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3 October 2006 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians. These highlights are not intended to substitute for articles as sources of information. For an embargoed copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656.

Medical Misdiagnoses in the Office Setting Are Caused by Multiple Breakdowns

A study of 181 closed malpractice claims in which patients alleged a missed or delayed diagnosis in an ambulatory setting found that 59 percent (106) of these errors were associated with serious harm and 30 percent (55) resulted in death (Article, p. 488). In 59 percent (106 cases), the missed or delayed diagnosis involved cancer, chiefly breast and colorectal cancers. Most errors occurred at four main “breakdown” points in the diagnostic process: failure to order an appropriate diagnostic test, failure to create a proper follow-up plan, failure to obtain an adequate history or perform an adequate physical examination, and incorrect interpretation of diagnostic tests. Patients also contributed to the errors, for example, by not providing complete information about their health or not keeping appointments. An editorial writer points out that most patient safety efforts to date have focused on hospitals (Editorial, p. 547). The writer says that hospital practice and office practice differ in ways that make errors more difficult to avoid in the office setting. “Nevertheless, the study helps point the way to changes in training, practice, and systems that might prevent many of these errors,” the writer says.

Hemodialysis Patients Whose Care Meets Clinical Targets Have Fewer Hospitalizations and Deaths

A survey of 15,287 patients receiving long-term hemodialysis found that those who got better quality of care were less likely to be hospitalized or to die than those who got worse care (Article, p. 512). The measures of quality of care were anemia, serum albumin levels, functioning vascular access, and dialysis adequacy. The annual death rates in patients who met zero, one, two, three, or four of the quality measures were 29 percent, 25 percent, 21 percent, 14 percent, and 7 percent, respectively. The authors note that a high proportion (69 percent) of the patients achieved two or fewer of the quality indicators. The study could not determine whether to blame poor quality care on patient factors or physician and health system factors.

Advice Program for Primary Care Doctors Didn’t Improve Depression

A study of 375 patients with depression found that those whose doctors used a depression decision support program did not get better (Article, p. 477). They did report more satisfaction with their care and were more likely to have received antidepressant medications than the ususal-care group. An editorial writer discusses why the results of this study might differ from previous studies (Editorial, p. 544).

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