Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions

Stunkel, Leanne; Sharma, Rahul; Mackay, Devin D.; Wilson, Brad; Stavern, Gregory P. Van; Newman, Nancy J.; Biousse, Valérie

doi:10.1016/j.ophtha.2021.03.008

Cited by 27 publications

(31 citation statements)

References 36 publications

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“…2021 Mar 11 [Epub ahead of print])TO THE EDITOR: As an aspiring neuro-ophthalmologist, I read with interest the article by Stunkel et al that sought to quantify the rates of diagnostic errors as well as their subsequent harm in neuroophthalmic conditions. 1 Perhaps the most concerning finding of this paper is that the misdiagnosis of neuro-ophthalmic conditions from other ophthalmologists was estimated to be 157 in 296 (53%) and that 40 of these patients (25%) were harmed directly as a result. The authors have not presented a breakdown of final ophthalmic diagnosis based on the type of referrer, but all the diagnoses listed in their study are likely to be within the curriculum of a general ophthalmologist, and therefore it is reasonable to expect a significantly higher rate of accurate diagnosis.…”

mentioning

confidence: 80%

Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021;128:1356–1362)

Harvey

2021

Ophthalmology

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Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021 Mar 11 [Epub ahead of print])TO THE EDITOR: As an aspiring neuro-ophthalmologist, I read with interest the article by Stunkel et al. that sought to quantify the rates of diagnostic errors as well as their subsequent harm in neuroophthalmic conditions. 1 Perhaps the most concerning finding of this paper is that the misdiagnosis of neuro-ophthalmic conditions from other ophthalmologists was estimated to be 157 in 296 (53%) and that 40 of these patients (25%) were harmed directly as a result. The authors have not presented a breakdown of final ophthalmic diagnosis based on the type of referrer, but all the diagnoses listed in their study are likely to be within the curriculum of a general ophthalmologist, and therefore it is reasonable to expect a significantly higher rate of accurate diagnosis. 2 The authors highlight the need to improve incentives to attract trainees to subspecialize in neuro-ophthalmology, and it is true that neuro-ophthalmology remains one of the least popular subspeciality and fellowship preferences. 3,4 However, the data presented in this study demonstrate the significant level of patient harm caused by ophthalmologists before being seen by a neuro-ophthalmologist. An increase in neuro-ophthalmologists will be unlikely to address the primary issue of patient harm caused by diagnostic error from ophthalmologists, particularly if they are unaware the patient has a neuro-ophthalmic condition, such as in those cases cited as examples by the authors: tumor, stroke, or idiopathic intracranial hypertension.I propose that an additional approach to addressing this issue is to improve neuro-ophthalmology training, and therefore competency, for ophthalmologists with little or no interest in the subspecialty because their current level of diagnostic accuracy seem to present a dangerous patient safety concern. I believe this can and should be delivered outside of a formal fellowship as all ophthalmologists are likely to be presented with patients with either a primary or comorbid neuro-ophthalmic condition and diagnostic error in these patients can have harmful or even fatal consequences.

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confidence: 80%

Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021;128:1356–1362)

Harvey

2021

Ophthalmology

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“…(17)(18)(19)(20)(21) This is particularly relevant as the negative outcomes to delayed neuro-ophthalmic care are becoming quantified. (22) There are some limitations to this study. Though the sample size of visits is large, the number of practices studied (4 practitioners in 3 settings) is small with only 2 geographic regions considered.…”

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confidence: 94%

The Impact of COVID-19 on Neuro-Ophthalmology Office Visits and Adoption of Telemedicine Services

