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Patient-Initiated Second Opinions: Systematic Review of Characteristics and Impact on Diagnosis, Treatment, and Satisfaction
Abstract
The impact of second opinions on diagnosis in radiology and pathology is well documented; however, the value of patient-initiated second opinions for diagnosis and treatment in general medical practice is unknown. We conducted a systematic review of patient-initiated second opinions to assess their impact on clinical outcomes and patient satisfaction and to determine characteristics and motivating factors of patients who seek a second opinion. We searched PubMed, EMBASE, Cochrane, and Academic OneFile databases using Medical Subject Headings (MeSH) indexes and keyword searches. Search terms included referral and consultation, patient-initiated, patient preference, patient participation, second opinion, second review, and diagnosis. Multiple reviewers screened abstracts and articles to determine eligibility and extract data. We assessed risk of bias using the Cochrane Risk of Bias Tool and rated study quality using Cochrane's GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We screened 1342 abstracts and reviewed full text of 41 articles, identifying 7 articles that reported clinical agreement data and 10 that discussed patient characteristics, motivation, and satisfaction. We found that a second opinion typically confirms the original diagnosis or treatment regimen but that 90% of patients with poorly defined conditions remain undiagnosed. However, 10% to 62% of second opinions yield a major change in the diagnosis, treatment, or prognosis. A larger fraction of patients receive different advice on treatment than on diagnosis. Factors motivating a second opinion include diagnosis or treatment confirmation, dissatisfaction with a consultation, desire for more information, persistent symptoms, or treatment complications. Patients generally believed that second opinions were valuable. Second opinions can result in diagnostic and treatment differences. The literature on patient-initiated second opinions is limited, and the accuracy of the second opinion through follow-up is generally unknown. Standardized methods and outcome measures are needed to determine the value of second opinions, and the potential of second opinions to reduce diagnostic errors merits more rigorous evaluation.
... Regarding patient characteristics and motivational aspects, previous studies from other countries have demonstrated that women tend to seek a second opinion more often than men, and that most patients who seek a second opinion are middleaged and have a relatively high level of education [13]. The primary motivations of patients in seeking a second opinion are their need for certainty about diagnosis or treatment options, a lack of trust in practitioners, dissatisfaction with the level of communication, or a need for more detailed information [14,15]. However, there is currently no exploration in depth of why certain patients decline a second opinion and the role of seeking a second opinion in patients' overall decision-making process to undergo elective forms of surgery has yet to be explored. ...
... Prior studies have investigated patients who sought a second opinion, supporting a number of general conclusions about why a second opinion was sought. As an example, we note dissatisfaction with the primary care provider and insufficient provision of information and education [13,15]. We have recapitulated those findings in our study. ...
... Rather, health insurance companies should be involved in this educational work, and national campaigns should be carried out. Educating patients that it is appropriate to seek a second opinion, especially when there is uncertainty in the decision-making process, can also reduce fears of consulting a second physician [15,44]. The acceptance of the directive would increase, making it more likely that patients would "dare" to seek a second opinion. ...
Background
To address the problem of overuse of elective surgery and to support patients in their decision-making process, a Second Opinion Directive was introduced in Germany, which enables patients with statutory health insurance to obtain a second opinion for certain surgical indications. The study aims to identify, based on the experiences of patients who have undergone elective surgery, the role of seeking a second opinion in reaching their decision.
Methods
Sixty-two patients who had undergone an elective surgery (hysterectomy, tonsillectomy, shoulder arthroscopy) were recruited using purposive sampling and interviewed during October to December 2020. The transcribed interviews were analysed using a framework analysis to create a typology from the patient’s perspective.
Results
The time spent by patients in making the decision to undergo surgery varies between individuals, and is influenced by factors such as the type of physician-patient relationship, individual patient aspects, prior experiences in the health care system, as well as information needs. Within the framework of the analysis, we were able to identify three patterns of patient types based on the three different time-points or phases when decisions were typically made, with one type being divided into two subtypes: Type 1a: Quick decision making, Type 1b: Overwhelmed quick decision making, Type 2: Time to consider, Type 3: Struggling with the decision.
Conclusions
Patients who followed a recommendation for elective surgery appreciate having the possibility to seek a second opinion. However, various factors influenced their opting for a second opinion during the decision-making process. Patients have differing information needs, such that a one-size-fits-all second opinion service may not fit adequately for all patients.
... The overall prevalence rate of doctor shopping is 18% in Canada (Macpherson et al., 2001) and 23% in Japan (Sato et al., 1995). According to Payne et al. (2014); Sansone and Sansone (2012), the reasons why patients conduct doctor shopping include confirmation of a diagnosis/treatment, dissatisfaction with an initial consultation, unfulfilled needs, a desire for additional information, hopes for a change of a diagnosis, high risks for major morbidity or mortality, and treatment complications and adverse effects. ...
... These results are consistent with those in the medical-related literature concerning whether or not doctor shopping is valuable to diagnosis tests. As noted in the review work by Payne et al. (2014), patients usually believe that second opinions from doctor shopping are valuable, whereas there is no any conclusive evidence of whether doctor shopping improves the quality of patient care. The value of doctor shopping is context-dependent. ...
... If doctor shopping stems from mere anxiety (which corresponds to the subjective welfare considered in our study), it may lead to patient confusion, resource waste, and a higher risk of in-hospital complications, especially when there is no informed reconciliation of conflicting opinions (Chang et al., 2013;Shmueli et al., 2017). However, doctor shopping is usually believed to improve the quality of care (which corresponds to the objective welfare considered in our study) in radiology and pathology (Payne et al., 2014), because there exist substantial discrepancies in the interpretation of imaging and histopathological diagnosis (i.e., a low diagnosis accuracy). ...
When a patient’s illness perception is inconsistent with a doctor’s diagnosis, she may seek opinions from multiple doctors without referrals, a behavior called doctor shopping. In this study, we model and derive patients’ optimal doctor shopping decisions. After each visit, patients update their beliefs about their health status following the Bayes’ rule. We show that the patients’ doctor‐shopping decisions are critically affected by the diagnosis accuracy, the relative value of identifying a severely ill patient, and the cost per visit. We examine how the patients’ doctor shopping behavior affects social welfare from two aspects, namely, an objective one that accesses whether doctor shopping improves the judgment accuracy regarding the patient’s health status, and a subjective one concerning whether doctor shopping relieves patients’ anxiety. We find that allowing patients to conduct doctor shopping exacerbates the system congestion (congestion effect), but it can help those patients who have decided to join obtain a higher reward (reward effect). There exists a diagnosis accuracy threshold above which allowing doctor shopping incurs a welfare loss and below which allowing doctor shopping improves welfare. Moreover, this diagnosis accuracy threshold increases as patients become more pessimistic or hold more diverse initial illness perceptions. The objective welfare maximization prefers a higher doctor shopping rate than the subjective welfare maximization does only when the value of identifying a severely ill patient is high enough, which may help explain why doctor shopping is encouraged for the critical illness such as cancer.
... A previous systematic review aimed to determine the clinical outcomes of patient-initiated SOs in general medical and surgical care, their satisfaction, characteristics and motivating factors for seeking SO. 18 The review reported that a surprising paucity of studies have examined the impact of patient-initiated SOs. Patients seeking a SO were mostly women with an average age of 54 years and a diagnosis of breast cancer. ...
... Overall, most patients perceived SOs to be valuable, either because of reassurance or the identification of an alternative. 18 Two other systematic reviews focus on SOs in oncology. 12 19 As new evidence has been accumulated since the last review, conducted in 2013, 18 we carried out an updated review. ...
... 18 Two other systematic reviews focus on SOs in oncology. 12 19 As new evidence has been accumulated since the last review, conducted in 2013, 18 we carried out an updated review. We aimed to summarise evidence on (1) the characteristics and motivating factors of patients who initiate SOs; (2) the impact of patient-initiated SOs on diagnosis, treatment, prognosis and patient satisfaction; and (3) their cost effectiveness. ...
Objectives
To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness.
Data sources
Embase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases.
Study design
A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.
Data collection/extraction methods
We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions.
Principal findings
Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.
Conclusions
This review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.
... An expert second medical opinion (SMO) enables a patient to confirm or re-evaluate a diagnosis and/or a treatment recommended by a general practitioner (GP) or specialist. The practice of seeking an SMO has been described in literature for a range of disease types [1][2][3][4][5][6][7][8][9][10][11][12], with different approaches according to the source of the referral given (patient or doctor), level of specialization of the physician performing the SMO (general practitioner or another specialist) and the modality of the second analysis (consultation or history and chart review) [3,9]. In the United States, SMOs were first known as a way to control rising healthcare costs, for example by preventing unnecessary elective surgery and for this purpose SMOs were mandatory for Medicaid recipients in the 1980 s but later appeared as a way to improve healthcare quality [13]. ...
... SMO can result in a change of diagnosis, treatment or prognosis in 10-62 % of cases [6]. This wide variation may be due to healthcare provider divergence, variations in the quality of the methodology used in the studies, or having small sample sizes. ...
... In the literature, the main reasons proposed for seeking a SMO were persisting symptoms, absence of diagnosis or the need for confirmation of a diagnosis, the need for more information, questioning the need for surgery [1] (such as total mastectomy), and a desire to change the proposed treatment [6,7]. In some cases, these reasons are largely independent of the quality of patient-physician relationship, although this could be less frequent in patients with a low education level [21]. ...
Objectives
The aim of this study was to describe the profile of patients who sought a second medical opinion (SMO) on their therapeutic or diagnostic strategy using nationwide data from a French physician network dedicated to SMOs.
Methods
An observational cohort study was conducted and the study population consisted of patients residing in France or in the French overseas territories who submitted a request for an SMO through a dedicated platform between January 2016 and October 2020. Patient characteristics were compared between convergent and divergent SMOs. The divergent rate for all patients excluding those with mental diseases were described. Logistic regression was used to estimate the probability of a divergent SMO according to patient characteristics.
Results and discussion
In total, 1,552 adult patients over several French regions were included. The divergence rate was 32.3 % ( n = 502 patients). Gynecological [Odds Ratio (OR) and 95 % CI: 5.176 (3.154 to 8.494)], urological [OR 4.246 (2.053 to 8.782)] and respiratory diseases [OR 3.639 (1.357 to 9.758)] had the highest probability of a divergent SMO. Complex cases were also associated with a significantly higher risk of a divergent opinion [OR 2.78 (2.16 to 3.59)]. Age, sex, region and profession were not found to be predictive of a divergent second opinion.
Conclusions
Policymakers should encourage new research on patient outcomes such as mortality and hospitalization rates after a SMO. When proven effective, SMO networks will have the potential to benefit from specific public funding or even play a key role in national healthcare quality improvement programs.
... Systematic reviews of the literature have indicated that the quest for a second opinion in different patient populations varied widely between 7 and 36% [20] and between 1 and 88% [22]. Patients sought a second opinion in order to confirm a diagnosis or treatment, or obtain information about persistent symptoms or treatment complications [22][23][24]. Systematic reviews have also indicated that the second opinion confirmed the original diagnosis or treatment in 43-82% of cases [20], and yielded a change in the diagnosis, treatment, or prognosis in 12-69% [20], 10-62% [23] and 2-51% [22]. Of particular interest were the outcomes of a program (Best Doctors, Inc.) that allows employee-beneficiaries to request free second opinion and to have trained physicians summarize the cases, identify unresolved clinical questions, and forward the cases to specialists for independent assessments and recommendations. ...
