State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults

Based on the available literature and identified gaps, we describe current practice improvement strategies, high-priority research topics and questions, and implications for policy to advance diagnostic safety in the older adult population.

Practice Improvement

Quality care for older adult patients relies on a comprehensive and coordinated approach to healthcare, including but not limited to preventive care, chronic disease management, and end-of-life care, to address their unique, diverse, and evolving needs. Recent efforts have called for the study and mitigation of harm from diagnostic errors in older adult populations. For example, a 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) workshop, Advancing Diagnostic Excellence for Older Adults,⁶ suggested strategies to improve diagnostic quality, including:

• Listen to older adults and their personal stories to enhance their voice in their care plan.
• Implement environmental modifications and intentional training in communication for clinicians to reduce barriers to the healthcare system for older adults with hearing loss.
• Shift shared decision making from being disease focused to being better aligned with patient priorities.
• Meaningfully involve family members and caregivers in the communication and diagnostic process.
• Integrate medication data in EHRs to help clinicians provide structured monitoring and followup of new medications, improve medication use, and reduce harm and burden.
• Identify and understand cultural factors to improve diagnosis and care.
• Provide more culturally relevant education on dementia symptoms and diagnosis to diverse communities.

Ongoing efforts to reduce diagnostic errors specifically in older adult populations are highlighted below.

The 4Ms and Age-Friendly Health Systems Initiatives. In their work to create Age-Friendly Health Systems to rethink care for older adults, The John A. Hartford Foundation developed the 4Ms framework to help system leaders and frontline teams consistently deliver high-quality, age-friendly care.¹¹⁸ This framework has been widely implemented across inpatient, ambulatory practices, convenience clinics, and nursing homes.

From a diagnostic perspective, the 4Ms framework can include:

1. What Matters: understanding patients’ health goals and care preferences to know and align diagnostic priorities and workup decisions, involving care partners per patient preference, and basing diagnostic decisions not solely on chronological age or age-based assumptions;
2. Medication: recognizing that medication side effects and drug-drug interactions may contribute to common symptoms and should be considered in the differential diagnoses and assessing the potential for polypharmacy and prescribing cascades;
3. Mentation: identifying changes in cognition, including early recognition of dementia, depression, and delirium across care settings; and
4. Mobility: evaluating changes in mobility thoroughly and ensuring that older adults can move safely to maintain function and achieve what matters to them.

Geriatric emergency departments. The establishment and rapid growth of accredited geriatric EDs (designation of a separate space for older adults or integration of best practices for older adults into EDs) support diagnostic improvement efforts for older adults. The concept of a geriatric ED was established in response to the growing geriatric population, higher rates of emergency department visits than nonseniors, and need for more extensive and complex evaluations.^119,120

By ensuring the resources to provide quality care and best practices to older adults at their encounter, geriatric EDs are a promising solution to improving diagnostic quality efforts for this high-risk population. A 2023 study compared diagnosis rates and outcomes in geriatric and nongeriatric EDs. Researchers found higher geriatric syndrome diagnosis rates (e.g., UTIs, dementia, and delirium/altered mental status states) and lower ED lengths of stay by older adults in geriatric EDs compared with matched nongeriatric EDs.¹²¹

Geriatrics educational interventions. Efforts to increase geriatrics competencies among health professionals who care for older adults have included a diagnostic competency component and can reduce harm from missed diagnostic opportunities. For example, the Advancing Geriatrics Academic Programs from the Association of Directors of Geriatrics Academic Programs (ADGAP) describes minimum competencies for medical students. The competencies are based on the American Geriatrics Society Geriatric 5Ms, which include:

1. Mind (i.e., mentation, dementia, delirium, and depression).
2. Mobility (i.e., assessment for mobility and function and fall risk screening and management).
3. Medications (i.e., polypharmacy and deprescribing, medication reconciliation, and adverse medication effects).
4. Multicomplexity (i.e., describing the whole person, living with MCCs, advanced illness, and/or complicated biopsychosocial needs); and
5. What matters most (i.e., identifying an individual’s own meaningful health outcome goals and care preferences).¹²²

