Spotlight on the relationship between medicine management and improving diagnosis
United Nations global awareness days are a chance to shine a light on a particular issue, raising awareness among healthcare workers, patients and the wider public. This year, September 17th is World Patient Safety Day. This year, the theme is improving diagnosis for patient safety with the slogan ‘Get it right, make it safe!’.
This slogan — which you might argue is basically a summary of medicine itself — highlights the crucial importance of treating the right condition. However, it also oversimplifies the situation. This disguises many potential problems surrounding diagnosis, especially for people with multiple conditions or taking multiple medicines. I think there is much to be said for exposing and discussing this issue, and not pretending that all errors in diagnosis can be solved by simple systemic responses such as heavy workloads or addressing cognitive factors such as tiredness or bias in clinicians.
Diagnosis of multiple conditions
The World Health Organization’s coverage of World Patient Safety Day states that ‘a diagnosis identifies a patient’s health problem’ and defines a diagnostic error as ‘a failure to establish a correct and timely identification of a health problem’. My issue with this is that many patients — and particularly those in certain groups such as people with mental health conditions, or older people — don’t have just one health problem.
The National Library of Medicine estimates that about 20% of people in the United States experience a diagnosable mental health problem in any given year. However, about 3% of the population have more than one problem at the same time. This is large — but pales into insignificance next to the estimate from the National Council on Aging that 95% of all people over 60 years old have a chronic health condition, and nearly 80% have two or more. Across the whole population, more than one quarter (27%) are estimated to have more than one chronic health condition.
Many or all of these conditions are likely to be managed by medication — and sometimes more than one. This means that people with multiple conditions are more likely to be taking multiple medications, a situation known as polypharmacy. A report from the US found that about a third of adults aged over 60 had taken five or more prescription drugs in the previous month.
The problem is that medicines interact. They also cause side effects, both by themselves and in combination with other drugs.
If an older patient presents at a doctor’s surgery with new symptoms, how is the doctor to distinguish between symptoms caused by a new or undiagnosed condition, side effects to a particular medication, or an interaction between medications? Medication management has a clear role to play here — and therefore in patient safety.
Medication management and improving diagnosis
Medication management ensures that patients are taking the right dose of the right drug at the right time. However, smart medication management systems have other benefits. One of the ideal features of a smart medication management system is enabling healthcare professionals to check individual patients’ prescriptions for potential drug interactions. These systems also ideally provide alerts for contra-indications for new medications.
What would this mean for diagnosis? When a healthcare professional saw a patient reporting new symptoms, their first port of call would be the medication management system. This would allow them to check the patient’s existing medications, including a list of potential side effects and interactions with other medications. We know that not all side effects or interactions are reported in clinical trials, but this is a very good starting point.
If a reported symptom is known to be a side effect of a particular medication, it is reasonable to assume this is what is happening. Medicine, by and large, follows Occam’s Razor: that the simplest explanation is usually the best. The ‘side effect’ hypothesis can easily be tested by stopping or changing the medication to an alternative, using the medication management system to try to prevent future interactions or problems.
Medication management, and especially medicine reviews and deprescribing, can also help to improve diagnosis by reducing polypharmacy. Fewer medicines should equal fewer complications — and therefore clearer diagnoses. There is also less potential for confusion.
Looking beyond the obvious
On World Patient Safety Day this year, let’s look at improving diagnosis, but let’s not pretend this is simple. People cannot be seen or treated as a single one-time diagnosis. If we try and do that, we will overlook the needs of people with more complex health problems — and also ignore some helpful potential solutions.