... Patients sought a second opinion in order to confirm a diagnosis or treatment, or obtain information about persistent symptoms or treatment complications [22][23][24]. Systematic reviews have also indicated that the second opinion confirmed the original diagnosis or treatment in 43-82% of cases [20], and yielded a change in the diagnosis, treatment, or prognosis in 12-69% [20], 10-62% [23] and 2-51% [22]. Of particular interest were the outcomes of a program (Best Doctors, Inc.) that allows employee-beneficiaries to request free second opinion and to have trained physicians summarize the cases, identify unresolved clinical questions, and forward the cases to specialists for independent assessments and recommendations. ...
... In summary, the main finding of these surveys was that a second opinion disagreed with the first one in a substantial proportion of patients [20][21][22][23]. The main limitation of these surveys is the absence of a gold standard that would identify "correct" opinions. ...
Observational studies have detected discrepancies between two expert interpreters of imaging and histopathological studies. Furthermore, in a substantial proportion of patients, an independent second opinion disagreed with the first one. Therefore, it is widely accepted that patients have a right to obtain a second opinion and, in case of divergent opinions, to deliberate and choose the option that they believe is most consistent with their individual circumstances. However, doctors are less likely to inform old and poorly educated patients about the possibility of seeking a second opinion, and this may contribute to healthcare inequalities. Hence the importance of (a) promoting doctors’ self-awareness of a possible tendency to discriminate against old and poorly educated patients, and (b) creating programs within the healthcare system that would help patients in seeking a second opinion, suggest specialists for the specific problem of the patient, and provide tools to reconcile between discrepant opinions.
... 12 A previous systematic review of the literature examining the factors motivating patient-initiated second-opinion consults revealed common rationale to be diagnosis or treatment con rmation, dissatisfaction with previous consultation, and desire for more information. 13 While patients are noted to see value in the secondopinion, a major change in treatment plan, diagnosis, or prognosis was observed in between 10%-62% of these visits. 13 Recent guidelines from Otolaryngology suggest referral to a specialist only under unique circumstances, as in the case of allergic rhinitis, where referrals are restricted to patients who require immunotherapy, or have inadequate response to initial therapies. ...
... 13 While patients are noted to see value in the secondopinion, a major change in treatment plan, diagnosis, or prognosis was observed in between 10%-62% of these visits. 13 Recent guidelines from Otolaryngology suggest referral to a specialist only under unique circumstances, as in the case of allergic rhinitis, where referrals are restricted to patients who require immunotherapy, or have inadequate response to initial therapies. 14 No studies have examined the impact of multiple-opinion referrals in allergy. ...
Background: Allergic disease is on the rise. Waitlists for specialists are long, and many referrals have already received prior allergic assessment. It is important to understand the prevalence and motivating factors for second opinion referrals, to deliver timely assessment for patients with allergic disease.
Methods:A retrospective chart review of demographic information, referral patterns, and motivation for new consults of pediatric patients aged 8 months – 17 years to BC Children’s Hospital Allergy Clinic from September 1, 2016 – August 31, 2017, was performed. Data were accessed through local Electronic Medical Records and subsequently analyzed for frequency and motivation for referrals to our clinic.
Results: Of 1029 new referrals received, 210 (20.4%) were multiple-opinion referrals. Food allergy was the predominant allergic concern prompting another opinion (75.7%). The main rationale for seeking further opinions was looking to speak with a certified Allergist, or dissatisfaction with previous opinions.
Conclusions: Many new consults at the BCCH Allergy Clinic are multiple-opinion assessments, contributing to long waitlists and poor patient satisfaction. Advocacy at the systems level is needed to provide better access in Canada for children needing a specialized Allergist.
Trial Registration - UBC/BCCH Research Ethics Board (H18-02528)
... This is in line with the literature on second opinions in other areas of healthcare. In a systematic review of patient-initiated second opinions for a range of health conditions, second opinions led to change in diagnosis, treatment, or prognosis in 10-62% of cases [1]. In a review of second opinion services for patients with cancer, substantial variability was found in the proportion of cases where changes in diagnosis, treatment recommendations or prognosis occurred: 12-69% [34]. ...
... The authors declare that they have no competing interests. 1 Institute for Musculoskeletal Health, The University of Sydney and Sydney ...
Background
Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.
Methods
We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.
Results
We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).
Conclusions
Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.
... In addition, they reduce the number of surgeries [3][4][5][6][7]. It has been found that they can lead to changes in diagnosis or treatment, even though there is some variation with regard to the rate of disagreements between first opinions and SOs [8,9]. SO programs were originally introduced in the USA in the 1970s [4]. ...
... Systematic review data show that internationally, SOs are often obtained for indications not currently covered by the German SO Directive. Many SOs are provided for oncological indications and elective surgery, but also for general medical concerns [8,9]. Overall, indications rated as important by patients have not been included in the SO Directive to date, while some indications included in the SO Directive are less important from the patient perspective. ...
Background
Second medical opinions (SOs) can assist patients in making informed treatment decisions and improve the understanding of their diagnosis. In Germany, there are different approaches to obtain a structured SO procedure: SO programs by health insurers and SOs according to the SO Directive. Through a direct survey of the population, we aimed to assess how structured SOs should be provided to fulfil patients’ needs.
Methods
A stratified sample of 9990 adults (≥18 years) living in the federal states of Berlin and Brandenburg (Germany) were initially contacted by post in April and sent a reminder in May 2020. The survey results were analyzed descriptively.
Results
Among 1349 participants (response rate 14%), 56% were female and the median age was 58 years (interquartile range (IQR) 44–69). Participants wanted to be informed directly and personally about the possibility of obtaining an SO (89%; 1201/1349). They preferred to be informed by their physician (93%; 1249/1349). A majority of participants would consider it important to obtain an SO for oncological indications (78%; 1049/1349). Only a subset of the participants would seek an SO via their health insurer or via an online portal (43%; 577/1349 and 16%; 221/1349). A personally delivered SO was the preferred route of SO delivery, as 97% (1305/1349) would (tend to) consider this way of obtaining an SO. Participants were asked to imagine having moderate knee pain for years, resulting in a treatment recommendation for knee joint replacement. They were requested to rate potential qualification criteria for a physician providing the SO. The criteria rated to be most important were experience with the recommended diagnosis/treatment (criterion (very) important for 93%; 1257/1349) and knowledge of the current state of research (criterion (very) important for 86%; 1158/1349). Participants were willing to travel 60 min (median; IQR 60–120) and wait 4 weeks (median; IQR 2–4) for their SO in the hypothetical case of knee pain.
Conclusion
In general, SOs were viewed positively. We found that participants have clear preferences regarding SOs. We propose that these preferences should be taken into account in the future design and development of SO programs.
... V.L. Payne и соавт. [6] представили метаанализ 23 работ, в которых изучалось мнение пациентов об эффективности терапии скелетно-мышечной боли. В среднем лишь в 21% случаев отмечалась полная удовлетворенность назначенным лечением. ...
... Как установлено в метаанализе V.L. Payne и соавт. [6], лишь 21% пациентов с хронической болью остались довольны результатом лечения. При опросе 2508 жителей Германии, проведенном в 2013 г. ...
Patient's satisfaction with treatment is a fundamental indicator of the quality of medical care, which is especially important for assessing the effectiveness of therapy for musculoskeletal pain in rheumatic diseases (RD).Objective: to determine satisfaction of patients with RD with pain relief therapy and to analyze the factors influencing the subjective assessment of analgesic therapy.Patients and methods. Anonymous survey of 1040 patients (age 55.8±14.0 years, 76.8% were women) with RD, rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthritis, systemic connective tissue diseases and gout, was carried out. The presence of pain and its therapy, satisfaction with treatment, and patient's opinion about the reasons of low pain relief effectiveness were assessed. The dependence of the presence of dissatisfaction with treatment on a number of demographic and clinical factors was analyzed.Results and discussion. 71.5% of patients experienced pain in one or more joint areas and/or in the back. 70.6% of patients used non-steroidal antiinflammatory drugs (NSAIDs), 1.6% – paracetamol, 40.0% – non-drug modalities and methods of alternative medicine. 15.6% of the respondents were completely satisfied with the treatment, 64.0% were partially satisfied, and 20.4% were completely dissatisfied. The main subjective reasons for the insufficient effectiveness of analgesic therapy were: fear of taking prescribed medications due to possible complications (45.4%), low effectiveness of drugs (15.7%), insufficient attention of doctors (20.3%). Male gender, body mass index >30 kg/m2 , severe pain, pain in several areas, and the diagnosis of OA were statistically significantly associated with treatment dissatisfaction. In contrast, patients with RA showed greater satisfaction with treatment.Conclusion. Most patients with RD are dissatisfied with the results of pain therapy. Educational work with patients and a personalized approach to prescribing analgesic therapy is needed.
... In surgical specialties, a Second Opinion (SO) is often sought when surgery is offered as a treatment option [1][2][3], when treatment complications have occurred [3,4], or when low levels of communication with the primary consultant regarding treatment options were reported [5,6]. Patients often seek self-initiated SOs from orthopedic surgeons [1,4,5]. ...
... In surgical specialties, a Second Opinion (SO) is often sought when surgery is offered as a treatment option [1][2][3], when treatment complications have occurred [3,4], or when low levels of communication with the primary consultant regarding treatment options were reported [5,6]. Patients often seek self-initiated SOs from orthopedic surgeons [1,4,5]. This need for a SO for treatment options concerning orthopedic conditions is well justified since spine surgery for degenerative diseases can be considered a type of elective surgery [7]. ...
Background
Factors that influence a patient’s decision for spinal surgery and selection of the spine surgeon have not been studied in the context of a Second Opinion (SO). Providing insight into these factors will guide surgeons in their discussion of treatment options with patients.
Objective
This study aims to assess the impact of a discordant SO on the final decision of patients as compared to their initial preference regarding spinal disc disease treatment for chronic neck and low back pain.
Patient Involvement
Patients in this study engage in clinical vignettes designed to induce decisional conflict.
Methods
A cross-sectional study using clinical vignette-based questionnaires was presented to patients at the Family Medicine, Orthopedic, and Neurosurgery clinics at a university-based tertiary academic medical center.
Results
A total of 246 patients participated in the study (response rate, 66.8%). Irrespective of the initial offered treatment, most patients wanted to consult a SO (64.2%). Most patients preferred conservative treatment to surgery after getting the initial recommendation (78.5%) and after getting a discordant SO (56.5%). There was an association between the agreement of the patient with the initial recommendation and the effect of the SO on the final decision of patients (p < 0.001). Patients who disagreed with the initially offered treatment were more likely to abide by their initial decision after the SO (80.8%) as compared to those who were in agreement (17.7%), while those who agreed with the initially offered treatment were more likely to change their decision (39.5%) or to take a third opinion (42.9%).
Discussion
A discordant SO may validate patients’ wishes when they disagree with the initially offered treatment and may lead to confusion when they agree with the initial physicians’ recommendations.
Practical Value
As patients tend to abide by their initial preference, physicians should explicitly consider patients’ wishes when discussing options for management of spinal disc disease.
... 1,2 This belief is supported by studies documenting frequent diagnostic or treatment changes from second opinions. [3][4][5][6] The purported value is such that many medical centers advertise their second opinion services in oncology, and online digital health companies facilitate such consultations. 3 Yet data on the clinical value of second-opinions are limited. ...
