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Priyanath Gupta A, Patel D, Lee JY, Volpentesta M, Schachter M, Persell SD. Health information technology tools to accelerate gastrointestinal evaluation in patients with iron deficiency anaemia: a cluster randomised controlled trial. BMJ Open Qual 2024; 13:e002565. [PMID: 38626940 PMCID: PMC11029187 DOI: 10.1136/bmjoq-2023-002565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/28/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE System-level safety measures do not exist to ensure that patients with iron deficiency anaemia (IDA) undergo proper diagnostic evaluations. We sought to determine if a set of EHR (electronic health record) tools and an expedited referral workflow increase short-term completion of bidirectional endoscopy in higher risk patients with IDA. MATERIALS AND METHODS We conducted a pragmatic, cluster-randomised trial randomised by primary care physician (PCP) that included 16 PCPs and 316 patients with IDA. Physicians were randomised to intervention or control groups. Intervention components included a patient registry visible within the EHR, point-of-care alert and expedited diagnostic evaluation workflow for IDA. Outcomes were assessed at 120 days. The primary outcome was completion of bidirectional endoscopy. Secondary outcomes were any endoscopy completed or scheduled, gastroenterology consultation completed, and gastroenterology referral or endoscopy ordered or completed. RESULTS There were no differences in the primary or secondary outcomes. At 120 days, the primary outcome had occurred for 7 (4%) of the intervention group and 5 (3.5%) of the control group. For the three secondary outcomes, rates were 15 (8.6%), 12 (6.9%) and 39 (22.4%) for the immediate intervention group and 10 (7.0%), 9 (6.3%) and 25 (17.6%) for the control group, respectively, p>0.2. Lack of physician time to use the registry tools was identified as a barrier. DISCUSSION AND CONCLUSION Providing PCPs with lists of patients with IDA and a pathway for expedited evaluation did not increase rates of completing endoscopic evaluation in the short term. TRIAL REGISTRATION NUMBER NCT05365308.
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Affiliation(s)
- Aparna Priyanath Gupta
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
| | - Dharmesh Patel
- Northwestern Medical Group Quality and Safety, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
| | - Michelle Volpentesta
- Department of Information Systems, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Michael Schachter
- Department of Information Systems, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, Illinois, USA
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Hajdarevic S, Högberg C, Marzo-Castillejo M, Siliņa V, Sawicka-Powierza J, Esteva M, Koskela T, Petek D, Contreras-Martos S, Mangione M, Ožvačić Adžić Z, Asenova R, Gašparović Babić S, Brekke M, Buczkowski K, Buono N, Çifçili SS, Dinant GJ, Doorn B, Hoffman RD, Kuodza G, Murchie P, Pilv L, Puia A, Rapalavicius A, Smyrnakis E, Weltermann B, Harris M. Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study. BJGP Open 2023; 7:BJGPO.2023.0029. [PMID: 37380218 PMCID: PMC11176697 DOI: 10.3399/bjgpo.2023.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.
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Affiliation(s)
- Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Cecilia Högberg
- Department of Public Health and Clinical Medicine, Education and Development Östersund, Unit of Research, Umeå University, Umeå, Sweden
| | - Mercè Marzo-Castillejo
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | - Vija Siliņa
- Department of Family Medicine, Riga Stradiņš University, Riga, Latvia
| | | | - Magadalena Esteva
- Majorca Primary Care Department, Spain
- Balearic Islands Health Research Institute (IdISBa), Balearic Islands, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Center of General Practice,Tampere University Hospital, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sara Contreras-Martos
- Research Support Unit Metropolitana Sud, University Institute for Primary Health Care Research IDIAPJordi Gol, Catalan Health Institute, Barcelona, Spain
| | | | - Zlata Ožvačić Adžić
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia
- Health Center Zagreb-Centar, Zagreb, Croatia
| | - Radost Asenova
- Department Urology and General Practice, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Mette Brekke
- Department of Health and Society, General Practice Research Unit, University of Oslo, Oslo, Norway
| | | | - Nicola Buono
- Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy
| | | | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Babette Doorn
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Robert D Hoffman
- Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Family Medicine, Maccabi Healthcare Services, Southern District, Israel
| | - George Kuodza
- Department of Family Medicine and Outpatient Care, Medical Faculty #2, Uzhhorod National University, Uzhgorod, Ukraine
| | - Peter Murchie
- Centre of Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Liina Pilv
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Aida Puia
- Department of Family Medicine, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Aurimas Rapalavicius
- Family Medicine Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Michael Harris
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- College of Medicine & Health, University of Exeter, Exeter, UK
