Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This ...study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy.
Physicians were presented with an interactive vignette describing a patient with a complex presentation of pernicious anemia. They were randomized to diagnose either a patient with or without (control) comorbid depression and related behaviors. All other clinical information was identical. Physicians recorded a differential diagnosis, ordered tests, and rated patient likeability.
Fifty-nine physicians completed the study. The patient with comorbid depression was less likeable than the control patient (p=0.03, 95 % CI 0.09, 1.53). Diagnostic accuracy was lower in the depression compared to control condition (59.4 % vs. 40.7 %), however this difference was not statistically significant χ
(1)=2.035, p=0.15. Exploratory analyses revealed that patient condition (depression vs. control) interacted with the number of diagnostic tests ordered to predict diagnostic accuracy (OR=2.401, p=0.038). Accuracy was lower in the depression condition (vs. control) when physicians ordered fewer tests (1 SD below mean; OR=0.103, p=0.028), but there was no difference for physicians who ordered more tests (1 SD above mean; OR=2.042, p=0.396).
Comorbid depression and related behaviors lowered diagnostic accuracy when physicians ordered fewer tests - a time when more possibilities should have been considered. These findings underscore the critical need to develop interventions to reduce diagnostic error when treating vulnerable populations such as those with depression.
The IOM report ‘Improving Diagnosis in Health Care’ represents a major advance in summarizing the problem of diagnostic error. Three new concepts in the report will be helpful in future efforts to ...understand and improve the diagnostic process: a new definition of diagnostic error, a new framework for understanding the diagnostic process, and a new concept of the diagnostic ‘team’. This paper highlights these new concepts and their relevance to improving diagnosis.
Background
Clinician notes are structured in a variety of ways. This research pilot tested an innovative study design and explored the impact of note formats on diagnostic accuracy and documentation ...review time.
Objective
To compare two formats for clinical documentation (narrative format vs. list of findings) on clinician diagnostic accuracy and documentation review time.
Method
Participants diagnosed written clinical cases, half in narrative format, and half in list format. Diagnostic accuracy (defined as including correct case diagnosis among top three diagnoses) and time spent processing the case scenario were measured for each format. Generalised linear mixed regression models and bias-corrected bootstrap percentile confidence intervals for mean paired differences were used to analyse the primary research questions.
Results
Odds of correctly diagnosing list format notes were 26% greater than with narrative notes. However, there is insufficient evidence that this difference is significant (75% CI 0.8–1.99). On average the list format notes required 85.6 more seconds to process and arrive at a diagnosis compared to narrative notes (95% CI -162.3, −2.77). Of cases where participants included the correct diagnosis, on average the list format notes required 94.17 more seconds compared to narrative notes (75% CI -195.9, −8.83).
Conclusion
This study offers note format considerations for those interested in improving clinical documentation and suggests directions for future research. Balancing the priority of clinician preference with value of structured data may be necessary.
Implications
This study provides a method and suggestive results for further investigation in usability of electronic documentation formats.
Sepsis as a model for improving diagnosis Graber, Mark L.; Patel, Monika; Claypool, Stephen
Diagnosis (Berlin, Germany),
3/2018, Letnik:
5, Številka:
1
Journal Article
Recenzirano
Diagnostic safety could theoretically be improved by high-level interventions, such as improving clinical reasoning or eliminating system-related defects in care, or by focusing more specifically on ...a single problem or disease. In this review, we consider how the timely diagnosis of sepsis has evolved and improved as an example of the disease-focused approach. This progress has involved clarifying and revising the definitions of sepsis, efforts to raise awareness, faster and more reliable laboratory tests and a host of practice-level improvements based on health services research findings and recommendations. We conclude that this multi-faceted approach incorporating elements of the ‘learning health system’ model has improved the early recognition and treatment of sepsis, and propose that this model could be productively applied to improve timely diagnosis in other time-sensitive conditions.
Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, ...providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report
The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.
A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent to which healthcare organizations can aggregate, analyze, share, and learn from these events. In ...response to this problem, the Agency for Healthcare Research and Quality (AHRQ) began the development of the Common Formats for Event Reporting for Diagnostic Safety Events (CFER-DS). We conducted a usability assessment of the draft CFER-DS to inform future revision and implementation.
We recruited a purposive sample of quality and safety personnel working in 8 U.S. healthcare organizations. Participants were invited to use the CFER-DS to simulate reporting for a minimum of 5 cases of diagnostic safety events and then provide written and verbal qualitative feedback. Analysis focused on participants' perceptions of content validity, ease of use, and potential for implementation.