Background:
Data on the clinical value of second opinions in oncology are limited. We examined diagnostic and treatment changes resulting from second opinions and the expected impact on morbidity and prognosis.
Methods:
This retrospective cohort study included patients presenting in 2018 to a high-volume cancer center for second opinions about newly diagnosed colorectal, head and neck, lung, and myeloma cancers or abnormal results. Two sub-specialty physicians from each cancer type reviewed 30 medical records (120 total) using a process and detailed data collection guide meant to mitigate institutional bias. The primary outcome measure was the rate of treatment changes that were "clinically meaningful", i.e., expected to impact morbidity and/or prognosis. Among those with treatment changes, another outcome measure was the rate of clinically meaningful diagnostic changes that led to treatment change.
Results:
Of 120 cases, forty-two had clinically meaningful changes in treatment with positive expected outcomes (7 colorectal, 17 head and neck, 11 lung, 7 myeloma; 23-57%). Two patients had negative expected outcomes from having sought a second opinion, with worse short-term morbidity and unchanged long-term morbidity and prognosis. All those with positive expected outcomes had improved expected morbidity (short- and/or long-term); 11 (0-23%) also had improved expected prognosis. Nine involved a shift from treatment to observation; 21 involved eliminating or reducing the extent of surgery, compared to 6 adding surgery or increasing its extent. Of the 42 with treatment changes, 13 were due to clinically meaningful diagnostic changes (1 colorectal, 5 head and neck, 3 lung, 4 myeloma; 3%-17%) .
Conclusions:
Second-opinion consultations sometimes add clinical value by improving expected prognoses; more often, they offer treatment de-escalations, with corresponding reductions in expected short- and/or long-term morbidity. Future research could identify subgroups of patients most likely to benefit from second opinions.
... A physician's training and experience is very idiosyncratic, and it is no wonder that two clinicians hearing the same story might arrive at very different diagnostic conclusions. Second and third opinions [10], and diagnosis via groups of clinicians [11] would seem to be appropriate answers to this problem, and hopefully will become more prevalent in clinical practice going forward. ...
... Nell was careful not to completely dismiss our conclusions and recommendations, but she quickly pushed for a consultation with a spiritual medium to validate her stance on the anomalous experiences. This shift appeared to us as a form of "doctor shopping (or hopping), " which involves patients who seek multiple clinicians or second opinions (Sansone and Sansone, 2012;Velma et al., 2014;Lane, 2020) often as a way "to interpret, regulate, and mediate various forms of self-understanding and activity" (Brinkmann, 2017, p. 170). This behavior can be particularly aggravated when an individual is dealing with medically unexplained symptoms (de Zwaan and Müller, 2006). ...
Haunted People Syndrome (HP-S) denotes individuals who recurrently report various “supernatural” encounters in everyday settings ostensibly due to heightened somatic-sensory sensitivities to dis-ease states (e.g., marked but sub-clinical levels of distress), which are contextualized by paranormal beliefs and reinforced by perceptual contagion effects. This view helps to explain why these anomalous experiences often appear to be idioms of stress or trauma. We tested the validity and practical utility of the HP-S concept in an empirical study of an active and reportedly intense ghostly episode that was a clinical referral. The case centered on the life story of the primary percipient, a retired female healthcare worker. Secondary percipients included her husband and adult daughter, all of whom reported an array of benign and threatening anomalies (psychological and physical in nature) across five successive residences. Guided by prior research, we administered the family online measures of transliminality, sensory-processing sensitivity, paranormal belief, locus of control, desirability for control, and a standardized checklist of haunt-type phenomena. The primary percipient also completed a measure of adverse childhood events and supplied an event diary of her anomalous experiences. We found reasonably consistent support for HP-S from a set of quantitative observations that compared five proposed syndrome features against the family members’ psychometric profiles and the structure and contents of their anomalous experiences. Specifically, the reported anomalies both correlated with the family’s scores on transliminality and paranormal belief, as well as elicited attributions and reaction patterns aligned with threat (agency) detection. There was also some evidence of perceptual congruency among the family members’ anomalous experiences. Putative psi cannot be ruled out, but we conclude that the family’s ordeal fundamentally involved the symptoms and manifestations of thin (or “permeable”) mental boundary functioning in the face of unfavorable circumstances or overstimulating environments and subsequently acerbated by poor emotion regulation, histrionic and catastrophizing reactions, and active confirmation biases.
... Retrograde ejaculation is a known side effect of PVP, and this case demonstrates how clear communication regarding possible adverse events at the time of, or following, surgery may decrease litigation. 21 Our legal database review can be helpful to urologists who wish to learn about the circumstances that may lead to litigation involving SD claims, the reasons why a urologist may or may not be favored by the jury, and what steps may be taken by a urologist to prevent or protect themselves from such litigation. However, our study is not without significant limitations. ...
Introduction:
Procedural specialties are at higher risk for malpractice claims than non-procedural specialties. Previous studies have examined common damages and malpractice lawsuits resulting from specific procedures. Our goal was to analyze urological interventions that led to sexual dysfunction claims.
Methods:
The Casetext legal research platform was queried using search terms for medical malpractice and common men's health procedures between 1993 and 2020. In total, 236 cases were found and 21 cases met the inclusion criteria: malpractice cases against a urologist or urology group, clearly stated legal outcome, and allegation of sexual dysfunction from an intervention that directly caused damages.
Results:
A total of 42 damages were cited in 21 lawsuits. The top three damages claimed were erectile dysfunction (14/42, 33.3%), genital pain syndrome (7/42, 16.7%), and urinary incontinence (5/42, 11.9%). The most commonly cited treatments were urinary catheter placement or removal (3/21, 14.3%), robotic-assisted laparoscopic radical prostatectomy (RALP) (3/21, 14.3%), circumcision (3/21, 14.3%), and penile implant (3/21, 14.3%). In 19 of 21 suits (90.4%), the outcome favored the defendant. Two cases favored the plaintiff: penile implant (failure to prove the patient was permanently, organically impotent prior to the procedure; $300 000) and vasectomy (damage to vasculature resulting in loss of testicle, $300 000).
Conclusions:
Most suspected malpractice cases resulting in sexual dysfunction favored the defendant urologist. Interestingly, urinary catheter placement is as likely to result in litigation as other operative interventions, such as RALP, inflatable penile prosthesis, and circumcision. It is possible that thorough preoperative counselling and increased responsiveness to patients' postoperative concerns may have avoided litigation in several cases.
... First, it appears that the most common type of diagnostic opinion as 'second opinion' functions as a patient-initiated quality control (cf. Payne et al 4 ). In this process, a physicianin-charge proposes a diagnosis to a patient, which is based on the available evidence and the status of the physician as expert of collecting and assessing this evidence. ...
In this paper, we first classify different types of second opinions and evaluate the ethical and epistemological implications of providing those in a clinical context. Second, we discuss the issue of how artificial intelligent (AI) could replace the human cognitive labour of providing such second opinion and find that several AI reach the levels of accuracy and efficiency needed to clarify their use an urgent ethical issue. Third, we outline the normative conditions of how AI may be used as second opinion in clinical processes, weighing the benefits of its efficiency against concerns of responsibility attribution. Fourth, we provide a ‘rule of disagreement’ that fulfils these conditions while retaining some of the benefits of expanding the use of AI-based decision support systems (AI-DSS) in clinical contexts. This is because the rule of disagreement proposes to use AI as much as possible, but retain the ability to use human second opinions to resolve disagreements between AI and physician-in-charge. Fifth, we discuss some counterarguments.
... The oncologist experiences the patient's search for a second opinion as a defeat, which is, at times, accompanied by the more or less explicit fear that another oncologist will not confirm the appropriateness of cancer management so far. A second opinion, as the patients' right, should lead to a discussion of the case among colleagues and be shared with the attending oncologist (Payne et al., 2014), but it often leads to overtreatment (Philip et al., 2010). ...
... Some patients will always experience uncertainty (e.g., anxiety/negative emotions) about their test results regardless of outcome or method of notification [51]. Further, patients may experience uncertainty when faced with conflicting second opinions [53,54]. ...
Objective
Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate, timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing 1) where patients and clinicians experience uncertainty within the diagnostic process, 2) how uncertainty affects the diagnostic process, 3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and 4) strategies to manage uncertainty.
Discussion
Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined.
Conclusion
Scientific knowledge on diagnostic uncertainty, while previously elusive, is now getting better defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
... In a representative survey in Germany, 56% of the respondents considered it important to have the opportunity to obtain an SO before orthopaedic surgery [16]. However, the literature on the effects of an SO is limited [17,18]. It therefore remains unclear whether an SO actually improves adherence to guidelines and offers more certainty to patients. ...
Abstract Background German social legislation gives patients the right to obtain a second opinion before elective surgery and defines quality criteria for reimbursement by statutory health insurances. However, the effects of second opinions before elective surgery are largely unknown. The aim of this study was to evaluate the effects of a second opinion programme in patients recommended for knee arthroplasty. Methods The largest statutory health insurance funds in Bavaria offered patients who had been recommended to have knee arthroplasty the opportunity to partake in a second opinion programme which consisted of an in person presentation to an experienced knee surgeon. In this cohort study, consecutive patients from this second opinion programme who signed informed consent were included from 07/10/2016 to 14/02/2020. Data were collected before and after the second opinion visit. Results A total of 141 (66%) of 215 patients who presented for a second opinion participated in the evaluation study. The second opinion physician recommended knee arthroplasty to 40% of the patients, later knee arthroplasty if the conditions worsened to 40%, and no knee arthroplasty to 20%. After receiving the second opinion 28 of 56 (41%) undecided patients preferred knee arthroplasty, 14 no knee arthroplasty, 14 remained undecided. Four of 46 patients with a preference for “arthroplasty” changed their decision to “no arthroplasty”, five of 35 patients from “no arthroplasty” to “arthroplasty”. The patients were more confident in their decision according to the decision confidence scale (before: 5.4 ± 3.0; after: 7.8 ± 2.5; p
... В качестве примера можно привести работу S. Taylor и соавт. [15], которые проанализировали результаты применения НПВП у 713 больных ОА из Германии, Испании и Англии. Среди пациентов с тяжелыми формами этого заболевания 60% были не удовлетворены результатом обезболивания. ...
The problem of chronic musculoskeletal pain, the cause of severe suffering and disability of hundreds of millions of people on our planet, is far from being solved. Pain control is particularly difficult in patients with severe forms of osteoarthritis (OA) and chronic non-specific low back pain (CLBP). Popular analgesics – nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, demonstrate moderate effectiveness and a high risk of adverse events (AE). This leads to the search for new approaches for analgesic therapy. Tanezumab is a monoclonal antibody that specifically blocks nerve growth factor, which plays a key role in the development of chronic pain. A series of phase II and III studies showed that tanezumab was administered intravenously or subcutaneously at a dose of 2.5 mg to 20 mg once every 8 weeks. In patients with OA or CNSLBP, it has a pronounced and persistent analgesic effect that exceeds the effect of placebo, and is equal to or superior to the effect of many months of daily intake of naproxen, celecoxib, diclofenac, oxycodone and tramadol. Tanezumab can cause various AE, primarily rapid progression of OA (in 2.6–6.0%) and neurological disorders (paresthesia and hyposthesia, in ≈5%). At the same time, the progression of OA was significantly more often observed with the combined use of tanezumab and NSAIDs. Nevertheless, taking into account the characteristics of patients who used tanezumab (patients with pain refractory to standard treatment; severe forms of OA), the good analgesic potential of tanezumab allows us to consider it as a promising tool for the control of chronic musculoskeletal pain, which will be widely used in real clinical practice.
