Course 1B: Value-Based Health Care Delivery (Modules 4-5) > 3.The Harms of Fragmented Care

3.The Harms of Fragmented Care

MODULE 4 | Section 3 of 10

The Harms of Fragmented Care

The current care system is largely structured around clinicians’ medical expertise (e.g. cardiologist, oncologist, or orthopedic surgeon), with fragmented care that is organized at the level of individual units or facilities. For example, a patient with knee pain may see their primary care clinician, a physical therapist, and an orthopedic surgeon all in separate buildings, potentially scattered across town.
We are asking a lot of our patients. Depending on their needs, they must often make several different appointments in several disparate locations, take time off work, coordinate travel to different clinics, and fill out redundant paper forms in each location. The more complex a person’s needs, the more likely it is their care will be fragmented, further complicating the care of those who need it the most. In addition, patients and their families often have to serve as the coordinators of all this care, ensuring that they are obtaining all of the records and test results they need to share with their other physicians or clinicians.

THIS FRAGMENTATION OF CARE CONTRIBUTES TO MANY HARMS FOR PATIENTS

M4s3img4

missed or delayed diagnoses 1

M4s3img5

repeat testing

 

M4s3img6

lack of follow-up to test results 2

M4s3img7

medication errors 3

M4s3img8
financial harms of needing to take time off work to attend appointments in different locations
M4s3img9
financial stress of paying different specialty clinics the costs of care
M4s3img10
the associated psychological stress of coordinating it all
Transitions in care are particularly vulnerable times for patients, placing them at risk for many potential adverse events. One example is the period just following hospital discharge. One study found that for patients seen by different physicians following hospital discharge, information from a previous visit was available at a subsequent visit only 22% of the time.4 This sort of lack of communication and coordination makes the delivery of safe, high-value care essentially impossible.

ADDITIONAL RESOURCES

OVERKILL

Read Dr. Atul Gawande’s article “Overkill,” which discusses the harms to the patient from unnecessary care in the medical system.
READ ARTICLE

VISUALIZATION OF PATIENT HARMS

Vis 1
A 2005 study of 134 patients found that 100% of handoffs (transfer of patient from one clinician to another) contained errors (absence or inaccuracy), and 94% involved more than one error.5
VIEW FULL STUDY
Vis 3
In a 2006 study of 181 claims, 59% of claims involved diagnostic errors . 59% of these resulted in serious harm to the patient while 30% resulted in patient death.1
VIEW FULL STUDY
Vis 4
Communication contributed to 91% of medical mishaps in a 2011 study of 70 such cases . These were overwhelmingly attributed to concern of looking incompetent through sharing negative or unfavorable information.7 >VIE
VIEW FULL STUDY
Vis 5
A 2012 study conducted a systematic analysis of 768 articles, finding that results for up to 62% of laboratory tests and 35.7% of radiology test were not followed up with patients . This led to missed cancer diagnoses, among other negative patient outcomes.2
VIEW FULL STUDY
“[Better] performance is not simply – it is not even mainly – a matter of effort; it is a matter of design.”
Dr. Don Berwick, Senior Fellow of the Institute for Healthcare Improvement and Former Administrator of CMS.

Learn More

STUDY

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations.

Study estimates that 5% of adults in the United States experience a missed or delayed diagnosis each year. When the diagnosis is wrong, all the care that follows is waste or harm.

Singh H, Meyer AND, Thomas EJ.
BMJ Qual Saf.
2014;23:727-731.

STUDY

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

Data, which suggest that untimely information availability and managing test results contribute to delayed and missed diagnoses in outpatient care.

Sarkar U, Bonacum D, Strull W, et al.
BMJ Qual Saf.
2012;21:641-648.

STUDY

Care Fragmentation, Quality, and Costs Among Chronically Ill Patients

Study shows patients with higher levels of fragmented care suffer from lower standards of care, higher rates of preventable hospitalizations, and higher costs of care.
Brigham R. Frandsen, PhD; Karen E. Joynt, MD, MPH; James B. Rebitzer, PhD; and Ashish K. Jha, MD, MPH

REFERENCES

  1. 1- Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Ann Intern Med. 2006;145:488–496.

 

  1. 2- Callen JL, Westbrook JI, Georgiou A, Li J. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. Journal of General Internal Medicine. 2012;27(10):1334-1348.

 

  1. 3-
  2. Da Silva BA, Krishnamurthy M. The Alarming Reality of Medication Error: A Patient Case and Review of Pennsylvania and National Data. Journal of Community Hospital Internal Medicine Perspectives. 2016;6(4):10.3402/jchimp.v6.31758.

 

  1. 4-van Walraven C, Taljaard M, Bell CM, et al. Information Exchange Among Physicians Caring for the Same Patient in the Community. CMAJ 2008;179:1013–8.

 

  1. 5-Spitzberg BH. (Re)Introducing Communication Competence to the Health Professions. Journal of Public Health Research. 2013;2(3):e23. doi:10.4081/jphr.2013.e23.

 

  1. 6-Chang VY, Vineet MA, Lev-Ari S, D’arcy M, Keysar B. Interns Overestimate the Effectiveness of Their Hand-Off Communication. Pediatrics. 2010;125(3):491-496; http://dx.doi.org/10.1542/peds.2009-0351

 

  1. 7-Sutcliffe KM, Lewton E, Rosenthal MM. Communication Failures: An Insidious Contributor to Medical Mishaps. Acad Med. 2004;79(2):186-194. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14744724.

Leave a Comment