Association between referral letters and diagnostic errors: a single-center, cross-sectional study in general internal medicine in Japan
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Sakura Kamiya
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Hiroki Ozawa
Abstract
Objectives
Referral documentation may either contribute to diagnostic excellence or play a role in diagnostic errors (DEs), but its exact impact remains unclear. This study investigates the association between referral documentation and DEs among patients initially evaluated by another hospital or department and subsequently referred to the general internal medicine (GIM) outpatient clinic of an acute care tertiary hospital in Japan.
Methods
This cross-sectional study analyzed outpatients who visited the GIM outpatient clinic between April 1, 2017 and March 31, 2023. Patients initially evaluated at another medical facility or department, who then visited the GIM outpatient clinic, and were subsequently readmitted unexpectedly within 14 days after GIM outpatient clinic visit were included. DEs were identified using the Revised Safer Dx Instrument. Errors were analyzed using the Diagnostic Error Evaluation and Research (DEER) taxonomy. Logistic regression analysis was performed to assess the relationship between referral letters and DEs.
Results
Of 80 patients, 29 (36.3 %) experienced DEs. Referral letters were present for 52 (65.0 %) patients. The proportion of DEs was lower in the referred patients compared to non-referred patients (25.0 vs. 57.1 %; p-value=0.004). After adjusting for age, sex, race, multimorbidity, type of previous physicians, and post-graduate year of the GIM physician, the presence of a referral letter was associated with a substantially likelihood of DEs (OR=0.20, 95 % CI: 0.06–0.62, p-value=0.005).
Conclusions
The presence of a referral letter facilitates accurate diagnoses while markedly reducing DEs. Healthcare systems should consider promoting the proper use of referral systems.
Acknowledgments
We sincerely thank Hardeep Singh, MD, MPH, Professor Medicine-Health Srvcs Research, Baylor College of Medicine, Houston, TX US, for his advice based on the results of our research.
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Research ethics: The protocol of this study was approved by the Institutional Ethics Committees at St. Luke’s International Hospital (23-J020).
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Informed consent: Informed consent was not required because this was a retrospective observational study. However, we allowed patients to opt out of this study.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Use of Large Language Models, AI and Machine Learning Tools: We used Chat GPT for proofreading this manuscript. All revisions were carefully reviewed and verified by the authors.
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Conflict of interest: The authors state no conflict of interest.
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Research funding: None declared.
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Data availability: Not applicable.
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Supplementary Material
This article contains supplementary material (https://doi.org/10.1515/dx-2024-0197).
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