... This time includes patient interview, analyzing disease history and family history, physical examination, prescription, and care procedures [22]. Another study found that 90% of patients with poorly defined conditions remain undiagnosed in the primary care [23]. A different study discovered that 88% of patients were misdiagnosed during primary diagnosis and needed second opinion [24]. ...
Health care can be either ‘Reactive Care’ or ‘Proactive Care’. Reactive care is self-referral where a medical help is solicited by the person or family members on suspecting illness. In Proactive care an individual seeks medical help before the appearance of symptoms in order to prevent illness, or detect and treat it early before the disease progresses or becomes chronic. There are advantages and disadvantages for both of these approaches. Reactive approach relies on healing followed by self-referrals wherein the right care is often delayed, or even neglected, resulting in accelerated disease progression. Proactive care, on the other hand, takes into account the potential risk factors in a person’s health. Proactive care carries risks of overdiagnosis, overtreatment, and unnecessary interventions. In this paper we make a balance between the reactive care and the proactive care through the use of data driven algorithms, models, and knowledge graphs. We show how diseasome network constructed from tacit knowledge of Spatial Comorbidity and Temporal Comorbidity, and Patholome explicit knowledge can offer ‘Precision Health’. We looked at the real-world EHR data (mostly reactive diagnosis by hundreds of doctors) to construct spatial comorbidity knowledge network. We then combined disease trajectories data (temporal comorbidity) with the spatial comorbidity. This helped us understand how diseases manifest in a target population and their interrelationships. Finally we constructed patholome disease-diagnostic-test explicit knowledge and integrated with the diseasome knowledge network to form evidence based Knowledge Graph or a Clinical Expert System. We added a Semantic Engine (Reasoning Knowledge Network) on this statistically significant knowledge graph to help a health service provider to make an accurate informed decision on balancing the reactive care and the proactive care with a focus on ‘Right Care’ through explainable AI (XAI). To offer the knowledge driven right care at the right time at anywhere point-of-care we used Big-Data Analytics, Statistics, Artificial Intelligence, Knowledge Discovery & Management, WebRTC, and Smartphones.
... In a representative survey in Germany, 56% of the respondents considered it important to have the opportunity to obtain an SO before orthopaedic surgery (15). However, the literature on the effects of an SO is limited (16,17). Therefore, it remains unclear whether an SO actually improves adherence to guidelines and offers more certainty to patients. ...
Background: German social legislation gives patients the right to obtain a second opinion before elective surgery and defines quality criteria for reimbursement by statutory health insurance. However, the effects of second opinions before elective surgery are largely unknown. The aim of this study was to evaluate the effects of a second opinion programme in patients recommended for knee arthroplasty.
Methods: The largest statutory health insurance funds in Bavaria offered patients to whom knee arthroplasty was recommended participation in a second opinion programme with personal presentation to an experienced knee surgeon. In this cohort study, consecutive patients from this second opinion programme who signed informed consent were included from 07/10/2016 to 14/02/2020. Data were collected before and after the second opinion visit.
Results: A total of 141 (66%) of 215 second opinion patients participated in the evaluation study. The second opinion physician recommended knee arthroplasty to 40% of the patients, later knee arthroplasty if the conditions worsened to 40%, and no knee arthroplasty to 20%. The frequency of undecided patients decreased from 41% to 12%. After the second opinion, the patients were more confident in their decision according to the decision confidence scale (before: 5.4 ± 3.0; after: 7.8 ± 2.5; p < 0.001). Logistic regression analyses showed that higher radiological severity of osteoarthritis on the Kellgren/Lawrence scale (p = 0.001) and lower knee-joint-specific quality of life on the KOOS questionnaire (p = 0.041) were associated with the recommendation for knee arthroplasty by the second opinion physician. The patients rated their satisfaction with the second opinion programme with a mean grade of 1.35 (± 0.60) on a scale from 1 to 5.
Conclusion: The second opinion of an experienced knee surgeon frequently deviates from the initial recommendation for knee arthroplasty. The results of this study suggest that a second opinion may improve adherence to guidelines for indications of knee arthroplasty. From the patient perspective, the second opinion reduces uncertainties in their treatment decision.
... Since the advent of primary care medicine, patients largely accepted physician recommendations, including prognoses and treatment plans. Today however, between 20 and 40% of patients seek second opinions (Payne et al. 2014). As will be elucidated later in this chapter, this newly empowered patienta consumer of healthcare that is not only acutely aware of their medical autonomy but chooses to maximize itelicits numerous ethical implications for neuropsychopharmacotherapy. ...
... Therefore, ensuring that patients know that they have the right to seek a second opinion, and supporting patients to seek a second opinion where they express a preference for this, aligns with the ethos of patient-centred care. Consumers have also recommended that information on the 'possibility of a second opinion' be considered an indicator of patient-centred care [3]. ...
Background:
The current study aimed to further our understanding of second opinions among medical oncology patients by examining the proportion of patients who sought a second opinion about their cancer treatment, and why.
Methods:
The study was conducted between 2013 and 2015 in three medical oncology clinics located in public hospitals in Australia: in metropolitan New South Wales, metropolitan Queensland, and in Tasmania. Those patients who provide written informed consent were asked to complete a brief paper and pencil survey in the clinic containing questions on sociodemographic, disease and treatment characteristics. Approximately 1 month later, participants were mailed a second paper and pencil survey which contained questions about whether they had sought a second opinion and their motivation for doing so. Non-responders were followed up by letter at 3 and 6 weeks.
Results:
Of 823 patients screened for eligibility, 698 eligible patients, 612 provided consent. Of those who consented, 355 completed both the initial survey and the second survey and were included in the analyses. Of the 57 patients who sought a second opinion, the most frequent reasons given for doing so were the need for reassurance (49.1%) and the need to consider the range of treatment options (41.8%). Of the 297 (83.6%) participants who did not seek a second opinion, the main reason was confidence in the first doctor (88.7%). Only 3.1% patients did not know that they could ask for a second opinion. Occasionally the doctor will initiate the referral for a second opinion.
Conclusions:
Our study suggests that a minority of cancer patients seek a second opinion at some phase during their care. Most did so for reassurance or to ensure that they had covered all of the treatment options and not because of discomfort or distrust of their treating doctor. Few patients reported a lack of awareness of second opinions. This suggests that second opinions form part of a patient-centred approach to information provision about care options. Whether the second opinion improves the quality of care or indeed outcomes has been difficult to demonstrate.
... Research attending to what happens after an encounter has often been restricted to understanding "second opinions" (Goldman et al., 2009;Greenfield et al., 2012;Gross et al., 2017;Moumjid et al., 2007;Payne et al., 2014). The research conducted on "second opinions" has acknowledged that they are not always sought from medical professionals, but only recognises holistic therapies as complementary (Sutherland and Verhoef, 1994;Tam et al., 2005), thereby not recognising strategies that might be used beyond complementary medicine (Cant and Sharma, 2004). ...
Purpose
Research has long focused on the notion of access and the trajectory towards a healthcare encounter but has neglected what happens to patients after these initial encounters. This paper focuses attention on what happens after an initial healthcare encounter leading to a more nuanced understanding of how patients from a diverse range of backgrounds make sense of medical advice, how they mix this knowledge with other forms of information and how they make decisions about what to do next.
Design/methodology/approach
Drawing on 160 in-depth interviews across four European countries the paper problematizes the notion of access; expands the definition of “decision partners”; and reframes the medical encounter as a journey, where one encounter leads to and informs the next.
Findings
This approach reveals the significant unseen, unrecognised and unacknowledged work that patients undertake to solve their health concerns.
Originality/value
De-centring the professional from the healthcare encounter allows us to understand why patients take particular pathways to care and how resources might be more appropriately leveraged to support both patients and professionals along this journey.
... In the last decades second opinions became available for other medical indications besides the elective surgery and patients were able to seek an additional independent opinion on voluntary basis [5]. Seeking a second opinion can help improving the diagnosis and treatment of medical indications and possibly preventing the patient of unnecessary operations [6,7]. Especially for medical indications as cancer or operations of the spine or hip, consulting another expertise can help to clarify the diagnosis and/or needed therapy. ...
Background:
As of 2015, second opinions are legally implemented in Germany. However, empirical results from German second opinion programs are lacking. The aim of this study was to examine several aspects within a population of a German second opinion program.
Methods:
Study population consisted of patients who sought a second opinion in the period from August 2011 to December 2016. Multivariate logistic regression and ANOVA were used to examine differences in patient characteristics, differentiated by agreement of initial therapy recommendation and second opinion. Follow-up points for patient satisfaction and HRQoL were defined at 1, 3 and 6 months after obtaining the second opinion.
Results:
Total number of patients who sought a second opinion was 1414. Most common indications concerned the knee (37.3%), spine (27.3%), hip (11.5%) and shoulder (10.1%). The independent specialists did not confirm the initial therapy recommendations in two out of three cases. The type of indication influenced the agreement between initial therapy recommendation and the second opinion significantly (p = 0.035). The second opinion and the offered service was highly valued by the patients (89%).
Conclusions:
The second opinion offers patients the possibility to confirm a medical indication independently and support patients in their decision making process. Reasons for the large discrepancy between initial therapy recommendation and second opinion should be addressed in future research.
... Compatible with previous findings, 2 we found that most patients were satisfied with previous second opinions and found the information and outcomes different from the first consultation. 12,16 Literature shows that patients who seek a second opinion are hoping to receive a different diagnosis or treatment. 20 In addition, by the time they actually get the second opinion, patients may have already processed some of the information, gathered more information, and might be more receptive to the second opinion physician, perceiving him/her as more professional and a better communicator compared to the first physician. ...
Second opinions are used in medicine in order to make better-informed decisions. Only a few studies have examined patient-initiated second opinions, and even fewer have examined it in the context of acute hospitalization. It is not clear whether patients and families are aware of this right and how often they exercise it during acute hospitalization. The objective of this paper is to identify factors associated with the awareness and utilization of patient-initiated second opinions. A survey was conducted among 92 neurosurgical patients who completed a questionnaire that included information regarding: awareness of second opinion consultations, reasons for not seeking a second opinion, satisfaction from the second opinion and sharing the results of the second opinion with the first physician. Multivariate Logistic Regression analysis was performed to identify potential confounders associated with awareness and seeking a second opinion. Findings revealed that 79% percent of the participants were aware of their right to receive a second opinion; however, only 31% opted to receive a second opinion before/during the hospitalization. Fifty-eight percent received a second opinion related to previous medical conditions. Fifty-four percent did not inform the first physician about the results. The Logistic Regression showed that health insurance, education, religiosity and gender predicted awareness and utilization of second opinions. Current findings indicate that although patients are aware of their right to a second opinion and many have used it in the past, they rarely use it during acute hospitalization. Encouraging health professionals in hospitals to refer their patients to a second opinion as part of shared decision-making, may improve the liability and efficacy of patients' care.
Experience Framework
This article is associated with the Quality & Clinical Excellence lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this lens.
... Si concorda VO dopo il consulto specialistico cardiologico già programmato. Si consiglia in attesa di rimanere attivi fisicamente, evitare posture prolungate del rachide cervicale in flessione, si suggerisce di programmare una second opinion7 ORL per lo studio della funzione vestibolare. A ...