Estimated completion time was 30 to 90 minutes per event. Participants shared generally positive feedback about content coverage and item clarity but identified reporter burden as a potential concern. Participants also identified opportunities to clarify several conceptual definitions, ensure applicability across different care settings, and develop guidance to operationalize use of CFER-DS. Findings led to refinement of content and supplementary materials to facilitate implementation.
Standardized definitions of diagnostic safety events and reporting standards for contextual information and contributing factors can help capture and analyze diagnostic safety events. In addition to usability testing, additional feedback from the field will ensure that AHRQ's CFER-DS is useful to a broad range of users for learning and safety improvement.
PURPOSEExperienced clinicians derive many diagnoses intuitively, because most new problems they see closely resemble problems they’ve seen before. The majority of these diagnoses, but not all, will ...be correct. This study determined whether further reflection regarding initial diagnoses improves diagnostic accuracy during a high-stakes board exam, a model for studying clinical decision making.
METHODKeystroke response data were used from 500 residents who took the 2010 American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination. Data included time to initial response on each question, whether the answer was correct, and whether or not the resident changed her or his initial response. The focus was on 80 diagnosis questions that comprised realistic clinical vignettes with multiple-choice single-best answers. Cognitive skill (ability) was measured using overall exam scores. Case complexity was determined using item difficulty (proportion of examinees that correctly answered the question). A hierarchical generalized linear model was used to assess the relationship between time spent on initial responses and the probability of correctly answering the questions.
RESULTSOn average, residents changed their responses on 12% of all diagnosis questions (or 9.6 questions out of 80). Changing an answer from incorrect to correct was almost twice as likely as changing an answer from correct to incorrect. The relationship between response time and accuracy was complex.
CONCLUSIONSFurther reflection appears to be beneficial to diagnostic accuracy, especially for more complex cases.
Diagnostic Error in Internal Medicine Graber, Mark L; Franklin, Nancy; Gordon, Ruthanna
Archives of internal medicine (1960),
07/2005, Letnik:
165, Številka:
13
Journal Article
BACKGROUND The goal of this study was to determine the relative contribution of system-related and cognitive components to diagnostic error and to develop a comprehensive working taxonomy. METHODS ...One hundred cases of diagnostic error involving internists were identified through autopsy discrepancies, quality assurance activities, and voluntary reports. Each case was evaluated to identify system-related and cognitive factors underlying error using record reviews and, if possible, provider interviews. RESULTS Ninety cases involved injury, including 33 deaths. The underlying contributions to error fell into 3 natural categories: “no fault,” system-related, and cognitive. Seven cases reflected no-fault errors alone. In the remaining 93 cases, we identified 548 different system-related or cognitive factors (5.9 per case). System-related factors contributed to the diagnostic error in 65% of the cases and cognitive factors in 74%. The most common system-related factors involved problems with policies and procedures, inefficient processes, teamwork, and communication. The most common cognitive problems involved faulty synthesis. Premature closure, ie, the failure to continue considering reasonable alternatives after an initial diagnosis was reached, was the single most common cause. Other common causes included faulty context generation, misjudging the salience of findings, faulty perception, and errors arising from the use of heuristics. Faulty or inadequate knowledge was uncommon. CONCLUSIONS Diagnostic error is commonly multifactorial in origin, typically involving both system-related and cognitive factors. The results identify the dominant problems that should be targeted for additional research and early reduction; they also further the development of a comprehensive taxonomy for classifying diagnostic errors.Arch Intern Med. 2005;165:1493-1499-->
Improving diagnosis-related education in the health professions has great potential to improve the quality and safety of diagnosis in practice. Twelve key diagnostic competencies have been delineated ...through a previous initiative. The objective of this project was to identify the next steps necessary for these to be incorporated broadly in education and training across the health professions.
We focused on medicine, nursing, and pharmacy as examples. A literature review was conducted to survey the state of diagnosis education in these fields, and a consensus group was convened to specify next steps, using formal approaches to rank suggestions.
The literature review confirmed initial but insufficient progress towards addressing diagnosis-related education. By consensus, we identified the next steps necessary to advance diagnosis education, and five required elements relevant to every profession: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
The primary stakeholders, representing education, certification, accreditation, and licensure, in each profession must now take action in their own areas to encourage, promote, and enable improved diagnosis, and move these recommendations forward.
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