Moss¹,

Ko²,

Mackay³

et al. 2021

Journal of Neuro-Ophthalmology

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Background:The COVID-19 public health emergency (PHE) has significantly changed medical practice in the U.S., including an increase in the utilization of telemedicine. Here, we characterize change in neuro-ophthalmic care delivery during the early COVID-19 PHE, including a comparison of care delivered via telemedicine and in office.Methods: Neuro-ophthalmology outpatient encounters from three practices in the United States (four providers) were studied during the early COVID-19 PHE (March 15, 2020-June 15, 2020 and during the same dates one year prior. For unique patient visits, patient demographics, visit types, visit format, and diagnosis were compared between years and between synchronous telehealth and in-office formats for 2020.Results: There were 1276 encounters for 1167 patients. There were 30% fewer unique patient visits in 2020 vs. 2019 (477 vs. 670) and 55% fewer in office visits (299 vs. 670). Compared to 2019, encounters in 2020 were more likely to be established, to occur via telemedicine and relate to an efferent diagnosis. In 2020, synchronous telehealth visits were more likely to be established compared with in-office encounters. Conclusions:In the practices studied, a lower volume of neuro-ophthalmic care was delivered during the early COVID-19 public health emergency than in the same period in 2019. The type of care shifted toward established patients with efferent diagnoses and the modality of care shifted toward telemedicine.

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“…Main outcome measures included the percentage of eConsults in which enough information was provided at the time of eConsult for a definitive diagnosis and/or treatment decision to be made, percentage of patients who were recommended in-person evaluation, and eConsult's impact on patient care. The eConsult's impact on patient care was retrospectively ascertained into 6 classifications adopted from a previous study (2): negative (e.g., associated with poor patient outcome), no impact, provided reassurance (e.g., neuro-ophthalmologist agreed with referring provider's assessment and plan, which avoided unnecessary testing and/or in-person evaluation), avoided harmful treatment or provided urgent referral to appropriate provider, and directly saved vision and/or life.…”

Section: Methodsmentioning

confidence: 99%

Interprofessional Electronic Consultations for the Diagnosis and Management of Neuro-Ophthalmic Conditions

Xu¹,

Kung²,

Lai³

et al. 2022

Journal of Neuro-Ophthalmology

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Background:Interprofessional electronic consultation (eConsult) is a telemedicine modality in which consulting providers review outside records and provide recommendations without in-person consultation. The purpose of this study was to describe the utilization of eConsults in the management of neuro-ophthalmic conditions.Methods:Retrospective cohort study of all patients who received an eConsult for a neuro-ophthalmic condition at a single quaternary referral center from 2018 to 2020. Main outcome measures included proportion of eConsults in which sufficient data were provided to the neuro-ophthalmologist to generate a definitive management decision, proportion of patients for whom an in-person neuro-ophthalmology evaluation was recommended, and the eConsult's impact on patient care.Results:Eighty eConsults were conducted on 78 patients during the 3-year study period. Forty-eight (60.0%) subjects were female, mean age was 54 years, and 65 (81.3%) were White. The median time from eConsult request to completion was 4 days (range: 0–34 days). The most frequent eConsult questions were vision/visual field disturbances in 28 (35.0%) cases, optic neuropathies in 22 (27.5%), and optic disc edema in 17 (21.3%). At the time of eConsult, sufficient prior information was provided in 35 (43.8%) cases for the neuro-ophthalmologist to provide a definitive management decision. In 45 (56.3%) eConsults, further diagnostic testing was recommended. In-person neuro-ophthalmology consultation was recommended in 24 (30.0%) cases. Sixty-one (76.3%) eConsults provided diagnostic and/or treatment direction, and 12 (15.0%) provided reassurance.Conclusion:eConsults increase access to timely neuro-ophthalmic care and provide diagnostic and treatment direction to non–neuro-ophthalmology providers when sufficient information is provided at the time of eConsult.

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Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions

Cited by 27 publications

References 36 publications

Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021;128:1356–1362)

Re: Stunkel et al.: Patient harm due to diagnostic error of neuro-ophthalmologic conditions (Ophthalmology. 2021;128:1356–1362)

The Impact of COVID-19 on Neuro-Ophthalmology Office Visits and Adoption of Telemedicine Services

Interprofessional Electronic Consultations for the Diagnosis and Management of Neuro-Ophthalmic Conditions

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