Competencies specifically related to diagnosis in the ADGAP Advancing Geriatrics Academic Programs relate to:

• Expedited diagnosis of delirium.
• Consideration of conditions that may present uniquely in older adults when constructing a differential diagnosis for an older patient with an acute concern (e.g., infections, surgical emergencies, cardiac conditions, and electrolyte abnormalities).
• Identifying changes of normal aging within each organ system and how these impact function, physiologic reserve, diagnosis, and treatment.
• Demonstrating inclusion of prognostic information, frailty status, and patient preference in recommendations for screening, diagnosis, treatment, and end-of-life care.¹²²

Patient-provider communication interventions. A 2023 rapid review examined the effects of patient-provider communication strategies among older adult patients. The review identified seven studies (primarily using qualitative and observational approaches) that reported better performance on several patient-centered outcomes, such as patient satisfaction, quality of care, and quality of life associated with better communication strategies.¹²³

Evidence-based interventions aimed at enhancing communication between older adult patients, family members and caregivers, and their care providers include those focused on shared decision making¹²⁴ or advance care planning (e.g., SHARING Choices).¹²⁵ Such interventions typically rely on the communication of a diagnosis as a precursor to discussing treatment decisions. Thus, the implementation of these interventions may also improve the communication of an existing or potential diagnosis as part of proactively addressing the needs of older adults in their care appointments.

Similarly, interventions aimed at engaging patients or improving the information-gathering and history-taking aspects of clinical care for general patient populations can likely improve diagnostic communication for older adult populations at earlier stages in the diagnostic process. Examples include AHRQ’s “Be the Expert on You” planning worksheet¹²⁶ and the Institute for Healthcare Improvement’s My Health Checklist.¹²⁷

Decision support tools. The use of diagnostic clinical decision support tools and technologies, such as those that support the detection of infection, are promising avenues for improving the diagnostic process for both high-risk and general populations. A scoping review of the literature from 2010-2021 found 17 papers where decision support tools improved the detection of several different types of infection in older people (e.g., urine, respiratory, sepsis), with tools most frequently being deployed within hospital settings.¹²⁸ For older adult populations, the use of these tools and technologies requires specific consideration around their implementation in practice to create an optimally validated and tested intervention.

Research

A growing number of research and clinical experts, advocates and stakeholders, and healthcare leaders recognize that diagnostic safety research is a priority for geriatric care. Despite the body of evidence around the occurrence of diagnostic errors, research evaluating the implementation and outcomes of diagnostic safety interventions, particularly those tailored to older adult populations, is lacking.

In the final session at the NASEM Advancing Diagnostic Excellence for Older Adults workshop, experts and panelists reflected on their visions for diagnostic excellence in older adults. They emphasized the need to prioritize what matters to the patient most and develop “a system that cares for people who are living with illness or multiple conditions in the context of their lives aligned with their goals and preferences, as opposed to our current disease focused system.”⁶

The three research priorities that were identified and included in the workshop summary included:

• Expand inclusion of older adults in clinical trials and research studies.
• Collect high-quality data on older adults to better develop clinical artificial intelligence systems that consider the complex challenges specific to older adults.
• Partner with community organizations to help assess the needs of older adult populations and identify successful programs and communities, seeking to understand which characteristics of their settings encourage success.⁶

In addition, a 2024 AHRQ Special Emphasis Notice encourages health services researchers to address several key priorities related to diagnostic excellence in older adults.¹²⁹ Researchers should consider research questions around the coordination of care for older adults and patients with MCCs across providers and care settings. They focus on inequities in health and healthcare, as well as the evaluation of person-centered, whole-person healthcare delivery that appropriately addresses the needs, health goals, and priorities of older adults throughout the diagnostic process. Delivery interventions aimed at improving care delivery, particularly those that foster well-being and reduce the burden on clinicians and interdisciplinary teams, also need to be implemented and spread.