Background
La cervicogenic dizziness (CGD) è una sindrome clinica caratterizzata dalla presenza di vertigine associata al dolore al collo che può alterare sensibilmente la qualità della vita dei soggetti interessati. Non esistono test clinici o di laboratorio definitivi per la CGD, e quindi la CGD rimane una diagnosi di esclusione. Questo caso clinico aggiunge nuove conoscenze scientifiche in merito a somministrazione di misure appropriate, e terapia osteopatica nella gestione della CGD.
... A recent systematic review stresses the need for standardised methods and outcome measures. 36 The lack of objective data on SO utilisation by insurance type drove us to conduct a quantitative measurement of SO utilisation in a large-scale population. ...
Objectives
To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare.
Design
An observational study.
Setting
Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel.
Participants
The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance.
Outcomes measures
An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used.
Results
143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40–59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9).
Conclusions
Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.
... Furthermore, utilising second opinions to derive or review diagnostic conclusions has been effective at reducing errors in radiology [13]. Second opinions, across different settings, result in a different diagnosis in 10-62% of patient cases [27]. The implementation of team approaches to diagnosis or second opinions can normalise discussing diagnosis. ...
The purpose of this article is to synthesise review evidence, practice and patient perspectives on interventions to reduce diagnostic error in emergency departments (EDs). A rapid review methodology identified nine systematic reviews for inclusion. Six practice interviews were conducted to identify local contextual insights and implementation considerations. Finally, patient perspectives were explored through a citizen panel with 11 participants. The rapid review found evidence for the following interventions: second opinion, decision aids, guided reflection and education. Practitioners suggested three of the four interventions from the academic review: second opinion, decision aids and education. Practitioners suggested four additional interventions: improving teamwork, engaging patients, learning from mistakes and scheduled test follow-up. Patients most favoured interventions that improved communication through education and patient engagement, while also suggesting that implementation of state-wide standards to reduce variability in care and sufficient staffing are important to address diagnostic errors. Triangulating these three perspectives on the evidence allows for the intersections to be highlighted and demonstrates the usefulness of incorporating practitioner reflections and patient values in developing potential interventions.
... It harnesses the ability of a group to outperform the individual in a variety of cognitive tasks. 7 Indeed, obtaining a second opinion from a peer is a simple approach to improve clinical decision-making 8 IT platforms offer the opportunity to connect people and harness their collective intelligence. The use of collective intelligence among groups of primary care providers is a promising method to improve the accuracy of diagnoses and thereby reduce diagnostic error. ...
Objectives
Usable tools to support individual primary care clinicians in their diagnostic processes could help to reduce preventable harm from diagnostic errors. We conducted a formative study with primary care providers to identify key requisites to optimize the acceptability of 1 online collective intelligence platform (Human Diagnosis Project; Human Dx).
Materials and Methods
We conducted semistructured interviews with practicing primary care clinicians in a sample of the US community-based clinics to examine the acceptability and early usability of the collective intelligence online platform using standardized clinical cases and real-world clinical cases from the participants’ own practice. We used an integrated inductive-deductive qualitative analysis approach to analyze the interview transcripts.
Results and Discussion
Perceived usefulness, perceived accuracy, quality assurance, trust, and ease of use emerged as essential domains of acceptability required for providers to use a collective intelligence tool in clinical practice. Participants conveyed that the collective opinion should: (1) contribute to their clinical reasoning, (2) boost their confidence, (3) be generated in a timely manner, and (4) be relevant to their clinical settings and use cases. Trust in the technology platform and the clinical accuracy of its collective intelligence output emerged as an incontrovertible requirement for user acceptance and engagement.
Conclusion
We documented key requisites to building a collective intelligence technology platform that is trustworthy, useful, and acceptable to target end users for assistance in the diagnostic process. These key lessons may be applicable to other provider-facing decision support platforms.
... For example, completing lab tests, going to appointments with specialists, taking medications as prescribed -Follow up with your healthcare provider after appointments to obtain test results to ensure proper testing was conducted. Thus, both patient and healthcare provider are accountable 3. Second opinions are an effective way to detect diagnostic errors and working in teams provides the opportunity to regularly obtain this kind of input [48]. ...
Background:
A persistent depressive disorder has a major impact on both patients and health care systems. Despite the advice in guidelines to seek a second opinion if there is insufficient evidence of recovery after treatment, and the great number of second opinions in psychiatric care for patients with persistent depression, only a few studies have been published about their effects.
Methods:
Multilevel analyses were conducted to compare the mean test scores of a group of patients with a persistent depressive disorder who received the intervention of a second opinion with scores from a matched control group, at 3 time points: baseline, intervention, and follow-up.
Results:
A significant decrease in the severity of depression 3 months after the second opinion was found. No effects on quality of life or treatment satisfaction were found.
Limitations:
The study sample was a convenience sample without randomization, and many values were missing in the data. In addition, a 3-month follow-up may have been too short to expect effects of the recommendations from the second opinion. The instructions concerning how to rate treatment satisfaction were also ambiguous.
Conclusions:
A second opinion can be of value for persistent depression. Further research should address the question of whether the effect that was found is caused by the second opinion itself or is the result of subsequent changes in treatment.
Purpose
Second medical opinions (SMO) can improve patient outcomes and change medical decision-making. The purpose was to determine the concordance of initial management of thyroid nodules for patients seeking SMO to established management guidelines.
Materials and methods
Cases of patients consulting a single provider via DTCT for SMO on the workup and management of thyroid nodule(s) were reviewed from September 2011 to February 2022. The primary outcome was the overall rate of adherence to 2015 ATA guidelines (correct/incorrect) and complete agreement (yes/no) between SMO and initial treatment team.
Results
Most sought a second opinion for treatment options. Only 14 (29.2 %) cases had followed all the guidelines correctly. Living in North America compared to Asia (10/18 vs. 4/25, p = 0.004) and consulting endocrinology (11/21 vs. 3/26, p = 0.004) was associated with correct following of all guidelines. The most common violations of the guidelines were a lack of Bethesda scoring in pathology reports (31.8 %) and inappropriate initial FNA (25.5 %). The SMO was in complete agreement with the initial treatment recommendation in 31 cases (64.6 %), in partial agreement in 12 cases (25 %), and in disagreement in 5 cases (10.4 %).
Conclusions
In our study, adherence to guidelines was low. However, the SMO agreed with the workup and management of most patients, as most of this discordance with guidelines did not affect the overall treatment. The virtual second opinion consult was valuable in addressing patient-specific concerns, explaining additional treatment options, and, in a few cases, recommending against inappropriate surgical intervention.
The patient rights movement has designated medical autonomy as the predominant principle within the contemporary biomedical ethics paradigm. The principles that govern the clinical delivery of medicine and clinical research have, as of late, elicited numerous ethical concerns within the realm of neuropsychopharmacotherapy that can only be addressed by reviewing the principles of biomedical ethics through the lens of contemporary psychotherapeutic research, practice, and healthcare delivery. In this chapter, we address three overarching categories of emerging ethical questions in the field of neuropsychopharmacotherapy, namely (i) trust within the clinician–patient relationship, (ii) the nontherapeutic acquisition and usage of psychotropics for neuroenhancement, and (iii) the socioenvironmental factors that have contributed to the increase of psychotropic drug use in society. We then contextualize these ethical considerations by providing case studies of two of the most prolific and widely used psychotropic medications – Fluoxetine (Prozac®) and Modafinil (Provigil®). We conclude with a discussion on the future of neuropsychopharmacotherapy as it continues to evolve in a global society that is characterized by exponential increases in the prescription and use of psychotropic medications.
Digital pathology is a new stage in the development of pathomorphological diagnostics. This topic was most widespread during the COVID-19 pandemic. The advantages of digitization of diagnostics include the possibility of remote work of a pathologist, remote asynchronous consultation, and automation of business processes. They provide an increase in diagnostic quality and speed up the diagnosis process. These benefits are only a small part of what digital cancer diagnostics can provide. This article is written on our own experience of Russia's first fully digital pathomorphological laboratory UNIM. All advantages and disadvantages of digitization, peculiarities of using technology, differences from the conventional approach to diagnostics, the economics of the process, the importance of integration with LIS (laboratory information system) and MIS (medical information system), errors and principles of their solution, payback will be discussed, and every stage of laboratory work will be considered in detail: from logistics and registration to diagnosis and archiving. Due to the fact that all data has been digitized over several years, we will present a comprehensive analysis of statistics and observations on how to organize processes in a fully digital laboratory. A key feature of our experience is the high cost-effectiveness of the platform and approach, which allowed us to win the competition in the market. The result of the survey of doctors' attitudes towards digital pathology will also be presented.
Stratification in professional careers arises in part from interpersonal dynamics in client-expert dyads. To reduce perceived uncertainty in judgments of the quality of experts, clients may rely on ascriptive characteristics of experts and on pairwise, relational factors to assess the advice they receive. Two such characteristics, expert gender and client-expert gender concordance, may lead to differences in clients’ trust in expert advice. To explore these issues, we investigate the incidence of patient-initiated second opinions (SOs) in medicine. In an examination of millions of medical claims in Massachusetts, we find that male patients are much more likely than female patients to obtain an SO if the first specialist they consult is female. Moreover, when the first specialist a patient consults is gender non-concordant and the patient seeks an SO, male patients are substantially more likely to switch to a same-gender specialist in the SO visit. Because patients who lack confidence in the advice of the first-seen specialist infrequently return to this specialist for medical services, female specialists generate lower billings. Analyses of medical spending in follow-up visits suggest that gendered patterns in questioning the advice of medical experts have the potential to contribute substantially to the gender pay gap in medicine.
Objective
Cancer patients may seek a second opinion (SO) driven by reduced trust in their own providers. Their trust may be diminished or reinforced through the SO. This study aimed to assess (1) what proportion of patients seek SOs motivated by lacking trust and how trust changes over time; (2) whether patients’ trust differs by the outcome of the SO (i.e. similar/different opinion); and (3) how communication during the SO affects trust.
Design
A longitudinal mixed methods study including self-report assessments before (T0), immediately following (T1), and two months after the SO (T2). SO consultations (N = 62) were audio recorded, and patient-oncologist communication about the referring oncologist was coded.
Main outcome measures
Patient-reported motives and their trust in referring oncologists.
Results
Reduced trust motivated 21% of patients to seek a SO. Most patients criticised their referring oncologist. Consulting oncologists generally defended their colleagues, but such affirmation was unrelated to patients’ subsequent trust. Over time, trust did not change substantially. Yet, it was restored in patients motivated by impaired trust, and remained low for patients receiving a different medical outcome.
Conclusion
Patients need support to more constructively discuss their treatment relationship. Oncologists need support in providing independent SOs without harming trust relations.
Eltern, bei deren Kind die Diagnose einer schwerwiegenden Erkrankung gestellt wird, sind psychisch stark belastet. Unsicherheit und das Bedürfnis nach einer Validierung der Erstmeinung, aber auch mangelndes Vertrauen oder die Unzufriedenheit mit der Arzt-Patienten-Kommunikation gehören zu den wichtigsten Gründen für die Initiierung einer Zweitmeinung durch Eltern im pädiatrischen Kontext. Die Motivation von ratsuchenden Eltern zu kennen, hilft unnötige Zweitmeinungsberatungen zu vermeiden.
