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application of CRICO's decision support tools, appears at the end of
this quiz.
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By Jock Hoffman, CRICO
While Obamacare is the ultimate political Frisbee, a different set
of laws—about breast cancer screening —may soon have physicians’ heads
spinning.
To date, five states1 have enacted some form of legal requirement that the significant percentage2
of women with dense breasts be apprised of the limitations of
radiographic mammography and informed of alternate or adjunct imaging
options. Now, in addition to having to help patients navigate
conflicting studies about the when of screening, providers also have to
guide patients through the how. Even in states (including Massachusetts)
where such laws are not in place, physicians should be prepared to
address this emerging aspect of breast care with an eye toward patient
safety.
Radiologists and primary care physicians (PCPs) are trying to
determine what to write and what to say to patients that is both legally
compliant and reflective of appropriate care. The biggest challenge is
the lack
of clinical evidence that screening alternatives for women with dense
breasts, i.e., whole breast ultrasound and MRI, are beneficial.
Providers have to convey to patients both sides of the potential consequences
of additional screening without increasing their own risk of being
deemed liable for a missed or delayed breast cancer diagnosis.
Given that patients—especially women who have a screening
mammogram—have increased access to their medical records and reports,
radiologists and PCPs will do well to coordinate their breast density
messaging. Wording
the information about density in the mammogram report to help the PCP
frame the patient discussion (about screening options) will reduce
tension between providers. Along with the foundation of evidence-based
care, clearly documenting what was discussed, and the patient’s
expressed plan (if any) for subsequent imaging will be a strong defense
for PCPs whose standard of care is later questioned.
While the breast density issue has received considerable attention,
malpractice cases related to breast cancer more frequently involve the
mismanagement of symptomatic patients than insufficient screening.3
Capturing and updating patient and family histories, and following
breast complaints to resolution will best position physicians to provide
optimal care that can be defended against allegations of diagnostic
missteps. To that end, CRICO’s Breast Care Management Algorithm offers PCPs a clear course of best practices that balance evidence-based care with practical risk management recommendations.
Additional Materials
References
- California, Connecticut, New York, Virginia, Texas
- The relationship of mammographic density and age: implications for breast cancer screening
- Process of Care Failures in Breast Cancer Diagnosis
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
The health care community is experiencing increasing tension between proponents
of evidence-based decision making and dissent driven by provider habits
and patient expectations. Exhibit A is any proposal to scale back
cancer screenings: even those recommendations based on a preponderance
of evidence now instantly face a barrage of counter proposals. Debates
about annual mammograms for women under 50, routine PSA testing, and Pap
tests are just the beginning. Physicians, especially in primary care,
find themselves on the horns of a dilemma: amidst the uproar generated
by political factions, medical societies, patient advocates, and
conspiracy theorists, physicians may well wonder, “Whose advice do I
follow?”
Decision Support from a Malpractice Insurer
Since 1995, CRICO has published and promoted decision support guides
for managing patients through the screening and diagnostic process,
initially for breast cancer, later for colorectal and prostate cancer.
Along with representing three of the four most commonly occurring
cancers, these (plus lung cancer) are those most commonly involved in
failure to diagnose malpractice claims.
CRICO’s primary goal is to help primary care providers assess a
patient’s risk status and need for screening, and to appropriately
manage complaints or symptoms that may indicate the presence of cancer.
In tandem with the risk assessment, the key components of CRICO’s
decision support tools are:
- age and risk stratified screening and intervals between tests;
- recommended steps in response to complaints, symptoms, or abnormal test results;
- triggers for specialty referrals; and
- tips for test results management, coordination of care, and documentation.
To validate its advice for clinical practice, CRICO relies on
accordance between clinical experts from Harvard-affiliated health care
organizations, public agencies, professional societies (and their
respective guidelines), and widely accepted research studies. CRICO’s
process is designed to anchor recommendations in evidence that
withstands time and scrutiny. Each decision support tool is reviewed
every 18–24 months and revised (if necessary) in conjunction with new
evidence and changes in health care delivery practices. In the interim
periods, our expert panels review the literature to determine if they
merit provisional communication with our insured physicians.
CRICO has found that experts from primary care and specialists who
are committed to evidence-based practice develop recommendations that
are credible and practical, especially those that frame the patient’s
decision to undergo testing and those that guide the PCP’s decision to
refer.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
A recently published study measuring the scope of care in an ambulatory practice (Harvard Vanguard Medical Associates) notes that a typical (full-time) general practitioner annually manages more than 1,100 different diagnoses, medications, lab tests, referrals, imaging studies and procedures; some do many more than that. That is both a testament to the complexity of primary care and a yardstick for the risk inherent in a profession that combines so many variables.
