The health conditions most likely to be misdiagnosed

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TechnologyA large analysis of US claims data has identified three major disease categories – vascular events, infections and cancers – that account for nearly three-fourths of all serious harms from diagnostic errors. Failures of clinical judgement were identified as causes in more than 85% of the misdiagnosed cases.

For a patient, a diagnostic error can mean the difference between life and death. While estimates vary, likely more than 100,000 in the US die or are permanently disabled each year due to medical diagnoses that initially miss conditions or are wrong or delayed.

The researchers found that diagnostic errors were the most common, most catastrophic and most costly of medical mistakes. Diagnostic errors leading to death or serious, permanent disability were associated with misdiagnosed cancers (37.8%), vascular events (22.8%) and infections (13.5%) – categories that the team led by Dr David Newman-Toker, director of the Johns Hopkins Armstrong Institute Centre for Diagnostic Excellence, calls the “big three.”

The authors describe 15 specific “big three” conditions that together account for nearly half of all the serious, misdiagnosis-related harms. The top conditions in each category are stroke, sepsis (a blood infection) and lung cancer, respectively. These are accompanied by heart attack, venous thromboembolism (blood clots in the legs and lungs), aortic aneurysm and dissection (a rupture of the aorta), arterial thromboembolism (a blockage of the blood supply to internal organs), meningitis and encephalitis, spinal infection, pneumonia, endocarditis (a heart infection) and breast, colorectal, prostate and skin cancers.

“We know that diagnostic errors happen across all areas of medicine. There are over 10 thousand diseases, each of which can manifest with a variety of symptoms, so it can be daunting to think about how to even begin tackling diagnostic problems,” says Newman-Toker, “Our findings suggest that the most serious harms can be attributed to a surprisingly small number of conditions. It still won’t be an easy or quick fix, but that gives us both a place to start and real hope that the problem is fixable.”

For the study, the researchers analysed all 11,592 diagnostic error cases between 2006 and 2015 that were drawn from a list of open and closed US malpractice claims documented in the national Comparative Benchmarking System (CBS) database.

Frequently used as a source for patient safety research projects, CBS is owned and maintained by Controlled Risk Insurance Compan (CRICO), the medical malpractice insurance programme associated with Harvard medical institutions and their affiliates. The database includes information from 400 hospitals, including more than 30 academic and teaching hospitals covered by both member-owned and commercial insurance programs representing more than 180,000 physicians from all 50 states plus Washington DC, and Puerto Rico.

The research team, which included Dana Siegal, director of patient safety at CRICO Strategies, a division of CRICO, grouped all health conditions presented in the claims according to a standard, epidemiologic classification system created by the Agency for Healthcare Research and Quality, with the help of the agency’s Clinical Classifications Software. This allowed the authors to identify and rank top conditions.

For example, says Newman-Toker, “There are dozens of different diagnosis ‘codes’ that all represent strokes. The same is true for heart attacks and some of the other conditions as well. These differences often matter more for treatment than diagnosis. To my knowledge, grouping these codes together to identify the most common harms from diagnostic error had not been done before, but doing so gives us an ‘apples to apples’ comparison of the frequency of different diseases causing harms.”

Among diagnostic-error cases of varying severity, the median age of the patients with errant diagnoses was 49, and more than half were female. For children and young adults (0-20 years old), harms most often were from missed infections (27.6%) rather than vascular events (7.1%) or cancers (9.1%), while the reverse was true for middle aged and older adults. About half of the high-severity harm cases the researchers studied resulted in patient death, while the other half resulted in permanent disability.

Based on claims data, the analysis also found that failures of clinical judgment were identified as causes in more than 85% of the misdiagnosed cases. The researchers say this adds to growing evidence that health care systems must do more to support bedside diagnostic decision-making by clinical providers. The authors point to interventions such as deploying computer-based diagnostic decision support tools, increasing immediate access to specialists at the point of care, supporting more effective teamwork and patient engagement in diagnosis, providing routine diagnostic performance feedback for clinicians and improving diagnostic education through simulation training.

Researchers also found that most of the diagnostic errors (71.2%) associated with the malpractice claims occurred in ambulatory settings – either in emergency departments, where missed infections and vascular events such as strokes were more of a concern, or outpatient clinics, where misdiagnoses were more likely to be cancer-related. “These findings give us a road map for thinking about what kind of problems we need to solve in which clinical settings,” Newman-Toker says.

He cautions that the focus on serious harms in the analysis leaves out many chronic or long-term conditions such as migraines or multiple sclerosis that can be misdiagnosed for years or even decades, leading to substantial patient suffering even if the diseases are eventually treated. He also says there is a bias built in the types of cases brought forth by attorneys that could have affected their findings. “It’s easier to bring a cancer claim forward, for example, since there’s usually more of a paper trail,” he says.

To address this anticipated bias, Newman-Toker and the research team analysed previously published studies using non-claims data from various clinical care settings. They still found that roughly three-quarters of diagnostic error cases were associated with the “big three” disease categories – though, unlike with the malpractice claims data, vascular events and infections dominated over cancers.

“The high percentage of serious-harm cases attributable to these ‘big three’ categories of conditions is likely accurate, despite the inherent biases in malpractice data,” Newman-Toker says.

He says the findings suggest that harms from diagnostic errors could be substantially reduced over the next decade, but only if the medical community takes seriously the National Academy of Medicine‘s 2015 call to action that improving diagnosis “represents a moral, professional and public health imperative.” “Our current annual federal investment to fix diagnostic errors is less than what we spend each year researching smallpox, a disease eradicated in the US over half a century ago,” he says. “If we devoted appropriate resources to tackling misdiagnosis of the ‘big three’ diseases we identified, we could potentially save half of the people who die or are permanently disabled from diagnostic errors.”

The researchers plan to build on their findings as they continue the phases of their planned three-part study. The next phase will estimate how frequently the 15 most common conditions are misdiagnosed, and the final phase will use nationally representative data sets to derive a population-level estimate of the total number of people in the US harmed by diagnostic error each year.

Background: Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms.
Methods: We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)’s Comparative Benchmarking System (CBS) database (2006–2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the “Big Three”), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6–9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale.
Results: From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36–60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0–88.8%).
Conclusions: The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.

David E Newman-Toker, Adam C Schaffer, C Winnie Yu-Moe, Najlla Nassery, Ali S Saber Tehrani, Gwendolyn D Clemens, Zheyu Wang, Yuxin Zhu, Mehdi Fanai, Dana Siegal

Johns Hopkins Medicine material
Diagnosis abstract

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