[EXTERNAL] [IMPROVEDX] Patient-Provider Communication and Diagnostic Error

Graber, Mark Mark.Graber at VA.GOV
Tue Jul 15 21:54:12 UTC 2014

Barbara - Thanks for asking a GREAT question.  I think we all know the answer.   The bad news is that I don't think you'll find a paper that clearly links effective communication with improved diagnostic accuracy.  The reason is that so far we don't have a good way to actually measure diagnostic accuracy.  We really need that tool to start making progress in studying diagnostic accuracy and error.  David Sofen (Palo Alto Foundation Medical Group) and I have discussed this exact issue a couple of times, and the possibility of looking to see if there is correlation between communication style and diagnostic accuracy just amongst all the physicians in a large practice.  Hopefully he will weigh in on his own as well.

The good news is that there is PLENTY of INDIRECT evidence to support the relationship between effective communication and diagnostic quality:

1)   Communication breakdowns are a common cause of diagnostic error.  (Graber et al.  Diagnostic Error in Internal Medicine.  Arch Int Med (2005). 165:1493-99).  Hardeep Singh also has a series of publications on diagnostic errors arising from breakdowns in lab communications, which is a related issue.

2)  As Charlene Weir points out, there is evidence that the diagnosis emerges from the history alone in the majority of cases.    (Peterson MC, Holbrook JH, Von Hales D, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. The Western Journal of Medicine. BMJ 1992;156:163-5.  Wahner-Roedler DL, Chaliki SS, Bauer BA, et al. Who makes the diagnosis? The role of clinical skills and diagnostic test results. J Eval Clin Pract 2007;13:321-5.)  There is also a famous Osler quote on this:  "Listen to your patient, he is telling you the diagnosis".

3  There is substantial evidence that high levels of patient satisfaction (typically reflecting communication) correlate with improved health outcomes in general. Articles that David sent me address this point:

§  Doyle, C., Lennox, L., & Bell, D. (2013). "A systematic review of evidence on the links between patient experience and clinical safety and effectiveness." BMJ Open, 3. Available at http://bmjopen.bmj.com/content/3/1/e001570.full. This study finds consistent positive associations among patient experience, patient safety, and clinical effectiveness for a wide range of disease areas, settings, outcome measures, and study designs. It finds that patient experience is positively associated with clinical effectiveness and patient safety, and the results support the case for the inclusion of patient experience as one of the central pillars of quality in health care.

§  Boulding, W., Glickman, S. W., Manary, M. P., Schulman, K. A., & Staelin, R. (2011). "Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days", American Journal of Managed Care, 17(1), 41-48. Focusing on three common ailments-heart attack, heart failure and pneumonia-the authors measured 30-day readmission rates at roughly 2,500 hospitals and found that patient satisfaction scores were more closely linked with high-quality hospital care than clinical performance measures. Hospitals that scored highly on patient satisfaction with discharge planning also tended to have the lowest number of patients return within a month for all three specified ailments. Overall, high patient satisfaction scores were more closely linked to a hospital's low readmission rates than a solid showing on clinical performance measures.

§  Glickman, S. W., Boulding, W., Manary, M., Staelin, R., Roe, M. T., Wolosin, R. J., et al. (2010). "Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction", Cardiovascular Quality and Outcomes, 3(2), 188-195. Hospitals use patient satisfaction surveys to assess their quality of care. The objective of this study was to determine whether patient satisfaction is associated with adherence to practice guidelines and outcomes for acute myocardial infarction and to identify the key drivers of patient satisfaction. The authors found that higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients are good discriminators of the type of care they receive. Thus, patients' satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care.

§  Isaac, T., Zaslavsky, A. M., Cleary, P. D., & Landon, B. E. (2010). "The relationship between patients' perception of care and measures of hospital quality and safety", Health Services Research, 45(4), 1024-1040. The overall rating of the hospital and willingness to recommend the hospital had strong relationships with technical performance in all medical conditions and surgical care. The authors found that better patient experiences for each measure domain were associated with lower decubitus ulcer rates, and for at least some domains with each of the other assessed complications, such as infections due to medical care.

§  Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). "Patients' perception of hospital care in the United States", New England Journal of Medicine, 359, 1921-1931. This study assessed the performance of hospitals across multiple domains of patients' experiences and found a positive relationship between patients' experiences and the quality of clinical care. The authors found that patients who received care in hospitals with a high ratio of nurses to patient-days reported somewhat better experiences than those who received care in hospitals with a lower ratio, and hospitals that performed well on the HCAHPS survey provided a higher quality of care across all measures of clinical quality than did those that did not perform well on the survey.

Mark L Graber MD FACP
President, SIDM
Sr Fellow, RTI International

From: Barbara Balik <Barbara at THECOMMONFIRE.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Barbara Balik <Barbara at THECOMMONFIRE.COM>
Date: Tue, 15 Jul 2014 10:30:03 -0400
Subject: [EXTERNAL] [IMPROVEDX] Patient-Provider Communication and Diagnostic Error

I am looking for citations that link effective patient-provider communication and improvement in diagnosis accuracy.

Effective communication from the patient's view is often described as an effective listener, understanding the patient's story, and respecting values and choices

I appreciate any help

Barbara Balik, RN, EdD

Balik.Barbara at gmail.com
www.thecommonfire.com <http://www.thecommonfire.com>

Cell: 651.249.9237
Office: 505.797.8933

Common Fire Healthcare Consulting:
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