Association between Primary Care Physician Diagnostic Knowledge and Death, Hospitalisation and Emergency Department Visits Following an Outpatient Visit at Risk for Diagnostic Error: A Retrospective Cohort Study Using Medicare Claims
Open accessAbstract
Objective: Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors. Setting/participants: 1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke). Outcome measures: 90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations. Design: Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics. Results: Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits. Conclusion: Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Greater diagnostic knowledge, including the ability to analyze clinical data, make accurate differential diagnoses, and use diagnostic tests effectively, is associated with fewer adverse outcomes among high-risk diagnostic error situations.
“Greater diagnostic knowledge, including the ability to analyze clinical data, make accurate differential diagnoses, and use diagnostic tests effectively, is associated with fewer adverse outcomes among high-risk diagnostic error situations [82].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [82]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
The citation lists haven’t been fetched yet
References 31 · Cited by 16
Research works printed but not linked: 27
- [1]National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington, DC: The National Academies Press, 2018.
- [2]Graber ML, Trowbridge R, Myers JS, et al. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf 2014; 40: 102– 10. 10.1016/S1553-7250(14)40013-8 24730205 · DOI
- [3]Cresswell KM, Panesar SS, Salvilla SA, et al. Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med 2013; 10: e1001554. 10.1371/journal.pmed.1001554 24260028 PMC3833831 · DOI
- [4]Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract 2008; 25: 400– 13. 10.1093/fampra/cmn071 18842618 · DOI · Paper page
- [5]Goyder CR, Jones CHD, Heneghan CJ, et al. Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care. Br J Gen Pract 2015; 65: e838– 44. 10.3399/bjgp15X687889 26622037 PMC4655738 · DOI
- [6]Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: The "Big Three" - vascular events, infections, and cancers. Diagnosis 2019; 6: 227– 40. 10.1515/dx-2019-0019 31535832 · DOI · Paper page
- [7]Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving us adult populations. BMJ Qual Saf 2014; 23: 727– 31. 10.1136/bmjqs-2013-002627 PMC4145460 24742777 · DOI · Paper page
- [10]Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49: 196– 205. 10.1016/j.annemergmed.2006.06.035 16997424 · DOI
- [11]Poon EG, Kachalia A, Puopolo AL, et al. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. J Gen Intern Med 2012; 27: 1416– 23. 10.1007/s11606-012-2107-4 22610909 PMC3475819 · DOI
- [12]Chisholm A, Askham J. A review of professional codes and standards for doctors in the UK. USA and Canada: Picker Institute Europe Oxford, 2006.
- [13]Irvine D. Doctors in the UK: their new professionalism and its regulatory framework. Lancet 2001; 358: 1807– 10. 10.1016/S0140-6736(01)06800-3 11734261 · DOI
- [14]Kovacs E, Schmidt AE, Szocska G, et al. Licensing procedures and registration of medical doctors in the European Union. Clin Med 2014; 14: 229– 38. 10.7861/clinmedicine.14-3-229 PMC4952532 24889564 · DOI
- [16]Petterson SM, Liaw WR, Phillips RL, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med 2012; 10: 503– 9. 10.1370/afm.1431 23149526 PMC3495923 · DOI
- [17]Freed GL, Dunham KM, Singer D. Use of board certification and recertification in hospital privileging: policies for general surgeons, surgical specialists, and nonsurgical subspecialists. Arch Surg 2009; 144: 746– 52. 10.1001/archsurg.2009.28 19687379 · DOI
- [20]Lipner RS, Bylsma WH, Arnold GK, et al. Who is maintaining certification in internal medicine--and why? A national survey 10 years after initial certification. Ann Intern Med 2006; 144: 29– 36. 10.7326/0003-4819-144-1-200601030-00007 16389252 · DOI
- [24]Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med 2009; 169: 1881– 7. 10.1001/archinternmed.2009.333 19901140 · DOI · Paper page
- [25]Gray B, Vandergrift J, Lipner RS, et al. Comparison of content on the American Board of internal medicine maintenance of certification examination with conditions seen in practice by general internists. JAMA 2017; 317: 2317– 24. 10.1001/jama.2017.6853 28609535 PMC5815000 · DOI
- [26]Samonte K, de la Cruz S, Garcia MJ. An Overview of the ABIM Cardiovascular Disease Maintenance of Certification Examination. J Am Coll Cardiol 2020; 75: 1083– 6. 10.1016/j.jacc.2019.12.048 32138969 · DOI
- [28]Huber PJ. The behavior of maximum likelihood estimates under non-standard conditions. Paper presented at: Fifth Berkeley symposium on mathematical statistics and probability, Berkeley, CA, 1967.
- [29]White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica 1980; 48: 817– 38. 10.2307/1912934 · DOI · Paper page
- [30]Newman-Toker DE, Makary MA. Measuring diagnostic errors in primary care: the first step on a path forward. Comment on "Types and origins of diagnostic errors in primary care settings". JAMA Intern Med 2013; 173: 425– 6. 10.1001/jamainternmed.2013.225 23440273 · DOI
- [31]Waxman DA, Kanzaria HK, Schriger DL. Unrecognized cardiovascular emergencies among Medicare patients. JAMA Intern Med 2018; 178: 477– 84. 10.1001/jamainternmed.2017.8628 29482196 PMC5876812 · DOI
- [32]Liberman AL, Newman-Toker DE. Symptom-Disease pair analysis of diagnostic error (spade): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 2018; 27: 557– 66. 10.1136/bmjqs-2017-007032 PMC6049698 29358313 · DOI
- [33]Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff 2013; 32: 1368– 75. 10.1377/hlthaff.2013.0130 PMC3822525 23918480 · DOI
- [34]Zwaan L, Monteiro S, Sherbino J, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf 2017; 26: 104– 10. 10.1136/bmjqs-2015-005014 26825476 · DOI
- [35]Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin 2015; 33: 565– 75. viii. 10.1016/j.ncl.2015.04.009 26231272 PMC9023124 · DOI
- [36]Lipner RS, Brossman BG, Samonte KM, et al. Effect of access to an electronic medical resource on performance characteristics of a certification examination: a randomized controlled trial. Ann Intern Med 2017; 167: 302– 10. 10.7326/M16-2843 28806791 · DOI
- Authors
- Gray, B. M., Vandergrift, J. L., McCoy, R. G., Lipner, R. S., & Landon, B. E.
- Affiliations
- American Board of Internal Medicine (US)
- Mayo Clinic (US)
- Harvard University (US)
- Corresponding author
- Gray, Bradley M
- Venue
- BMJ Open
- Publisher
- BMJ
- Published
- 2021-04
- Volume
- 11
- Issue
- 4
- Pages
- e041817
- ISSN
- 2044-6055 (ISSN-L)
- PMC
- PMC8021735
- OpenAlex
- W3143665415
- Cited by
- 16
- References
- 31
- Citations by year
- 2026: 7 · 2025: 3 · 2024: 1 · 2023: 2 · 2022: 1 · 2021: 2
- FWCI
- 1.64
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMJ Open (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Keywords
- diagnostic errors, diagnostic knowledge, primary care physicians, general internists, maintenance of certification, adverse outcomes, mortality, hospitalization, emergency department visits, Medicare beneficiaries, physician performance
- MeSH terms
- Diagnostic Errors, Emergency Service, Hospital, Medicare, Hospitalization, Humans, Outpatients, Retrospective Studies, United States, Physicians, Primary Care
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
