The gaps in specialists' diagnoses

Scott, Ian A; Campbell, Donald

doi:10.5694/mja17.00905

Cited by 8 publications

(10 citation statements)

References 29 publications

(43 reference statements)

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“…In addition, while the majority of readmissions following hospitalisations for common acute ACSC were for different primary diagnoses, many readmissions were for these same acute conditions (more than 30% of early readmissions following UTI and 40% following cellulitis). These findings are consistent with evidence that primary acute diagnoses are common antecedents and/or consequences of chronic conditions and multimorbidity, 29,32 and that patients with multimorbidity are more likely to present with acute problems related to interactions between multiple diseases and/or drugs. 8,31,32 This helps explain why many readmissions are spread across diagnostic groups and highlights why attention should not be focussed on primary diagnoses and/or readmissions with the same primary diagnoses as the index admissions.…”

Section: Discussionsupporting

confidence: 88%

“…These findings are consistent with evidence that primary acute diagnoses are common antecedents and/or consequences of chronic conditions and multimorbidity, 29,32 and that patients with multimorbidity are more likely to present with acute problems related to interactions between multiple diseases and/or drugs. 8,31,32 This helps explain why many readmissions are spread across diagnostic groups and highlights why attention should not be focussed on primary diagnoses and/or readmissions with the same primary diagnoses as the index admissions.…”

Section: Discussionsupporting

confidence: 88%

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Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service

et al. 2020

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Objectives To describe morbidity and multimorbidity patterns among adults readmitted to an Australian regional health service, in terms of occurrence of the same and different morbidities at index admission and readmission. Methods This cohort study used hospital admissions data for patients admitted between 1 July 2014 and 30 June 2016 to estimate proportions of unplanned readmissions (‘early’ within 30 days and ‘late’ within 1–6 months) with the same and different morbidities as the index admission. Readmission rates were estimated by selected sociodemographic, admission and diagnostic characteristics. Results The majority of early and late readmissions were in different diagnostic groups and for different primary morbidities to the index admission. Only 38.8% of readmissions were in the same major diagnostic group as the index admission and 18.4% in the same Adjacent Diagnosis-Related Group. Twenty one percent of admitted patients were readmitted within six months, with this increasing to 35.3% among multimorbid patients. Conclusion With increasing prevalence of multimorbidity, particularly among those at increased risk of readmission, it is essential to step away from a single disease focus in the design of both hospital avoidance and chronic disease management programmes. Holistic interventions and strategies that address multiple chronic conditions are required.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionsupporting

confidence: 88%

Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service

et al. 2020

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“…It is not surprising that the likelihood of consultation with a specialist physician by elderly patients is more linked to their incomes than healthcare needs 29. Gaps in specialists’ clinical knowledge base often lead to cross-referrals to other specialties resulting in tortuous patient journeys leading to diagnostic delays 30…”

Section: Discussionmentioning

confidence: 99%

Provision of primary care by specialist physicians: a systematic review

Hashim¹

2020

Fam Med Com Health

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Patients with stable chronic diseases such as diabetes and hypertension can be safely managed at the primary care level. Yet many such patients continue to follow-up with specialists at a higher expense with no added benefit. We introduce a new term to describe this phenomenon: scope inversion, defined as the provision of primary care by specialist physicians. We aimed to quantify the extent of scope inversion by conducting a systematic review. MEDLINE and five other databases were searched using the keywords ‘specialist AND (routine OR primary) AND provi*’ as well as other variations. The search was limited to human research without restrictions on language or date of publication. The inclusion criterion was studies on rates of the provision of routine primary care by specialist physicians. Thirteen observational studies met the inclusion criteria. A wide range of primary care involvement was observed among specialists, from 2.6% to 65% of clinic visits. Among children, 41.3% of visits with specialists were routine follow-ups for conditions such as allergic rhinitis and seborrhoeic dermatitis which could be managed in primary care. Data quality was moderate to low across the studies due to limitations of source data and varying definitions of primary care. Specialist physicians provide primary care to patients in a substantial proportion of clinic visits. Scope inversion is wasteful as it diverts patients to more expensive care without improving outcomes. A systems approach is needed to mitigate scope inversion and its harmful effects on healthcare service delivery.

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“… 6 , 7 Inappropriate referral and a lack of appropriate differential diagnoses are risk factors of diagnostic errors. 2 , 8 Some studies reported that specialists see more patients with stable chronic diseases than generalists 9–11 in daily practice; therefore, when they encounter patients with undiagnosed new health problems that are irrelevant to their specialty domain, more unnecessary cross-referrals to other specialists and diagnostic tests occur, 9 , 11 , 12 which result in diagnostic errors, patient harm, and consumption of healthcare resources. 2 , 5 Indeed, a previous study showed that approximately 10% of infectious disease consultations from other specialty departments associated with fever or inflammation of undetermined origin were due to non-infectious diseases.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of General Internal Medicine Consultations for Diagnosis from Specialists in a Tertiary Hospital: A Retrospective Observational Study

Yokose¹,

Harada²,

Hanai³

et al. 2022

IJGM

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Purpose The data on the diagnostic contribution of general internal medicine (GIM) consultations for undiagnosed health problems from specialists are scarce. This study aims to explore the role of generalists as diagnostic medicine consultants in tertiary care settings. Patients and Methods We conducted a retrospective observational study at a Japanese university hospital. GIM consultations for diagnosis from other departments on outpatients aged ≧ 20 years from January 2018 to December 2020 were included. Data were extracted from electronic medical records. The primary outcome was new diagnosis rates. The secondary outcomes were new diagnosis rates with clinical significance and clinical outcomes at 90 days from the index visit. Results A total of 328 patients were included. The top five consulting departments were orthopedics (17.0%), cardiovascular (10.3%), otorhinolaryngology (8.8%), neurology (8.8%), and gastroenterology (7.9%). GIM identified 456 chief complaints (CCs), and the top five were fever (10.9%), abnormal laboratory results (8.3%), fatigue (5.9%), and pain (7.4%) or numbness (4.6%) in the extremities. There were 139 (104/328 patients: 31.8%) specialty consultations from GIM, and the top five departments were rheumatology (21.1%), gastroenterology (19.2%), orthopedics (9.6%), psychiatry (9.6%), and neurology (9.6%). In total, 277 new diagnoses were established in 232 patients (70.7%), and 203 patients had new diagnoses with clinical significance (61.8%). Clinical outcomes at 90 days from the time of the index visit were resolution/improvement (60.7%), unchanged/worsened (22.3%), and unknown (17.0%). Conclusion Over 70% of GIM consultations from other departments established new diagnoses with favorable outcomes in >60% of the patients.

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The gaps in specialists' diagnoses

Cited by 8 publications

References 29 publications

Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service

Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service

Provision of primary care by specialist physicians: a systematic review

Outcomes of General Internal Medicine Consultations for Diagnosis from Specialists in a Tertiary Hospital: A Retrospective Observational Study

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