By Dorothy Brooks
Diagnostic errors are particularly common in older adults.1 In a panel discussion about this issue at the annual forum of the Institute for Healthcare Improvement (IHI) in December, experts in diagnostics and elder care discussed the unique challenges of coming to a correct diagnosis in older patients and how healthcare providers can improve their performance.
Terry Fulmer, PhD, RN, FAAN, is president of the John A. Hartford Foundation in New York City, an organization focused on improving the care of older adults. During an IHI spotlight session, she acknowledged that achieving diagnostic excellence in older patients requires specificity and tenacity. She also noted how clinicians might draw conclusions based on age or appearance, essentially making judgments about what older patients should be experiencing, rather than listening to the patient and probing further.
“Ageist stereotypes can really obscure the diagnostic thinking that goes on for any of us,” Fulmer said. “We need to be very personal in the way we approach care.”
There also are differences in disease expression among older adults. Fulmer offered an example of an older patient who presents with pneumonia but no fever. “They may have an acute MI [myocardial infarction] and no chest pain,” she said. “A symptom may be as vague as someone saying that they just feel off today. That should put your alarm up when it comes to older people.”
Communication challenges can be an obstacle when trying to find the root of a problem in an older adult. For instance, if patients with vision or hearing difficulties have not arrived with glasses or hearing aids, that can create a barrier. Other patients might present with mild cognitive impairment. “It certainly changes the way we need to interface with them as clinicians and as people,” Fulmer said.
Older patients also might present with a long list of seemingly divergent symptoms. For instance, Fulmer noted a patient who might have received a diagnosis of congestive heart failure — but he or she also could be living with Parkinson’s disease, reporting pulmonary symptoms, and struggling with arthritis — and maybe even more ailments. “You have to pay attention to all of them because they confound one another,” Fulmer said. “The medicines, upon treating these patients, interact all the time.”
It is critical to pay close attention to what older patients say, along with any family members. “About 20% of older people get the wrong diagnosis in either direction, either overdiagnosis or underdiagnosis,” Fulmer estimated. “We want to make sure we are paying attention.”
To make improvements in this area, Fulmer advised providers caring for older adults to prioritize the four Ms framework: What Matters, Medication, Mentation, and Mobility.2
Despite the public health effects of diagnostic errors, not enough federal research dollars are invested into the issue. Meanwhile, health systems are not paying enough attention to the problem, observed Daniel Yang, MD, who spoke during the same session with Fulmer. Yang is a program director at the Gordon and Betty Moore Foundation, where he established the Diagnostic Excellence Initiative. This program is aimed at preventing harm from erroneous or delayed diagnoses; lowering costs and eliminating redundancy in the diagnostic process; and improving patient outcomes through timely and accurate, patient-centered diagnoses. Why are healthcare stakeholders not paying more attention to diagnostic errors? Yang noted some significant obstacles stand in the way.
“It is really hard to measure diagnostic performance,” Yang offered. “When we think about financial incentives, there are not really strong incentives for accountability mechanisms for healthcare delivery systems to get diagnosis right.”
Another possible reason could be psychological. “Providers, particularly physicians, do not like talking about the errors that they make,” Yang observed. “If there is one type of error that cuts really close to home and affects our sense of professional competency, it is diagnostic errors.”
To combat these obstacles, Yang called for a more inclusive view of diagnostic excellence, one that can be gleaned from the Institute of Medicine’s landmark 2001 report.3 Yang argued the six dimensions of healthcare quality outlined in that report also are the six dimensions of diagnostic excellence. “Safety is a key component of excellence,” he said.
However, Yang acknowledged these six dimensions often are in tension with one another. “A company may introduce a new diagnostic test that is faster and more accurate. But if that diagnostic test is cost-prohibitive or only available to a subset of the population, is that diagnostic excellence? Some people may say yes, and others may say no,” Yang noted. “It is important that we keep all six of these dimensions [in mind] because ... optimizing one of these dimensions leads to unintended consequences elsewhere.”
Yang also observed it is important to clear up the misconception that diagnosis is a decision made at a single point in time. “Diagnosis is a process that unravels longitudinally over time,” he said. “It is really important that we view diagnosis as a longitudinal process that is more like a video than just a snapshot at one point in time.”
Another misconception, according to Yang, is diagnosis primarily is a cognitive task only for clinicians with advanced skills. “Diagnosis is a team sport that is, at its core, multidisciplinary,” he noted. “It includes all these different providers who may not even know that they are working on the same team ... I think we need to think about diagnostics as a systems issue, not as a cognitive issue.”
Further, as someone who works in the ED, Yang said he always thought the diagnostic journey begins from the moment the patient steps into the ED. But today, Yang believes differently, preferring to take a patient-centered perspective.
“If our goal and aspiration is timely, accurate, and equitable diagnosis, I think we need to realize that there are opportunities to improve diagnosis that go beyond the four walls of the health system or hospital,” he explained, adding that it is important to think of diagnostics as a public health issue.
Perhaps a start to diagnostic excellence is simply putting more thought into it. “Diagnostic excellence, in some ways, has been the forgotten stepchild of the quality and safety movement,” Yang said. “It is challenging, but that doesn’t mean we shouldn’t be working on it.”
From there, Yang suggested working on diagnostic improvement where there is opportunity. For example, clinicians could focus on one care setting or on one of the handful of conditions that cause a disproportionate share of harm and suboptimal diagnoses (e.g., heart attacks, strokes, infections).
Another approach is to study specific populations — perhaps geriatric patients. “Older adults are one of the most vulnerable populations; they disproportionately experience harmful diagnostic errors,” Yang noted.
REFERENCES
1. Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: A systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med 2016;9:137-146.
2. John A. Hartford Foundation. Age-friendly care.
3. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press; 2001.
Experts in diagnostics and elder care recently discussed the unique challenges of coming to a correct diagnosis for older patients and how healthcare providers can improve their performance.
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