Background: Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. No studies have attempted to summarise the available evidence for second opinion services designed for people with back pain that have been recommended to have surgery.
Methods: We conducted a scoping review. Two independent researchers screened PubMed, EMBASE and Cochrane CENTRAL from their inception to May 6th, 2021. Studies of any design were eligible provided that they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality of studies with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) their effectiveness in reducing surgery rates and improving patient –reported outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.
Results: We included 12 studies (11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53% to 96% across studies. Agreement for need for surgery between first and second opinions ranged from 0% to 83%. There is some very-low quality evidence that second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and some healthcare use (e.g. imaging), but might increase others (e.g. injections, prescription drugs).
Conclusions: There is a need for high-quality studies to determine the value of second opinion services for reducing spinal surgery.
Prognostic communication is essential for patients with advanced cancer to enable informed medical decision-making and end-of-life planning. Discussing prognosis is challenging, and might be especially complex for oncologists conducting a second opinion (SO). Survival data are often lacking, and consulting oncologists need to consider previously conveyed information and patients’ relationship with the referring oncologist. We qualitatively investigated how advanced cancer patients and consulting oncologists discuss prognosis during audio-recorded SO consultations (N = 60), including prognostic information received from the referring oncologist. Our results show that patients regularly expressed implicit cues to discuss prognosis or posed explicit questions tentatively. Consulting oncologists were mostly unresponsive to patients’ cues and cautious to prognosticate. They also seemed cautious when patients brought up the referring oncologist. Consulting oncologists checked which prognostic information patients had received from the referring oncologist, before estimating prognosis. They agreed with the first opinion or rectified discrepancies carefully. Altogether, this study exposes missed opportunities for open prognostic discussions in SOs. Consulting oncologists could explicitly explore patients’ information preferences and perceptions of prognosis. If desired, they can provide tailored, independent information to optimise patients’ prognostic awareness and informed medical decision-making. They may additionally support patients in dealing with prognosis and the uncertainties associated with it.
Background
To date, the outcomes of second opinions in internal medicine in terms of diagnostic yield and patient benefit have not been studied extensively. This retrospective study explores the outcomes of second opinions at a general internal medicine outpatient clinic in an academic hospital.
Methods
A register of all patients referred to the general internal medicine outpatient clinic of the University Medical Center in Utrecht for a second opinion, was kept. All 173 patients referred between June 2016 and August 2018 were selected. Case records were analyzed for patient characteristics, referring doctor, chief complaint, performed investigations, follow-up time and, established diagnosis, additional diagnoses, initiated treatment and reported benefit.
Results
A new diagnosis was established in 13% of all patients. A new treatment was initiated in 56% of all patients: 91% and 51% of patients with and without a new diagnosis respectively (p < 0.001). Of all patients, 19% received an effective treatment (52% vs 14% of patients with vs without a new diagnosis, p < 0.001). Regardless of treatment, resolution or improvement of the chief complaint was achieved in 28% of all patients (52% vs 25% of patients with vs without a new diagnosis, p = 0.006). Regarding diagnostics, 23-33% of radiology, endoscopy and pathology tests performed during second opinion were a repetition of previously conducted investigations. Conventional blood tests were a repetition in 89% of cases. Median time to diagnosis was 64 days (IQR: 25–128 days) and median time to discharge was 75 days (IQR: 31–144 days).
Conclusion
Second opinions in general internal medicine lead to the establishment of a new diagnosis in a small proportion of patients. However, the value of second opinions may not be limited to the establishment of diagnoses, as new treatments are often initiated and overall patients report improved symptomatology in 28% of cases.
Telepathology has been an important application for second opinion consultation ever since the introduction of digital pathology. However, little is known regarding teleconsultation for second opinion in transplantation. There is also limited literature on telepathology during organ donor procurement, typically utilized when general pathologists on-call request back-up to help assess donor biopsies for organ suitability or to diagnose newly discovered tumors with urgent time constraints. In this review, we searched Pubmed/Embase and websites of transplant organizations to collect and analyze published evidence on teleconsultation for donor evaluation and organ procurement. Of 2725 records retrieved using the key terms ‘telepathology’, ‘second opinion’ and ‘transplantation’, 26 suitable studies were included. Most records were from North America and included validation studies of telepathology being used for remote frozen section interpretation of donor biopsies with whole slide imaging. The data from these published studies supports the transition towards digital teleconsultation in transplant settings where consultations among pathologists are still handled by pathologists being called on site, via telephone and/or email.
The practice of the clinical podiatrist traditionally focuses on the diagnosis and treatment of conditions of the foot, ankle, and related structures of the leg. Clinical podiatrists are expected to be mindful of “the principles and applications of scientific enquiry.” This includes the evaluation of treatment efficacy and the research process. In contrast, the forensic podiatrist specializes in the analysis of foot-, ankle-, and gait-related evidence in the context of the criminal justice system. Although forensic podiatry is a separate, specialized field, many aspects of this discipline can be useful in the clinical treatment and management of foot and ankle problems. The authors, who are forensic podiatrists, contend that the clinical podiatrist can gain significant insights from the field of forensic podiatry. This article aims to provide clinical podiatrists with an overview of the principles and methods that have been tested and applied by forensic podiatrists in their practice, and suggests that the clinical practice of the nonforensic foot practitioner may benefit from such knowledge.
Older adults' self-advocacy in patient safety: a cross-sectional study.
Abstract
BACKGROUND:
patient advocacy is a major nursing role, which is linked to supporting, encouraging and reinforcing self-advocacy in patients. Patient safety is an important nursing outcome, especially in older adults.
AIMS:
older adults' self-advocacy regarding patient safety behaviour and its relationship with some demographic characteristics were assessed.
METHODS:
a valid older adult patients' self-advocacy questionnaire, which included subscales of behaviour, self-efficacy, attitude and outcome efficacy (range of scores=0-63), was used. In this cross-sectional study, 230 patients aged over 60 years were selected using a stratified sampling method.
FINDINGS:
an association was found between total self-advocacy score (mean=40.16; SD=9.6) and rural living (β=-0.168; P=0.016) using multiple linear regression analysis. Similar findings were found between questionnaire subscales and sex, rural living, occupation and age.
CONCLUSION:
older adults, especially women, those of advanced age and those in rural areas, may benefit from nursing interventions to improve their self-advocacy in patient safety.
KEYWORDS:
Cross-sectional descriptive study; Older adults; Patient safety; Self-advocacy
PMID: 31518535 DOI: 10.12968/bjon.2019.28.16.1076
Bei der Abwägung der Vor- und Nachteile einer patienteninitiierten Zweitmeinung spielen die psychischen Motive des Patienten eine zentrale Rolle: Die Motivation und Erwartung des Patienten zu kennen, hilft, Zweitmeinungsberatungen, die mit hoher Wahrscheinlichkeit keinen Nutzen für den Patienten bringen, zu vermeiden.
Bei der Abwägung der Vor- und Nachteile einer patienteninitiierten Zweitmeinung spielen die psychologischen Motive des Patienten eine zentrale Rolle: Die Motivation und Erwartung des Patienten zu kennen, hilft, Zweitmeinungsberatungen, die mit hoher Wahrscheinlichkeit keinen Nutzen für den Patienten bringen, zu vermeiden.
Background:
Requesting a second opinion (SO) is common in oncology. The reasons and barriers for patients not seeking an SO have yet been to be investigated. Why do patients have difficulties evaluating their need for an SO and what could be done to minimize these barriers?
Patients and methods:
A 2-stage qualitative study was conducted. 1) Participants were studied in 3 focus groups (FGs). The participants themselves analyzed and then grouped their statements into defined categories. 2) Results of the FGs were discussed with 7 experts from different professional backgrounds. The interviews were unstructured and detailed in the protocol. The statements underwent thematic analysis.
Results:
The following 4 main barriers were identified: 1) state of shock, 2) pressure of time, 3) sense of excessive demands and uncertainty triggered by information overload, 4) fear of jeopardizing the patient-physician relationship. The following 4 main suggestions for minimizing the barriers were identified: 1) written patient information, 2) improvement of communication, 3) patient empowerment (PE), 4) holistic approach.
Conclusion:
These barriers incapacitate the patients from evaluating the need for an SO. To minimize the barriers, PE, self-management support and shared decision making is recommended. While the implementation of these concepts advances, patients can be empowered by psycho-oncological assistance.
Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
Background:
Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.
Objective:
To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.
Design:
The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.
Setting:
Primary care practices in 3 U.S. states.
Participants:
Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.
Measurements:
Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.
Results:
110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.
Limitations:
Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.
Conclusion:
Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.
Primary funding source:
The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.
The frequency of outpatient diagnostic errors is challenging to determine due to varying error definitions and the need to review data across multiple providers and care settings over time. We estimated the frequency of diagnostic errors in the US adult population by synthesising data from three previous studies of clinic-based populations that used conceptually similar definitions of diagnostic error.
Data sources included two previous studies that used electronic triggers, or algorithms, to detect unusual patterns of return visits after an initial primary care visit or lack of follow-up of abnormal clinical findings related to colorectal cancer, both suggestive of diagnostic errors. A third study examined consecutive cases of lung cancer. In all three studies, diagnostic errors were confirmed through chart review and defined as missed opportunities to make a timely or correct diagnosis based on available evidence. We extrapolated the frequency of diagnostic error obtained from our studies to the US adult population, using the primary care study to estimate rates of diagnostic error for acute conditions (and exacerbations of existing conditions) and the two cancer studies to conservatively estimate rates of missed diagnosis of colorectal and lung cancer (as proxies for other serious chronic conditions).
Combining estimates from the three studies yielded a rate of outpatient diagnostic errors of 5.08%, or approximately 12 million US adults every year. Based upon previous work, we estimate that about half of these errors could potentially be harmful.
Our population-based estimate suggests that diagnostic errors affect at least 1 in 20 US adults. This foundational evidence should encourage policymakers, healthcare organisations and researchers to start measuring and reducing diagnostic errors.
We conducted a systematic review to determine the effect of providing patients access to their medical records (electronic or paper-based) on healthcare quality, as defined by measures of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
Articles indexed in PubMed from January 1970 to January 2012 were reviewed. Twenty-seven English-language controlled studies were included. Outcomes were categorized as measures of effectiveness (n=19), patient-centeredness (n=16), and efficiency (n=2); no study addressed safety, timeliness, or equity.
Outcomes were equivocal with respect to several aspects of effectiveness and patient-centeredness. Efficiency outcomes in terms of frequency of in-person and telephone encounters were mixed. Access to health records appeared to enhance patients' perceptions of control and reduced or had no effect on patient anxiety.
Although few positive findings generally favored patient access, the literature is unclear on whether providing patients access to their medical records improves quality.
Although healthcare quality and patient safety have longstanding international attention, the target of reducing diagnostic errors has only recently gained prominence, even though numerous patients, families and professional caregivers have suffered from diagnostic mishaps for a long time. Similarly, patients have always been involved in their own care to some extent, but only recently have patients sought more opportunities for engagement and participation in healthcare improvements. This paper brings these two promising trends together, analysing strategies for patient involvement in reducing diagnostic errors in an individual's own care, in improving the healthcare delivery system's diagnostic safety, and in contributing to research and policy development on diagnosis-related issues.
