What doctors miss: The ailments that go undiagnosed

EHRs, care continuity can help reduce missed diagnoses, researcher says

A new study in JAMA Internal Medicine identifies diagnoses that are most often missed in the primary care setting and the key factors contributing to those misdiagnoses.  

According to Johns Hopkins School of Medicine’s David Newman-Toker, who wrote a commentary on the study, doctors misdiagnose more than 150,000 patients each year in the primary care setting.

For the study, Texas-based researchers used electronic health records (EHRs) to track 190 diagnostic mistakes—including 68 missed diagnoses—that primary care physicians (PCP) made at one of two health centers. In each case, the patient was admitted to the hospital, went to the ED, or returned to the PCP for additional treatment within two weeks.

The researchers found that PCPs missed a wide array of common diagnoses, including:

  • Pneumonia (which accounted for 6.7% of all misdiagnoses);
  • Congestive heart failure (5.7%);
  • Kidney failure (5.3%);
  • Cancer (5.3%); and
  • Urinary tract or kidney infection (4.8%).

Among the 190 patients who endured a diagnosis error, 36 could have suffered serious complications from the missed diagnoses and 27 could have died, according to the study. Moreover, the researchers note that most of the mistakes, however, could have resulted in moderate-to-severe harm.  

Communication breakdowns between providers and patients—which can lead to incomprehensive physical exams and patients histories—contributed to 80% of all errors, the study found. Other contributed factors to missed diagnoses were related to:

  • Patient referrals (which contributed to 19.5% of misdiagnoses);
  • Patient-related factors (16.3%);
  • Follow-up and tracking of diagnostic data (14.7%); and
  • Performance and interpretation of diagnostic tests (13.7%). 

"There's a great heterogeneity of conditions [that are missed]," says study author Hardeep Singh, chief of the Health Policy, Quality and Informatics Program at the Houston VA Health Services Research and Development Center of Excellence. For example, "If somebody would come in with mild shortness of breath and a little bit of cough, people would think you might have bronchitis, you might have phlegm... and lo and behold they would come back two days later with heart failure," he told Reuters Health.

Singh says that supporting physicians with staff and comprehensive EHRs can help cut down on such errors. In addition, patients can help by coming prepared to their physician consultations with details of their symptoms, family histories, and questions.

Seeking care from the same provider is also important, Singh adds. "Continuity of care is a strong ally. [Physicians] can get to know the patients and know the symptoms," he says (Gardner, HealthDay, 2/25; Pittman, Reuters, 2/26; Singh et al., JAMA Internal Medicine, 2/25).

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