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V. Lowry1,2, A. Bass1,2, T. Vukobrat1, S. Décary3, P. Bélisle4, M.-P. Sylvestre2,5, F. Desmeules1,2
1Hôpital Maisonneuve-Rosemont, Montréal, Canada, 2Université de Montréal, Montréal, Canada, 3Université Laval, Québec, Canada, 4Institut de Cardiologie de Montréal, Montréal, Canada, 5Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
Background: Almost 50% of adults will report knee symptoms at some time in their life, making these disorders one of the most frequent musculoskeletal condition encountered in primary care. An early and accurate knee diagnosis is necessary to guide toward an efficient management and limit disability and loss of quality of life. Making a valid initial knee diagnosis based on physical examination remains a common challenge for healthcare providers. Diagnostic errors have mostly been attributed to cognitive errors of the clinician or errors related to technical or organizational problems. No study to date has looked at patients’ characteristics that could potentially affect the diagnostic process in knee assessment.
Purpose: The purpose of this study was to identify potential patients’ socio-demographic, psycho-social and clinical characteristics associated with diagnostic discordance between medical musculoskeletal specialists and physiotherapists for knee disorders. We have hypothesized that diagnostic discordance between two providers are a reflect of the difficulty to make a valid diagnosis, thus increasing the probability of diagnostic errors.
Methods: This exploratory study is a secondary analysis from a diagnostic cohort study including participants seeking care with a medical musculoskeletal specialist for knee disorders. Participants answered questionnaires including socio-demographic and clinical information. They also filled out the Knee Injury Outcome Score questionnaire to assess self-reported disability and the Kessler-6 to evaluate psychological distress. Medical musculoskeletal specialists and a physiotherapist independently assessed the participants and indicated a primary and secondary diagnosis - if necessary. Concordance was defined as identical primary and secondary diagnoses for both evaluators. The association between participants’ characteristics and diagnostic discordance was assessed with multivariate logistic regression. We also used Bayesian Information Criterion to select the most probable models combining participants’ characteristics to explain diagnostic discordance. Odds ratio and credibility intervals(CrI) were calculated.
Results: 279 participants consulting for a knee problem were recruited. The mean age of the participants was 49.1±15.8 years. The most common diagnosis was knee osteoarthritis(41.9%) and 68.8% of the participants had a non-traumatic onset of symptoms. Discordance was observed for 78 participants (28%). The most probable model explaining diagnostic discordance between providers included the presence of depressive symptoms as measured by one question of the K6 and the number of comorbidities. Having depressive symptoms was associated with an increased probability of diagnostic discordance (OR: 3.9; 95%CrI: 1.9 – 8.0) and having a higher number of comorbidities was associated with an increased probability of diagnostic concordance (OR: 0.6; 95%CrI: 0.5 – 0.9). Depressive symptoms as measured with the K6 item was the most common factor to explain diagnostic discordance and the overall the cumulative probability of that factor was 99.4% across developed models.
Conclusion(s): Having depressive symptoms was associated with a higher probability of diagnostic discordance between providers. These findings need to be confirmed in future studies. However, several studies have found that depressive symptoms can significantly increase the severity of knee pain, which may influence the results of physical examination tests.
Implications: Patients’ psycho-social and clinical characteristics may alter symptoms and clinical presentation of knee disorders, which could impede the ability to make a valid diagnosis.
Funding, acknowledgements: François Desmeules is a FRQS and CIHR Scholar.
Keywords: Knee, Diagnosis, Concordance
Topic: Musculoskeletal: lower limb
Did this work require ethics approval? Yes
Institution: CIUSSS de l'Est-de-l'Île de Montréal
Committee: Comité d'Éthique de la Recherche du CIUSSS de l'Est-de-l'Île de Montréal
Ethics number: MP-12-2015-767
All authors, affiliations and abstracts have been published as submitted.
