In summary, using a national physician-focused forensic case repository – the largest of its kind in the world – we found no cases of overuse of cardiac diagnostic tests. However, this result does not reduce the problem of overuse in health care2, nor does it suggest that overuse is less frequent or risky than underuse. Rather, it indicates an extremely low medico-legal risk resulting from the overuse of diagnostic tests by cardiologists in Canada. While there was criticism of the underuse of cardiac diagnostic tests by peer experts and academia, such criticism was also extremely rare, and clinical scenarios were not related to Choosing Wisely Canada`s recommendations on when not to test. Instead, the cases highlighted problems in diagnosing symptomatic patients. Overall, the review order did not appear to be a significant factor in medico-legal complaints. However, our findings may not fully address cardiologists` medico-legal concerns about evidence-based campaigns to promote appropriate diagnostic tests. Future studies to understand the relationships between cardiac diagnostic test prescription, Choosing Wisely Canada recommendations, patient harm, and “near misses” for a medical complaint in a larger sample of physicians would complement our findings. Out of 368 cardiology cases, we found no criticism of the overuse of cardiac diagnostic tests by peers, colleges or hospitals.
However, there were 15 cases of criticism on the insufficient use of diagnostic tests (4.1%). This criticism concerned diagnostic tests such as echocardiograms, coronary angiography and stress tests performed between 1994 and 2016, involving cardiologists from 3 Canadian provinces, mainly Ontario (11 out of 15; 73.3%). When the inappropriate use of diagnostic tests was criticized, case types were civil or collegiate cases (8 and 7 cases, respectively). Civil proceedings were generally decided in favour of the plaintiff (6 out of 8; 75.0%); others were dismissed by mutual agreement before being tried (2 out of 8; 25.0%). No collegiate case was decided in favour of the cardiologist (7 out of 7 negative). Throughout the build, you will develop transferable critical thinking, legal reasoning and analytical skills. Importantly, our findings do not reduce the problem of overuse in health care,2 nor do they reflect a lack of overuse of cardiac diagnostic tests. From April 1, 2008 to March 31, 2018, coronary angiography was performed with increasing frequency in Ontario (23.0% higher in 2017/2018 than in 2008/2009; Fig. additional S2). While an aging population and increasing rates of cardiac morbidity likely contributed to this increase,24 research suggests that a variety of cardiac diagnostic tests are overused,6, 7, 8 and these tests, in turn, may have led to referrals. In the example given (additional figure S2), approximately 42% of coronary angiograms in Ontario were prescribed by non-cardiologists. Depending on the type of referral and the tests that accompany it, cardiologists may have thought they had to respond and may have ordered other invasive tests for which they questioned the clinical indication.
The inherent nature of our forensic data did not allow us to capture this complexity when ordering tests. The Canadian Cardiovascular Society`s Choosing Wisely Canada Clinical Practice Guidelines99 and Choosing Wisely Clinical Guidelines10 are evidence-based campaigns to support appropriate screening and diagnostic testing in cardiology, but there are several reasons why they may not be followed when indicated.11, 12, 13 pitfalls in clinical decision-making, such as cognitive biases or lack of knowledge; can lead to misdiagnosis and insufficient use of tests.14, 15 Conversely, lack of knowledge or accidental results can trigger a heart test and overuse. Fear of litigation is cited as another reason for excessive test use.12,16, 17, 18 In a recent Canadian survey, a sample of cardiologists and cardiologists were concerned that they would increase their medico-legal risk if they took fewer tests according to the list of five things doctors and patients should question for cardiology – a list to combat overuse of cardiac diagnostic tests (Appendix Additional S1).16 To date, however, very little information has been published on medico-legal issues involving cardiologists in Canada. For the purposes of this study, we did not always assess under- or over-use of the diagnostic test. Instead, we assessed criticisms and complaints regarding under- and over-use, as documented in the forensic record. Therefore, our definition of underuse of tests was the failure to perform cardiac screening or diagnostic testing when clinically indicated, based on reviews from peer experts, universities or hospitals in the forensic case (S1 complementary methods list cardiac tests in our medico-legal cases). Our definition of test overuse was to perform a cardiac or diagnostic screening test that was not clinically indicated or did not provide clinically relevant diagnostic information, based on criticism made by peer experts, colleges or hospitals in the forensic record. Discordant patient complaints were cases where a patient or family complained about under- or over-use of cardiac tests, but there was no criticism from peer experts, colleges, or hospitals; These complaints were of secondary interest. Additional Figure S1 illustrates our classification system. To identify these 3 subgroups, we applied the extraction methodology described in the additional methods S2. Conclusions: Medical cases with cardiologists and excessive or inappropriate use of cardiac diagnostic tests were extremely rare in Canada, despite the potential for harm. The criticism of the underuse of the cardiac diagnostic test concerned problems with the diagnosis of symptomatic patients.
The factors most often associated with underuse of cardiac diagnostic tests were inadequate clinical decision-making by a cardiologist and loss of situational awareness (Figure 1A). For example, patients in 3 cases repeatedly had similar or aggravating health problems. In 1 case, patient-related factors may have contributed to the underuse of the diagnostic test because the patient had atypical symptoms. In 6 of 15 cases (40.0%), physician criticism was combined with criticism of communication or health systems (e.g., in 4 cases [26.7%], lack of resources or inadequate office systems were found in the forensic file). Figure 1B shows the specific criticisms of care. Other points of criticism from cardiologists concerned documentation in the medical record, consent process, patient advice on symptom management, and procedural engineering. For each case involving a patient, a nurse analyst reviewed the medico-legal records and then coded the clinical details and factors that could have contributed to each case. These methods have already been described.19 Analysts used the Canadian Classification of Health Interventions20 to code interventions (defined in Supplementary Table S1).
They coded patient harm using a classification system based on the American Society for Healthcare Risk Management`s classification of preventable health care harms21 (Supplementary Table S2). In addition, analysts used an internal coding framework19 to assign patient safety indicators and contributing factor codes (provider, team, system) based on peer, academic or hospital reviews (defined in Supplementary Table S1) in the medico-legal case. Analysts conducted weekly quality assurance checks of their coding, both electronically and in groups, to reduce classification errors. Nevertheless, our study provides important insights into the underuse of cardiac diagnostic tests associated with misdiagnosis in symptomatic patients. Forensic studies conducted in the United States have shown that misdiagnosis is one of the leading complaints against cardiologists.25, 26, 27 They also identified specific cardiac tests that were misinterpreted by cardiologists28 or were not performed in time,23,29 and misdiagnosed heart disease.25,28,29 In a contributory factor analysis, Oetgen et al.