Finally, researchers should consider the roles of caregivers in patient-facing interventions and increase efforts to include caregivers in diagnostic safety research on older adults. Today, more than one in five Americans are caregivers¹³⁰ and it is estimated that at least 17.7 million individuals in the United States are family caregivers of someone over age 50 who needs help because of a limitation in physical, mental, or cognitive functioning.¹³¹

Because they help maintain the health and care needs of older adults, caregivers are critical historians and messengers when it comes to reporting patterns of older adults’ day-to-day lives and recognizing any acute changes in cognitive and behavioral symptoms.¹³² Unfortunately, caregivers have very few formal channels to share information that could be essential to improving diagnosis. Tools to enhance caregiver communication with providers have been developed. But these efforts mostly focus on:

• Acknowledging and addressing caregivers’ needs and perspectives generally.^133-136
• Understanding and enhancing caregiver engagement through online patient portals.^137-140 
• Including caregivers in shared decision making after a diagnosis has been made.^141,142

Although providers may informally rely on caregiver input and information during the diagnostic process, few tools formally incorporate caregiver perspectives into the process of establishing or communicating diagnoses. Future research efforts to meaningfully include patients, caregivers, and clinical perspectives and co-design interventions to improve diagnostic safety are urgently needed. Research to evaluate the implementation and scale-up of care delivery interventions aimed at improving care delivery and communication for older adult populations is also needed.

Policy

Diagnostic errors are a multipronged problem, as discussed earlier. They have roots in a payment system that favors volume over value. Additional issues include knowledge gaps among clinicians, cognitive fatigue of clinicians evaluating complex medical conditions in time-limited appointments, lack of clinical support experienced by clinicians, and distraction due to competing clinical challenges during an encounter.

Policy recommendations from NASEM’s 2015 Improving Diagnosis in Health Care report⁷ included:

• Goal 6: developing a reporting environment and medical liability system that facilitates timely identification, disclosure, and learning from diagnostic errors.
• Goal 7: designing a payment and care delivery system that supports the diagnostic process.
• Goal 8: providing dedicated funding for research on the diagnostic process and diagnostic errors through a coordinated research agenda.

These policy recommendations were not specific to older adults, so we have additional considerations and opportunities to highlight for this population.

Policies and initiatives aimed at broadly improving care for older adults will also help improve diagnostic safety in this population. For example, efforts to improve holistic, person-centered coordinated care and support for incorporating geriatrics competencies in healthcare workforce training programs have direct implications for reducing diagnostic errors and improving diagnostic accuracy for older adults. Initiatives aimed at improving diagnostic accuracy cannot bring any meaningful change without a strong commitment toward improving the general medical care of older adults and a holistic approach to all factors that affect the provision of safe medical care to older adults.

Current challenges to improving care for older adults include, but are not limited to, a fragmented healthcare system, clinician burnout, a payment system that values quantity over quality and procedural care over preventive care, and a dwindling geriatrics workforce. In short, reducing diagnostic errors for older adults requires transformative changes in the U.S. healthcare system.

Below are several recommendations, adapted from the NASEM report and other referenced resources that can inform policy discussions to improve care of older adults broadly and support diagnostic accuracy in this growing population.

Developing policies to support the voluntary reporting of diagnostic errors and near-misses. The first step in reporting a diagnostic error is detecting the error. However, reporting diagnostic errors in older adults is complicated because geriatric syndromes and other misdiagnosed conditions rely on the clinical decision making of expert clinicians and cannot be diagnosed solely by diagnostic tests or pathology examinations.

For example, delirium can be misdiagnosed as dementia, asymptomatic bacteriuria can be misdiagnosed as a UTI, and acute functional decline can be labeled “old age.” In these cases, determining whether a diagnostic error has occurred relies on an expert clinician to thoroughly review the medical chart and obtain additional, potentially overlooked but clinically relevant history from the patient or an informed caregiver. Therefore, while research supports the frequent misdiagnoses of geriatric syndromes, the reported diagnostic errors pertaining to geriatric syndromes are likely just the tip of the iceberg.

Policies are needed to support all clinicians caring for older adults in voluntarily and forthrightly reviewing cases and reporting diagnostic errors. In addition, healthcare systems need to develop a nonpunitive culture that encourages active surveillance, reporting, and learning from diagnostic errors. The Patient Safety and Quality Improvement Act (PSQIA)¹⁴³ and AHRQ’s Patient Safety Organization (PSO) program¹⁴⁴ have established voluntary reporting requirements for healthcare providers for medical errors. These requirements can be broadened to cover diagnostic errors, including formats to report commonly misdiagnosed geriatric syndromes.

