FRAGMENTED patient care in general practice can lead to missed diagnoses, inappropriate prescribing, failure of preventive medicine, and subsequent medico-legal consequences for doctors, according to a Perspective published today by the Medical Journal of Australia.
The authors, led by Dr Jack Marjot, Medical Advisor with Avant Mutual, Australia’s largest medical defence organisations, wrote that continuity of care referred to “the holistic management of a patient by a single practitioner, or a well integrated network of practitioners in close communication”.
“There is a substantial body of literature that demonstrates the benefit of care continuity with respect to patient satisfaction, reduced mortality and reduced avoidable hospitalisation,” Marjot and colleagues wrote.
“However, we know that despite its importance, continuity of care with one practitioner is often lacking.”
Marjot and colleagues reviewed 14 cases of complaints to Australian medical regulators, compensation claims alleging medical negligence, and coroners’ cases.
They found three key areas where fragmented care was associated with adverse outcomes:
- Delayed or missed diagnoses – serious conditions diagnosed late in their natural history because of a variety of factors including missed pathology; patients with multiple comorbidities, polypharmacy, challenging patient behaviours; a failure to notice clinical warning signs; failure to reassess diagnosis when treatment was not effective; focus on treating the presenting symptom; false reassurance from involvement of secondary care; and, failure to acknowledge results of tests or investigations.
- Inappropriate prescribing – comprises one in 20 claims to Avant Mutual; “with no single GP assuming full responsibility for the patient, it appeared that each individual GP assumed a pattern whereby medications were prescribed based on previous prescribing behaviours”.
- Failure of preventive medicine – failure to address modifiable risk factors of disease, “which require patient engagement and motivation, regular follow-up, careful liaison with specialists, and titration of medication over time”.
“What a doctor must do to fulfil their duty of care will differ depending on each patient’s circumstances, including the presenting problem, history, and the potential harm that might result from inappropriate care,” Marjot and colleagues wrote.
“Whether or not the patient sees another doctor does not matter.
“A GP has a duty independent of any other practitioner and it is not a defence to say ‘they were not my patient’ or ‘I was not their usual doctor’.”
The authors suggested several risk mitigation strategies:
- Reviewing and recording the patient’s reason for the visit, reading through the records of recent consultations, and reviewing the patient’s health summary for important historical background.
- Reviewing important previous investigations, even if they were ordered by a different practitioner. In some cases, My Health Record may shed light on previous conditions and investigations.
- Explicitly asking patients if they have seen other clinicians for their current health problems.
- Advising the patient of the importance of following up the results of investigations and referrals.
- Being aware of anchoring bias, and a need for critical appraisal of previous assumptions, which may stave off delayed diagnoses.
- Attempting to ensure that appointment allocation within a practice is to the same doctor each visit where possible.
“An awareness of risk mitigation strategies is essential to ensure that the negative outcomes of fragmented care are limited,” Marjot and colleagues concluded.
- Cate Swannell