80 Overdiagnosis and error in general practice: the need of a new approach

Abstract

Objectives Diagnostic error (DE) is defined as a diagnosis unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made) (Graber, 2012). More recently, it has been proposed to include overdiagnosis in DE definition (Zwaan, 2015). Usually, the standard to analyze diagnostic process is the appropriateness of code assigned to a problem using the International Classification of Diseases (ICD). However at least one third of common symptoms do not have a disease-based explanation (Kroenke, 2014). This approach mean all expressions of illness must be associated to a disease label, against the context of general practice (Heath, 2011). ObjectivesTo assess diagnostic codes allocated to new cases of dyspnea in General PracticeTo study diagnostic error in patient attended by dyspnea in Primary CareTo determine the relationship between the occurrence of diagnostic error and patient harm. Method Cohort study of new episodes of dyspnea in patients receiving care from general practitioners (GPs) and GPs trainees at Primary Care Practices in Granada (Spain). In addition to filling out the electronic medical record of the patients attended, each physician fills out two specially designed questionnaires about the diagnostic process performed in each case of dyspnea: the first questionnaire includes questions on the physician’s initial diagnostic impression, the three most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the final diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. Our methods is based on the Zwaan methodology on Diagnostic errors in dyspnea patients treated in Dutch hospitals (Zwaan, 2009). Results Nine general practitioners and five GP trainees participated in this study. Initially, 373 records were collected for a year. 217 new cases of dyspnea were finally registered. Each of them received a diagnostic code by their general practitioner. The average number of cases recorded by each physician was 21.Mean time at until diagnosis was 32.89 days Final diagnosis included acute asthma exacerbation(37), acute bronchitis (34), asthma (30), COPD (27), other disease of respiratory system (26), anxiety (24) and congestive heart failure (20). In peer review process, Diagnostic testing requested were considered appropriate in 81.56% of the cases, Diagnostic process performed was considered not appropriate in 12.44%, and Diagnosis was wrong in 13.2% (32 of 217). Diagnostic error-related harm was not found. However, 4,15% of the cases in which a diagnostic tests were requested, adverse effects were found. Conclusions Although 1/3 of common symptoms don’t have a disease-based explanation, all new cases of dyspnea were categorized with a diagnostic code.It could can produce overdiagnosis, unnecessary tests and adverse effect. In our study, DE (13,2%) was similar to the only akin study (Zwaan, 2012), performed in five Dutch hospitals(13,8%). While in our study, carry out in PC, harm was not found as result of DE, patient was harmed in 11,3% cases in the Dutch study. The use of disease classifications as standard to define DE in PC may not reflect the general practice complexity: broad spectrum of symptoms, highest frequency of illness over disease, time as strategy to diagnosis (Irving, 2013). According to this, diagnosis-related harm (produced by missing, delayed or wrong diagnosis as well as early diagnostic and unnecessary procedures) could be an appropriate way to study DE in PC.