A few states have enacted “I am sorry” legislation that prevents healthcare providers’ disclosure of medical errors to patients from being used against them in a court of law.¹⁴⁵ Such laws can provide safe harbor to healthcare providers and healthcare systems for voluntarily reporting diagnostic errors and becoming allies with patients in improving diagnostic processes. Still, policies are needed to further incentivize and encourage clinicians to report these errors to improve care processes and learning.

Establishing payer-related policies to improve healthcare quality and value. Primary care visits are often time limited and do not allow sufficient time for clinicians to fully address the complexity of care for older patients.¹⁴⁶ Payers need to recognize the urgent need to support payments for care provided by primary care clinical teams instead of care provided by a single provider. This approach was recommended by the NASEM report Implementing High-Quality Primary Care: Rebuilding the Foundation of Healthcare.¹⁴⁷

Procedural codes that allow other healthcare providers, such as pathologists, radiologists, and geriatricians, to provide advice to healthcare providers regarding the interpretation of diagnostic studies and management of geriatric syndromes are also needed. National efforts to implement quality measures that include screening for delirium and frailty offer tremendous potential to improve diagnostic safety in older adults. For example, the Centers for Medicare & Medicaid Services intends to incorporate age-friendly hospital quality measures in the Hospital Inpatient Quality Reporting Program beginning in 2025. These measures will encourage healthcare systems to develop screening and management protocols for geriatric syndromes that are often undiagnosed on inpatient services.¹⁴⁸

Improving graduate medical education and interdisciplinary geriatric training. Geriatrics training and competency development for healthcare professionals and researchers are central to achieving diagnostic excellence in older adults. This training should be a mandatory component of all adult clinical specialty residency and fellowship programs for physician and nonphysician healthcare professionals.

The Veterans Health Administration has championed the mission of interdisciplinary geriatrics education by supporting a geriatric medicine residency for nurse practitioners.¹⁴⁹ The Health Resources and Services Administration provides funding to institutions that collaborate with community programs through the Geriatrics Workforce Enhancement Program.¹⁵⁰ Similar programs could be developed for other professional domains in healthcare to support an age-friendly workforce.

Geriatrics training should also include didactic and practical education on diagnostic safety and support interdisciplinary collaboration and team-based approaches to safety. Additional investments are also needed to develop and establish future leaders in geriatrics diagnostic safety research and improvement.

Developing meaningful patient-level measures and outcome assessment for older adults. Clinical guidelines have pointed to the importance of providing and tracking goal-based, patient-centered care, where “care is personalized and aligned with patients’ goals.”¹⁵¹ The establishment of well-defined patient-level measures and outcomes, particularly for older adults with MCCs and comorbidities, can provide a consistent method to evaluate whether a diagnostic workup can help patients achieve the outcomes that are important to them. This approach can help reduce the risk of overtesting and resulting harms.

Efforts to improve the integration of patient-level measures into organizations and care practices, as well as into existing financial reimbursement systems, offer great potential for better aligning care with what matters and reducing unnecessary tests and diagnostic harm in older adults.

Increasing support for research on diagnostic safety in older adults. The achievement of diagnostic excellence for older adults will involve coordinating resources from a broad array of disciplines, stakeholders, and institutions to translate evidence-based interventions that will improve diagnosis and reduce harm. Public and private funding organizations can be supported in funding projects related to diagnostic safety in older adults. Active efforts must be made to advocate for and support partnerships between researchers, healthcare leaders, frontline clinicians, and patient stakeholder groups that can carry out work to improve diagnosis of older adults.

Quality and safety collaboratives working on care of older adults must include diagnostic excellence as a key patient safety goal and prioritize projects that improve diagnosis. In addition, research and professional networks, societies, and organizations focused on older adults need to provide resources and support for initiatives to promote diagnostic excellence in settings across the geriatric care continuum.