Malpractice claims and suits alleging a diagnostic error in a (non-ED) outpatient setting account for 67 percent of all CRICO cases based on care rendered since 2002. Roughly half of those involve cancer, but more than 50 different types; an additional 50 non-cancer diagnoses make up the other half. For 75 diagnosis-related cases involving Emergency Department patients from the same time period, more than 30 different final diagnoses were listed. Clearly, patient safety cannot focus too narrowly on particular case types but, rather, needs to address the potential pitfalls in the diagnostic process for all patients, especially outpatients.
There is, however, value in applying to a broader set of circumstances, generalizable lessons drawn from a subset of high-severity claims, particularly those alleging a failure to diagnose breast, colorectal, or prostate cancer.
Self-detected symptoms
Whether or not you can detect what the patient has indicated (e.g., breast lump, bloody stool, abdominal pain) he or she expects to be followed to conclusion. Leaving a self-detected complaint unresolved (in the patient's mind) may foster distrust. A subsequent diagnosis may be considered "missed" by a patient who believes he or she wasn't taken seriously from the beginning.
Patient risk factors
An insufficient or outdated history (personal and family) can inhibit risk-stratified screening—and timely referrals for high-risk counseling. Patients may need to be prompted and guided through the process of providing an informative history.
Test results
Following an ordered diagnostic test through to a conclusion requires both the ordering physician and other clinicians involved in the process to confirm that it was conducted, and that the results were interpreted, communicated to all pertinent parties, and discussed with the patient. Unconfirmed assumptions put both patient and providers at risk.
Follow-up
A follow-up plan has to become a follow-up action. Documentation, especially when shared with the patient and family members, helps, but only if it is structured with alerts to missed appointments or milestones.
Referrals
A referral treated as a one-way engagement exposes you and your patients to diagnostic delays if anything alters the intended course of events. Make sure to coordinate a closed-loop communication process with clinical colleagues, and clarify for the patient the roles of each of his or her providers.
Managing expectations
Any doubts you have that you will be able to translate a patient's complaint or symptoms or test results into a concrete diagnosis need to be balanced against the patient's expectations. Sharing the limits of the diagnostic process with a patient may help maintain his or her trust during a period of anxiety, and ultimately protect you against an allegation of substandard practice.
Given the vast amount of information patients expect their physicians to learn, retain, and appropriately apply, those physicians who complement their routines and memory with decision support tools are likely to make fewer missteps along the diagnostic path.
Additional Material
Original Source, Strategies for Patient Safety
By Jock Hoffman, CRICO
For virtually every physician-patient interaction, your patient’s past is prologue to today’s encounter and tomorrow’s care plan. But coordination of care—even over a brief office visit or hospital stay—is as much of a patient safety challenge as is making a proper diagnosis or carrying out a successful treatment. The path of care from the initial complaint to completion of treatment is far from seamless. Indeed, it is full of cracks—opportunities for losing, misdirecting, or misunderstanding critical information—that pose serious risks for the patient and his or her multiple health care providers.
Coordination of care risks can derive from patients you see often for chronic care and for those who you’ve never met (e.g., a patient new to your panel being seen in the ED). Most malpractice cases involving poorly coordinated care are those alleging a missed or delayed diagnosis, commonly due to a mismanaged test result, referral, or hand-off. For 522 cases filed against CRICO insureds from January 2005 to October 2010 with care coordination issues, the following three contributing factors were prominent:
- Mismanagement of test results
(234 cases*/average incurred loss=$1M)
- Mismanagement of referral
(230 cases/average incurred loss=$852K)
- Mismanagement of hand-off or sign-out
(255 cases/average incurred loss=$888K)
Those categories comprise myriad communication and documentation factors that prevent multiple caregivers from having a complete picture of the patient’s status and subsequent care needs. Relying solely on memory—yours or the patient’s—is ill-advised; systems that fail to keep everyone (including future providers) well-informed about past care and future responsibilities are equally inadequate.
At the broad level, CRICO is working with its insured organizations to enhance closed-loop communication of test results and referrals, and improve team communication at key transitions for providers (e.g., hand-offs) and patients (e.g., discharge). For individual physicians and nurses, CRICO and its clinical experts have developed answers to a series of Frequently Asked Questions that address many coordination of care issues.
A quick review might help you and your co-providers keep crucial patient information from slipping between the cracks.
*A single malpractice case may involve more than one factor
Additional Material
Original Source, Strategies for Patient Safety