A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Although these different approaches provide important information and unique insights regarding diagnostic errors, each has limitations and none is well suited to establishing the incidence of diagnostic error in actual practice, or the aggregate rate of error and harm. We argue that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error, and to initiate quality improvement projects aimed at reducing the risk of error and harm. Three approaches appear most promising in this regard: (1) using 'trigger tools' to identify from electronic health records cases at high risk for diagnostic error; (2) using standardised patients (secret shoppers) to study the rate of error in practice; (3) encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process.
Importance Diagnostic errors are an understudied aspect of ambulatory patient safety.
Objectives To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions.
Design We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record–based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit.
Setting A large urban Veterans Affairs facility and a large integrated private health care system.
Participants Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007.
Main Outcome Measures Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors.
Results In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.
Conclusions and Relevance Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.
Errors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review was to identify interventions that might reduce the likelihood of these cognitive errors.
We searched PubMed and other medical and non-medical databases and identified additional literature through references from the initial data set and suggestions from subject matter experts. Articles were included if they either suggested a possible intervention or formally evaluated an intervention and excluded if they focused solely on improving diagnostic tests or provider satisfaction.
We identified 141 articles for full review, 42 reporting tested interventions to reduce the likelihood of cognitive errors, 100 containing suggestions, and one article with both suggested and tested interventions. Articles were classified into three categories: (1) Interventions to improve knowledge and experience, such as simulation-based training, improved feedback and education focused on a single disease; (2) Interventions to improve clinical reasoning and decision-making skills, such as reflective practice and active metacognitive review; and (3) Interventions that provide cognitive 'help' that included use of electronic records and integrated decision support, informaticians and facilitating access to information, second opinions and specialists.
We identified a wide range of possible approaches to reduce cognitive errors in diagnosis. Not all the suggestions have been tested, and of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice. Future progress in this area will require methodological refinements in outcome evaluation and rigorously evaluating interventions already suggested, many of which are well conceptualised and widely endorsed.
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.
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.
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.
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.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
The nomads are defined as patients related to multiple practicians of the same speciality or different specialities for the same symptomatology during a certain period. The objectives of this investigation were to evaluate the prevalence of medical nomadism of the followed patients in rheumatology and compare their profile with those patients followed in neurology and gastroenterology. A multicentric transverse study (September 2009-March 2010) was conducted in three departments of CHU Ibn Sina Rabat-Salé, Morocco; rheumatology, gastroenterology and neurology. Only patients seen in external consultations were included. Patients' socio-economic and demographic background (familial status, instruction level, monthly revenue, social assistance) were recorded, as well as the clinical parameters related to the pathology (pathology, duration of the illness, diagnosis final time). A questionnaire containing variables on the patients' state concerning diagnosis, satisfaction degree of the patients and other variables evaluated the notion of taking medication and the practice of alternative medicine. Medical nomadism has been defined by the consultation for the same symptomatology of three different practicians, either of the same speciality or of different specialities during the study period of 6 months. There were 250 patients included in this study (150 patients in rheumatology, 50 in gastroenterology and 50 in neurology), the mean age was 46 ± 13 years and females dominated (65.6%). The average duration of the evolution was 7 ± 5 years, 35% of the patients were illiterate, 30% had a primary school education, 22% had a secondary school education and 13% had a university-level education. Sixty-two percent of the patients were jobless, 27% were workers, 9% were the functionary and 2% were the based liberal. Fifty-six percent had no social assistance. Rheumatoid arthritis and degenerative pathology were the most frequent diagnoses in rheumatology, being 20% and 40%, respectively. In gastroenterology, the most frequent pathologies were functional colopathy (25%) and proctology (20%), and migraine (42%) in neurology. The global prevalence of nomadism was 51%; 36% in rheumatology, 58% in neurology and 86% in gastroenterology. The associated factors of nomadism phenomena in rheumatology were: the satisfaction degree of the patient (P = 0.001), the wrong beliefs (P = 0.007), the practice of alternative medicine (P = 0.009), the pathology (P = 0.01) and the psychic profile (P = 0.001). Our study suggests that medical nomadism is frequent. It seems to be more frequent in the gastroenterology area, was linked with the degree of the patients' satisfaction, the alternative medicine practice and the type of the pathologies. Other studies of a high level would be necessary.
This study describes urologist recommendations for treatment among local-stage prostate cancer patients presenting for initial management consultations versus second opinions. We hypothesized that urologists present a wider range of management recommendations and are less likely to consider the patient preference during the initial consultation.
Newly diagnosed local-stage prostate cancer patients and their urologists participated in a survey at urology practices in three states. The urologist's survey included questions about the patient's clinical status, treatments discussed and recommended, and factors that influenced the urologist's recommendations.
Of the 238 eligible patients, 95 men presented for an initial consultation, and 143 men presented for a second opinion. In multivariate analysis, urologists recommended 0.52 more treatments (standard error 0.19, P<0.001) during an initial consultation as opposed to a second opinion. The proportion recommending surgery increased from 71-91% (initial consultation versus second opinion setting). Among initial consultations, 59% had low-risk disease, and urologists' recommendations included surgery (80%), external radiation (38%), brachytherapy (seeds) (52%), and active surveillance (25%). Of the 54% with low-risk disease in a second opinion consultation, urologists' recommendations included surgery (90%), external radiation (16%), brachytherapy (14%), and active surveillance (16%).
In second opinion settings urologists discussed fewer treatment options and recommended surgery more often. These findings also applied to men with low-risk prostate cancer.
Although the number of neurological second opinions (SOs) and tertiary referrals (TRs) is increasing, only little is known about expectations and patient satisfaction in this group of patients. Therefore, the purpose of this study was to explore expectations of patients who get a neurological SO or TR and to assess patient satisfaction in these groups of patients. All new patients attending an academic neurological day-care clinic in a 6-month period were investigated. Demographic characteristics, duration of symptoms, expectations and motivation, new diagnoses and treatment consequences were studied, and patient satisfaction with the previous physician and the day-care clinic physician was assessed. Three hundred consecutive patients (183 SOs and 117 TRs) were evaluated. SO patients were younger (47 years vs. 51 years), and their duration of symptoms was longer (24 vs. 13 months) than TR patients. Most patients expected a new diagnosis or treatment (60%). SO patients were equally as satisfied with the day-care clinic consultation as TR patients (overall satisfaction using a VAS-score ranging 0-10: 7.4 vs. 7.5; p = 0.81), and significantly less satisfied with the referring physician (overall satisfaction: 5.6 vs. 7.0; p < 0.001). SO patients, in particular, were more satisfied with the degree of information and emotional support provided by the consulting neurologist as compared to the referring physician. Receiving a new diagnosis and/or treatment advice did not influence satisfaction. A day-care admission for neurological SO and TR leads to an increase of patient satisfaction, irrespective of making a new diagnosis or initiation of a new treatment.
To assess the patient care benefit of a recently implemented institutional policy requiring official second-opinion consultation for all studies performed outside the institution.
The institutional review board approved the retrospective review of patient data for this HIPAA-compliant study and waived the need for individual informed consent. The second-opinion consultation reports for outside neuroradiology studies finalized by subspecialty-trained neuroradiologists within calendar year 2008 were compared with the outside reports provided with the images. The reports were categorized by using a five-point scale: 1 indicated no difference in interpretation; 2, clinically unimportant difference in detection; 3, clinically unimportant difference in interpretation; 4, clinically important difference in detection; and 5, clinically important difference in interpretation. Clinically important differences were defined as those likely to change patient care or diagnoses. Statistical comparisons were performed by using two-sample continuity-corrected Z tests with two-sided alternatives. Bonferroni corrections were performed when more than two rates were compared. Confidence intervals for all rates were constructed by using the score interval along with the Yates continuity correction.
Of 7465 studies, 4534 (60.7%) had an outside report for comparison. There were 347 (7.7%) instances with clinically important differences. Of these 347 discrepancies, 233 (67.1%) were category 4 and 114 (32.9%) were category 5. When the final diagnosis was determined from pathology reports, clinical assessments, and/or imaging follow-up, the second-opinion consultation was noted to be correct in 163 (84.0%) of 194 studies with category 4 or 5 discrepancies.
A 7.7% rate of discrepant interpretations (347 of 4534 studies) was noted for a service offering second-opinion consultations for outside examinations. Most were discrepancies in detecting abnormalities rather than in interpreting identified findings. When a definitive diagnosis was obtainable, the second-opinion consultation was more accurate in 84% of studies. Review of outside studies benefits patient care.
To investigate the frequency, goals and outcomes of second-opinion consultations at the Sydney Cancer Centre.
A questionnaire-based study of patients who registered to see a medical oncologist at the Sydney Cancer Centre between January 2006 and January 2008 and who were seeking a second opinion.
Proportion and demographic characteristics of patients who had previously seen a medical oncologist and who stated they were seeking a second opinion.
123 of 1892 new patients (6.5%) stated that they were seeking a second opinion, of whom 22 declined study participation, were excluded from study participation or had been referred specifically for enrolment in a particular clinical trial. Of the remaining 101 patients, 77 completed a questionnaire; 59 were women and 26 had a university degree. Reasons for seeking second opinions included: to obtain information related to treatment (54 patients), for reassurance about diagnosis or treatment (47), and dissatisfaction with the information given by the first medical oncologist (24). Sixty-four patients reported that they received new information at the second-opinion consultation, with 45 identifying discussion of treatment options and 34 identifying discussion of future or prognosis. Fifty-one patients reported how the second-opinion consultation differed from the first, identifying it as longer (24), and indicating that the oncologist answered concerns (26). Most patients were aware of multidisciplinary teams and treatment guidelines, but fewer had read guidelines.
Patients seeking a second opinion from a medical oncologist are typically more educated, younger and female, probably due to preferences for more detailed information. The most common reasons for seeking a second opinion were to obtain additional information or reassurance about recommended management.
Interpretive performance of screening mammography varies substantially by facility, but performance of diagnostic interpretation has not been studied.
Facilities performing diagnostic mammography within three registries of the Breast Cancer Surveillance Consortium were surveyed about their structure, organization, and interpretive processes. Performance measurements (false-positive rate, sensitivity, and likelihood of cancer among women referred for biopsy [positive predictive value of biopsy recommendation {PPV2}]) from January 1, 1998, through December 31, 2005, were prospectively measured. Logistic regression and receiver operating characteristic (ROC) curve analyses, adjusted for patient and radiologist characteristics, were used to assess the association between facility characteristics and interpretive performance. All statistical tests were two-sided.
Forty-five of the 53 facilities completed a facility survey (85% response rate), and 32 of the 45 facilities performed diagnostic mammography. The analyses included 28 100 diagnostic mammograms performed as an evaluation of a breast problem, and data were available for 118 radiologists who interpreted diagnostic mammograms at the facilities. Performance measurements demonstrated statistically significant interpretive variability among facilities (sensitivity, P = .006; false-positive rate, P < .001; and PPV2, P < .001) in unadjusted analyses. However, after adjustment for patient and radiologist characteristics, only false-positive rate variation remained statistically significant and facility traits associated with performance measures changed (false-positive rate = 6.5%, 95% confidence interval [CI] = 5.5% to 7.4%; sensitivity = 73.5%, 95% CI = 67.1% to 79.9%; and PPV2 = 33.8%, 95% CI = 29.1% to 38.5%). Facilities reporting that concern about malpractice had moderately or greatly increased diagnostic examination recommendations at the facility had a higher false-positive rate (odds ratio [OR] = 1.48, 95% CI = 1.09 to 2.01) and a non-statistically significantly higher sensitivity (OR = 1.74, 95% CI = 0.94 to 3.23). Facilities offering specialized interventional services had a non-statistically significantly higher false-positive rate (OR = 1.97, 95% CI = 0.94 to 4.1). No characteristics were associated with overall accuracy by ROC curve analyses.
