researchers wrote in their new study. The research features data from more than 91,000 patients published in 28 studies.
The Top 5 vascular events are stroke, myocardial infarction, venous thromboembolism, aortic aneurysm and dissection, and arterial thromboembolism. The Top 5 infections are sepsis, meningitis and encephalitis, spinal abscess, pneumonia, and endocarditis. The Top 5 cancers are lung cancer, breast cancer, colorectal cancer, prostate cancer, and melanoma.
The new research, which was published this month in the journal Diagnosis, generated several key data points:
- False negative diagnosis rates for the 15 diseases ranged from 2.2% for myocardial infarction to 62.1% for spinal abscess. The median false negative diagnosis rate was 13.6%.
- Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% for myocardial infarction to 35.6% for spinal abscess. The median rate was 5.5%.
- One of 85 myocardial infarction patients experience death or permanent disability as a result of misdiagnosis.
- About one of 20 patients with any Top 5 "Big Three" disease experience death or permanent disability as a result of misdiagnosis.
- About one-third of spinal abscess patients experience death or permanent disability as a result of misdiagnosis.
Diseases that have historically gotten the most attention to diagnosis such as research funding and clinical quality improvement have the lowest harm rates, the Diagnosis researchers wrote.
"Myocardial infarction is the prototype and the only acute illness approaching the target 'standard' of <1% harmed often cited in the emergency department. This is, of course, after a half century of focused efforts to automate electrocardiogram interpretation, develop and refine biomarkers (e.g. troponin), and create routine diagnostic protocols for chest pain or suspected acute coronary syndromes."
Putting misdiagnosis in perspective
There are several reasons why some diseases have relatively higher diagnostic error rates and misdiagnosis-related harm rates, the lead author of the new research told HealthLeaders.
"In some cases, it is because the disease is rarer, so providers have less training and less experience to draw from. In other cases, the disease is simply harder to diagnose because our tests for it are less sensitive, or we don't have access to the tests or consultants we need. But, at a system level, the real problem is that we haven't invested in fixing these problems in a sustained and robust way. When we have—for example heart attack—we've done pretty well," said David Newman-Toker, MD, PhD, director of the Armstrong Institute Center for Diagnostic Excellence at Johns Hopkins and board president of the Society to Improve Diagnosis in Medicine.
The new research indicates which diseases should be targeted for diagnostic improvement initiatives, he said.
"We should focus on diseases where we have (1) the most room to improve, (2) the clearest path to improvement, and (3) the most people who could be helped. That probably includes some of the rarer diseases with really high rates of error such as spinal abscess and aortic dissection, but also some of the more common, dangerous diseases with intermediate rates of error such as stroke, sepsis, and lung cancer."
Like other efforts to create behavior change that has a positive impact on patient care, Newman-Toker said diagnostic improvement initiatives need to rise to two challenges:
- Technical barriers that make diseases difficult to diagnose
- Adaptive barriers rooted in people resisting change
To overcome technical barriers blocking improved diagnosis, he said the healthcare community needs to have disease- and problem-specific multifaceted solutions based on the "4T" principles. Teamwork that improves engagement of patients, nurses, and allied health professionals. Training to improve diagnostic ingenuity. Technology such as tests and telemedicine to improve diagnosis at the point of care. Tuning that promotes feedback for performance improvement.
To overcome the adaptive barrier, Newman-Toker said there should be adoption of change management principles such as John Kotter's eight-step model: creating urgency, forming a powerful coalition, developing a vision for change, communicating the vision, removing obstacles, generating short-term wins, building on change, and anchoring change in culture.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
New research found myocardial infarction has a low false negative diagnosis rate, at 2.2%.
The research found spinal abscess has a high false negative diagnosis rate, at 62.1%.
For 15 of the most common vascular events, infections, and cancers, the research found that the median false negative diagnosis rate was 13.6%.