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Sep
17

It’s the diagnosis…

If the diagnosis isn’t right, there’s a pretty good chance the treatment won’t be right.

A while back I had an interesting conversation with folks from Best Doctors about this issue, and they provided some interesting statistics about the incidence of misdiagnosis.

  • The American Journal of Medicine reported that at least 15% of all medical cases in developed countries are misdiagnosed.
  • Even doctors are not immune to misdiagnosis:  According to The New England Journal of Medicine, 35% of doctors have reported errors in their own care or that of a family member.
  • A July 2012 BMJ [British Medical Journal] Quality & Safety paper found that of 5,863 autopsies studied, 28% had at least one misdiagnosis.
  • A study in Mayo Clinic Proceedings of 100 autopsies found 26 of 100 patients who died in the hospital had been misdiagnosed. Same study also found “The number of missed major diagnoses remains high, and despite the introduction of more modern diagnostic techniques and of intensive and invasive monitoring, the number of missed major diagnoses has not essentially changed over the past 20 to 30 years.”
  • Review of pathology resulted in changes in interpretation in 29% of breast cancer cases, while in 34% of cases, a change in surgical management was recommended.  A second evaluation of patients referred to a multidisciplinary tumor board led to changes in the recommendations for surgical management in 77 of 149 of those patients studied (52%) (University of Michigan Comprehensive Cancer Center.)

Best Doctors’ own data for US-based cases in 2013 indicated they corrected or refined diagnoses in 37% of cases, and corrected or improved treatment in 75% of cases. 

Of course, BD’s cases are more likely to have a misdiagnosis; their clients send them claims that look problematic.

With that said, there’s no question diagnosticians can get it wrong; in fairness, it can be pretty difficult to pinpoint the specific physiological or anatomical issue that is causing a patient’s symptoms.  As an example, identifying the cause of back pain is notoriously difficult, especially when an MRI indicates an abnormality.  Liberty Mutual’s recently-published research spoke to this issue directly:

Claims in which MRI was performed either within the first 30 days of pain onset or when there was no specific medical condition justifying the MRI yielded significantly higher medical costs, even after controlling for severity. The study found these early or non-indicated MRIs led to a cascade of medical services in the six-month period post-MRI that included electromyography, nerve conduction testing, advanced imaging, injections or surgery. These procedures often occurred soon after the MRI and were 17 to nearly 55 times more likely to occur than in similar claims without MRI.

“Being a highly sensitive test, MRI will quite often reveal common age-related changes that have no correlation to the anatomical source of the lower back pain,” said Glenn S. Pransky, MD, MOccH, Center for Disability Research.

What does this mean for you?

The lesson here is clear – too much reliance on technology can be counter-productive.  And patients who demand MRIs are not helping themselves. 


5 thoughts on “It’s the diagnosis…”

  1. This confirms my own experience from many years ago, before the MRI binge. We were told that our main problem was under diagnosis at an early stage of the injury. Nine times out of ten, a swollen knee is just a bruise. Trouble was that our employees were always the tenth – and needed more thorough examination. The answer was to get folk to Sports Doctors rather than Family Physicians.

  2. This may be one of the most important posts among many. In WC, if an employer evaluates all open claims with a chronic pain component, a sizeable portion of those claims will involve “over-diagnosis” where the physician(s) are attributing symptoms to a more serious problem than warranted by the clinical situation combined with relevant studies. The key word here is “relevant”. MRI’s don’t diagnosis anything. It is the treater who is relying too much on these imaging studies to correlate normal aging changes to pain complaints without proof of causation. Over the past year working with numerous clients in evaluating their lingering claims, we have found this in over 70% of the cases where the physician is not identifying the components that underlie their patients’ complaints in most MSD and nerve-related pain conditions. I don’t have a dog in this hunt, but we are taking advantage of newer technology in this area with NeuroPAS Global’s neurophysiologic pain profile to identify to what extent, if any, the pain is cause by a psychosocial component. I am now sold on this technology following very successful cases. We now prefer to use the term “over-diagnosis” versus mis-diagnosis. For those of us having been in the business for many decades, it is a pleasure to finally see some light at the end of the tunnel.

  3. Thanks for another informative article! In a New York Times article titled “Sports Medicine Said to Overuse M.R.I.’s” in Oct 2011, Gina Kolata. (http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html?pagewanted=all&_r=0). There are some key points:

    1. It is very rare for an MRI to come back with the words ‘normal study’. MRI is a static diagnostic imaging, it does not evaluate function.
    2. MRI is over used, not only in WC, but also in sports medicine.
    3. Dr. James Andrews scanned the shoulders of 31 perfectly healthy professional baseball pitchers who were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.”

  4. Years ago, John Deere partnered with the Mayo Clinic. Their philosophy was, “First, get the diagnosis right, then do only those things that help.” The quality of care improved and costs declined.

  5. I love this post. Al Lewis and I published a book last year called Cracking Health Costs, an Amazon trade bestseller, in which we chronicled the gross levels misdiagnoses and poor treatment plans for severely ill patients.

    Keep up the good work.

    Cheers

    Tom

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Joe Paduda is the principal of Health Strategy Associates

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