Variation in diagnostic mammography interpretation exists across facilities. Failure to adjust for patient characteristics when comparing facility performance could lead to erroneous conclusions. Malpractice concerns are associated with interpretive performance.
To evaluate the effectiveness of screening mammography by estimating the variability in radiologists' ability to detect breast cancer within the US population of radiologists at mammography centers accredited by the American College of Radiology.
A two-way sample survey design was used as follows. Fifty mammography centers having an American College of Radiology-accredited unit were randomly sampled from across the United States. One hundred eight radiologists from these centers gave blinded interpretation to the same set of 79 randomly selected screening mammograms. The mammograms were from women who had been screened at a large screening center. Before their sampling, these women had been stratified by their breast disease status, established either by biopsy or by 2-year follow-up. Rates of biopsy recommendations were summarized by the mean, median, minimum, maximum, and range of sensitivity and specificity. Overall cancer detection ability was summarized by similar statistics for receiver operating characteristic curve areas. Ninety-five percent lower confidence bounds on the ranges in accuracy measures were established by boo-strapping.
There is a range of at least 40% among US radiologists in their screening sensitivity. There is a range of at least 45% in the rates at which women without breast cancer are recommended for biopsy. As indicated by receiver operating characteristic curve areas, the ability of radiologists to detect cancer mammograms varies by as much as 11%.
Our findings indicate that there is wide variability in the accuracy of mammogram interpretation in the population of US radiologists. Current accreditation programs that certify the technical quality of radiographic equipment and images but not the accuracy of the interpretation given to mammograms may not be sufficient to help mammography fully realize its potential to reduce breast cancer mortality.
Relatively little is known about the size and makeup of the growing population of cancer survivors or about the social implications of a diagnosis of cancer. To explore these issues, we analyzed cancer survivorship information from the 1992 National Health Interview Survey (NHIS), and resulting cancer prevalence estimates were compared with those derived from cancer registry data.
According to the NHIS, there were an estimated 7.2 million adult survivors of cancer-excluding nonmelanoma skin cancer-in 1992, representing 3.9% of the U.S. adult population. Comparisons with prevalence estimates from cancer registry data suggest that cancer is underreported in the NHIS. Nearly three fifths (58.0%) of cancer survivors self-identified on the NHIS reported that their cancer was first detected when they noticed something wrong and went to a doctor. The majority (55.7%) of cancer survivors had obtained a second opinion or multiple opinions regarding their treatment. Most (58.0%) had received patient educational materials from a health care provider. However, relatively few had received counseling or participated in support groups (14.2%), contacted cancer organizations after their diagnosis (10.9%), or participated in a research study or clinical trial as part of their cancer treatment (4.7%). One ninth (10.7%) of the survivors had been denied health or life insurance coverage because of their cancer. Nearly one fifth (18.2%) of the cancer survivors who worked before or after their cancer was diagnosed experienced employment problems because of their cancer.
While cancer appears to be underreported on the 1992 NHIS, the survey provides valuable information about the medical, insurance, and employment experience of cancer survivors selected from a nationally representative sample of U.S. households.
Six states require health plans to provide or authorize second medical opinions (SMOs). The intent of such legislation is to preserve consumer choice, to improve the flow of information, and to improve health outcomes in this era of managed care. However, it is unclear who benefits from these laws. This paper reviews the changing role of second opinions and, using a nationally representative data set from the Commonwealth Fund, examines who gets them. Of persons who had visited a doctor in the previous year, 19 percent received a second opinion, for an estimated cost of $3.2 billion in 1994. Findings suggest that cultural norms and sociocultural factors may partially determine who may benefit from SMO legislation.
Headache is a common problem in primary care. Although most patients are treated by GPs, many are referred to specialist consultation. Knowledge of how the referrals can be improved is therefore an important issue.
The aim of this study was to determine the relationship between self-initiating referral to a neurologist and the patient's satisfaction with the specialist consultation.
All patients who had been examined by a neurologist for headache within a 2-year period from three neurological centres in North Norway completed a questionnaire.
A total of 1052 patients from a population of 1403 headache patients (75%) returned the questionnaire while 927 patients answered questions about initiating the referral to the specialist. Two hundred and twenty patients (24%) initiated the referral to the neurologist themselves; 52% of those who self-initiated the referral were dissatisfied with the specialist consultation compared with 42% of those referred by the doctor, P = 0.002. Chronic headache, tension-type headache (TTH) and daily use of analgesic drugs were associated with dissatisfaction.
Patients with headache who initiated the referral to a neurologist themselves were less satisfied with the specialist consultation. Selecting referrals containing proper medical information may improve satisfaction in severe headache patients treated in a neurological practice.
Missed, delayed, or incorrect diagnosis can lead to inappropriate patient care, poor patient outcomes, and increased cost. This systematic review analyzed evaluations of interventions to prevent diagnostic errors. Searches used MEDLINE (1966 to October 2012), the Agency for Healthcare Research and Quality's Patient Safety Network, bibliographies, and prior systematic reviews. Studies that evaluated any intervention to decrease diagnostic errors in any clinical setting and with any study design were eligible, provided that they addressed a patient-related outcome. Two independent reviewers extracted study data and rated study quality.There were 109 studies that addressed 1 or more intervention categories: personnel changes (n = 6), educational interventions (n = 11), technique (n = 23), structured process changes (n = 27), technology-based systems interventions (n = 32), and review methods (n = 38). Of 14 randomized trials, which were rated as having mostly low to moderate risk of bias, 11 reported interventions that reduced diagnostic errors. Evidence seemed strongest for technology-based systems (for example, text message alerting) and specific techniques (for example, testing equipment adaptations). Studies provided no information on harms, cost, or contextual application of interventions. Overall, the review showed a growing field of diagnostic error research and categorized and identified promising interventions that warrant evaluation in large studies across diverse settings.
The objective of our study was to identify whether a substantive difference exists between the imaging interpretations of radiologists at outside referring institutions and those of radiologists at a tertiary care children's hospital and whether such reinterpretation affects the clinical management of pediatric patients.
This retrospective chart review examined the diagnostic imaging reports of all pediatric patients referred to a tertiary care freestanding children's hospital over a 17-month period (January 1, 2009-May 31, 2010); 773 examinations met the inclusion criteria. The original and second interpretations were compared. A fellowship-trained pediatric radiologist and neuroradiologist categorized each case using the content of the two radiology reports as agreement versus minor or major disagreement, and the results were analyzed for statistical significance. A cohort of cases in which a final diagnosis could be confirmed was also analyzed to evaluate the accuracy of both interpretations.
Disagreements were found in 323 of 773 reports (41.8%): 168 (21.7%) were major and 155 (20.0%), minor. Neurologic studies were most frequently requested for reinterpretation, 427 (55.2%), most commonly in the setting of trauma, 286 (67.0%). Among the 427 neuroimaging studies, major and minor disagreements occurred in 54 (12.6%) and 91 (21.3%) cases, respectively. Major disagreements most frequently observed were about the presence of fracture and hemorrhage. Among 305 body imaging cases, major and minor disagreements occurred in 99 (32.6%) and 57 (18.7%) cases, respectively. The most common setting for nontraumatic body imaging was concern for appendicitis (168/305 [55.1%]); this indication for imaging was responsible for 40.3% of major disagreements in nontraumatic abdominal imaging. Reinterpretation was rarely requested for radiographic studies (41/773 [5.3%]), which had major and minor disagreement rates of 36.6% and 17.1%, respectively. In the cohort of cases analyzed for final diagnosis, the second interpretation was more accurate than the original in 90.2% of cases with a p value of less than 0.0001.
Our findings suggest that discrepancy rates for second interpretations in studies of pediatric patients transferred to tertiary care pediatric institutions are substantial. Although the original and second interpretations in the majority of cases were in agreement, major discrepancies were prevalent-12.6% and 32.6% of neuroimaging and body studies, respectively-and the second interpretations were significantly correlated with the final diagnosis. These results indicate that interpretations by subspecialty radiologists at a point-of-care facility provide important clinical information about the pediatric patient and should be recognized by payers as integral to optimal care.
Context:
Original surgical pathology materials from external sources are reviewed by our pathologists for referred patients before their clinical evaluation and treatment.
Objective:
To identify the rate of major disagreements with diagnoses from external institutions and to characterize the nature and impact of discordant diagnoses on patient care.
Design:
We identified and reviewed all surgical pathology cases, except for medical liver, medical renal, and cardiac pathology cases, for the period between January 1, 2005, and December 31, 2010, to determine the overall frequency of major disagreements, defined as any change in diagnosis having a substantial impact on patient management.
Results:
Our review of 71 811 cases initially examined between 2005 and 2010 identified 457 major disagreements (0.6%). The most frequent areas of disagreement were gastrointestinal (80 cases; 17.5%), lymph node (73; 16.0%), bone/soft tissue (47; 10.3%), and genitourinary (43; 9.4%). For a subset of 166 cases reviewed between July 1, 2009, and December 31, 2010, follow-up data were available for 140 (84.3%). Treatment was affected by a changed diagnosis in 126 cases (90.0%), and prognosis was affected in 129 cases (92.1%). For 86 (51.8%) of the 166 cases, additional tissue was obtained. Revised diagnoses concurred with follow-up tissue diagnosis in 84.9% (73 cases), whereas they differed from follow-up tissue diagnosis in 15.1% (13 cases).
Conclusions:
Our findings demonstrate the value of outside case review of pathology materials for referred patients, and suggest that it decreases the likelihood of diagnostic errors and provides better protection for patients.
BACKGROUND
To the authors' knowledge, the frequency and clinical impact of errors in the anatomic pathology diagnosis of cancer have been poorly characterized to date.METHODS
The authors examined errors in patients who underwent anatomic pathology tests to determine the presence or absence of cancer or precancerous lesions in four hospitals. They analyzed 1 year of retrospective errors detected through a standardized cytologic–histologic correlation process (in which patient same-site cytologic and histologic specimens were compared). Medical record reviews were performed to determine patient outcomes. The authors also measured the institutional frequency, cause (i.e., pathologist interpretation or sampling), and clinical impact of diagnostic cancer errors.RESULTSThe frequency of errors in cancer diagnosis was found to be dependent on the institution (P < 0.001) and ranged from 1.79–9.42% and from 4.87–11.8% of all correlated gynecologic and nongynecologic cases, respectively. A statistically significant association was found between institution and error cause (P < 0.001); the cause of errors resulting from pathologic misinterpretation ranged from 5.0–50.7% (the remainder were due to clinical sampling). A statistically significant association was found between institution and assignment of the clinical impact of error (P < 0.001); the aggregated data demonstrated that for gynecologic and nongynecologic errors, 45% and 39%, respectively, were associated with harm. The pairwise kappa statistic for interobserver agreement on cause of error ranged from 0.118–0.737.CONCLUSIONS
Errors in cancer diagnosis are reported to occur in up to 11.8% of all reviewed cytologic-histologic specimen pairs. To the authors' knowledge, little agreement exists regarding whether pathology errors are secondary to misinterpretation or poor clinical sampling of tissues and whether pathology errors result in serious harm. Cancer 2005. © 2005 American Cancer Society.