geoffrey modest medical blogs

in the blog last week on recommendations for breast cancer screening (see  http://gmodestmedblogs.blogspot.com/2019/04/breast-cancer-screening-recs.html  ), i commented on some of the potential errors (eg misreading mammograms) as well as the poor results overall with screening and overdiagnosis/overtreatment.  in the process of reorganizing all of the blogs, i found this one finding that there were some pretty disturbing discrepencies in pathologist interpretation of breast biopsies (again, potentially leading to incorrect diagnoses and interterventions) geoff ------------------------------------------------------------------------------------------------------------------------------------------------------------------- discordance in interpreting breast biopsies March 18, 2015 one factor often not considered in the breast cancer screening algorithm is the accuracy of the pathology report after biopsies. the widespread use of mammograms h...

A recent Canadian study evaluated patients with physician-diagnosed asthma to see if they could be tapered off medications, and whether subsequent testing confirmed the diagnosis of asthma  (see  asthma diagnosis error jama2017  in dropbox, or Aaron SD. JAMA.2017;317(3):269) ​. Details: -- 701 patients who had physician-diagnosed asthma within the last five years were enrolled in a prospective multicenter study in 10 Canadian cities from 2012 to 2016. 613 people completed the study -- Mean age 51, 67% women, 90% white, BMI 30, 70% college-educated, 29% current smokers, mean age of asthma diagnosis was 45, spirometry or serial peak flow testing was done in the community in 56%, 18% had an urgent visit to healthcare facility for asthma in the past year, 90% using current asthma medications (49% using asthma controlling medications daily, 44% inhaled corticosteroids with or without long-acting beta-agonists, 7% leukotriene antagonists only), FEV1 pre-bronchodil...

A recent article revealed the dramatic variability in radiologists’ interpretations of mammographic breast density (see  mammog radiol variation AIM2016 ​ in dropbox, or Sprague BL. Ann Intern Med 2016; 165: 457). Determining breast density accurately is certainly important because increased breast density leads to difficulty in reading mammograms and is an independent risk factor for breast cancer.  In this light, one prerequisite for us in primary care is that the radiologic determination of breast density is consistent and accurate. But, details, from an NIH supported study: -- data from 216,783 screening mammograms from 145,123 women aged 40 to 89 were included, from 30 radiology facilities within three breast cancer screening research centers of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. --83 radiologists were involved; each interpreted at least 500 screening mammograms from 2011-3, u...

Bill  Galanter  just sent me the link to the UK report on primary care from the House of Commons Health Committee (which i could not find when sending out the initial blog). will attach a copy of the report as well as the link (http://www.publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/408.pdf ). Basic issues addressed in the report: --improve access to primary care by extending hours of service,  reaching out to those currently disenfranchised  by the existing model of care --improve record keeping and  access to medical records as a means to improve patient safety , with patient consent for more general access to records --facilitate phone and IT access for patients and for consultations --quality improvement initiatives: Care Quality Commission inspection of primary care practices, helping practices improve -- “ Ten-minute appointments do not allow adequate time for safe practice or to address whole person care . Relentless...

 There was a recent brief article looking at the approximate rate of medical errors leading to death, and suggesting that this was the 3rd leading cause of death in the US ( see  medical errors  bmj2016  in  dropbox , or doi : 10.1136/bmj.i2139). details: --a 1999 Institute of Medicine report, based on the 1984 Harvard Medical Practice Study and the 1992 Utah and Colorado Study, suggested that of the 180,000 reported iatrogenic deaths, 51% were preventable, though the lead Harvard researcher suggested that the number was closer to 78% (ie 140,400 preventable deaths). this number was based on a record review of a  population-based study of New York Hospitals reported in 1993.  overall there was a 4% incidence of adverse events reported in the hospitalized patients. --a 2004 report from the Agency for Healthcare Quality and Research Patient Safety Indicators for the Medicare population estimated 195,000 deaths from medical erro...

​one factor often not considered in the breast cancer screening algorithm is the accuracy of the pathology report after biopsies. the widespread use of mammograms has led to lots of biopsies (1.6 million women in the US each year), with a reported approx 25% being positive for cancer. from 2011 to 2014 highly experienced pathologists from 8 states reviewed slides and the concordance of their readings was assessed  (see  breast biopsy discordance JAMA 2015  in dropbox, or JAMA. 2015;313(11):1122-1132​) . results: --65% of the invited pathologists consented to participate (n=115) and each given 60 slides to review from a total of 240 cases  (1 slide/case), including 23 cases of invasive cancer, 73 of ductal ca in situ, 72 with atypical hyperplasi a (atypia) , and 72 benign cases without atypia --49% of cases were in women 40-49yo, 50.8% had either heterogeneously dense or extremely dense breast tissue on mammogram, 57.5% were from core biopsi...