System-related interventions to reduce diagnostic errors: a narrative review.

BACKGROUND: Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors. METHODS: The authors conducted a comprehensive search using multiple search strategies. First, they performed a PubMed search to identify articles exclusively related to diagnostic error or delay published in English between 2000 and 2009. They then sought papers from references in the initial dataset, searches of additional databases, and subject matter experts. Articles were included if they formally evaluated an intervention to prevent or reduce diagnostic error; however, papers were also included if interventions were suggested and not tested to inform the state of the science on the subject. Interventions were characterised according to the step in the diagnostic process they targeted: patient-provider encounter; performance and interpretation of diagnostic tests; follow-up and tracking of diagnostic information; subspecialty and referral-related issues; and patient-specific care-seeking and adherence processes. RESULTS: 43 articles were identified for full review, of which six reported tested interventions and 37 contained suggestions for possible interventions. Empirical studies, although somewhat positive, were non-experimental or quasi-experimental and included a small number of clinicians or healthcare sites. Outcome measures in general were underdeveloped and varied markedly among studies, depending on the setting or step in the diagnostic process. CONCLUSIONS: Despite a number of suggested interventions in the literature, few empirical studies in the past decade have tested interventions to reduce diagnostic errors. Advancing the science of diagnostic error prevention will require more robust study designs and rigorous definitions of diagnostic processes and outcomes to measure intervention effects.

Physicians' views on public reporting of hospital quality data.

This article describes physicians' responses to patient questions and physicians' views about public reports on hospital quality. Interviews with 56 office-based physicians in seven states/regions used hypothetical scenarios of patients questioning referrals based on public reports of hospital quality. Responses were analyzed using an iterative coding process to develop categories and themes from data. Four themes describe physicians' responses to patients: (a) rely on existing physician-patient relationships, (b) acknowledge and consider patient perspectives, (c) take actions to follow up on patient concerns, and (d) provide patients' perspectives on quality reports. Three themes summarize responses to hospital quality reports: perceived lack of methodological rigor, content considerations in reports, and attitudes/experience regarding reports. Findings suggest that physicians take seriously patients' questions about hospital-quality reports and consider changing referral recommendations based on their concerns and/or preferences. Results underscore the importance of efforts by report developers and physician outreach/education to address physicians' methodological concerns.

Disparities in immunizations among elderly Medicare beneficiaries, 2000 to 2002.

BACKGROUND: Research reveals that influenza and pneumococcal immunization rates among blacks, Asians, and Hispanics significantly trail those of whites. This 2003 study examines recent trends and disparities for influenza and pneumococcal immunizations among elderly, non-institutionalized Medicare beneficiaries. METHODS: National samples of approximately 179,000 Medicare fee-for-service beneficiaries were surveyed by mail and telephone each year from 2000 to 2002. Outcomes include self-reported influenza immunization in the previous year and receipt of a pneumococcal immunization ever. RESULTS: Influenza immunization dipped in 2001 (69%) and almost rebounded to its 2000 level (73%) in 2002 (72%). Very substantial racial and ethnic disparities in the receipt of this preventive service exist between non-Hispanic blacks and Hispanics relative to non-Hispanic whites. Pneumococcal immunization increased by 2% annually (61%, 63%, and 65%) for the same years. However, very substantial racial and ethnic disparities in the receipt of this preventive service also exist between non-Hispanic blacks, Asians/Pacific Islanders, and Hispanics relative to non-Hispanic whites. CONCLUSIONS: Younger, healthier, elderly persons must be encouraged to receive these immunizations to achieve the 2010 goal of 90% immunization. To reach that goal with no disparities, special efforts will be needed to target racial/ethnic minorities.