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Borghetti VS, Cintra VP, Ramos JDO, Marques VD, Onofre PT, Santana VAS, Bezerra LFP, Tomaselli PJ, dos Santos ACJ, Sobreira CFDR, Marques W. Misdiagnoses in a Brazilian population with amyotrophic lateral sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:676-680. [PMID: 36254439 PMCID: PMC9685820 DOI: 10.1055/s-0042-1755224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that affects the upper and lower motor neurons. The correct diagnosis at the onset of the disease is sometimes very difficult, due to the symptoms being very similar to those of other neurological syndromes. OBJECTIVE This study aimed to analyze the initial manifestations, the specialty of the first physician visited due the initial complaint, the misdiagnoses, as well as the unnecessary surgical interventions in a new ALS Brazilian population. METHODS The medical records of 173 patients with typical ALS were reviewed. RESULTS The present study demonstrated that other symptoms, besides weakness, were very frequent as initial presentation of ALS, and orthopedics was the medical specialty most sought by patients at the onset of symptoms. Our frequency of misdiagnoses was 69.7%, and in 7.1% of them, an unnecessary surgical intervention was performed. CONCLUSIONS Amyotrophic lateral sclerosis presents a very large pool of signs and symptoms; therefore, there is an urgent need of increasing the disease awareness to other specialties due to the high frequency of misdiagnoses observed in clinical practice.
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Affiliation(s)
| | - Vívian Pedigone Cintra
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
- Centro Universitário Municipal de Franca, Franca SP, Brazil
| | - Jean de Oliveira Ramos
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Patrícia Toscano Onofre
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | | | | | - Pedro José Tomaselli
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | | | | | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
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A Quality Improvement Intervention Leveraging a Safety Net Model for Surveillance Colonoscopy Completion. Am J Med Qual 2021; 37:55-64. [PMID: 34010167 DOI: 10.1097/01.jmq.0000743680.01321.2b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Systems to address follow-up testing of clinically positive surveillance colonoscopy results are lacking. The impact of an ambulatory safety net (ASN) intervention on rates of colonoscopy completion was assessed. The ASN team identified patients using an electronic registry, conducted patient outreach, coordinated care, and tracked colonoscopy completion. In all, 701 patients were captured in the ASN program: 58.1% (407/701) had possible barriers to follow-up colonoscopy completion, with rates of 80.1% (236/294) if no barrier, and 40.9% (287/701) overall. Colonoscopy completion likelihood increased with prior polypectomy (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.3), and decreased with White race (OR, 0.5; 95% CI, 0.3-0.9), increased inpatient visits (OR, 0.6; 95% CI, 0.4-0.9), more outreach attempts (OR, 0.6; 95% CI, 0.5-0.7), and fair/poor/inadequate preparation (OR, 0.4; 95% CI, 0.2-0.7) in logistic regression models. An ASN model for quality improvement promotes colonoscopy completion rates and identifies patient barriers.
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5
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Reece JC, Neal EFG, Nguyen P, McIntosh JG, Emery JD. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer 2021; 21:373. [PMID: 33827476 PMCID: PMC8028768 DOI: 10.1186/s12885-021-08100-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 01/07/2023] Open
Abstract
Background Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes. Methods A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design. Results Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up. Conclusions Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08100-3.
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Affiliation(s)
- Jeanette C Reece
- Colorectal Cancer Unit, Centre for Epidemiology and Biostatistics and Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3 207 Bouverie Street, Parkville, VIC, 3010, Australia. .,Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Eleanor F G Neal
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Peter Nguyen
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Jennifer G McIntosh
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of Software Systems and Cybersecurity, Faculty of Information Technology, Monash University, VIC, Clayton, Australia
| | - Jon D Emery
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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Gray BM, Vandergrift JL, McCoy RG, Lipner RS, Landon BE. Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims. BMJ Open 2021; 11:e041817. [PMID: 33795293 PMCID: PMC8021735 DOI: 10.1136/bmjopen-2020-041817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors. SETTING/PARTICIPANTS 1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 'index' outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke). OUTCOME MEASURES 90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations. DESIGN Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics. RESULTS Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI -5.0 to -0.7, p=0.008), 4.1 fewer hospitalisations (95% CI -6.9 to -1.2, p=0.006) and 4.9 fewer ED visits (95% CI -8.1% to -1.6%, p=0.003) per 1000 visits. CONCLUSION Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.
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Affiliation(s)
- Bradley M Gray
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Jonathan L Vandergrift
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Rozalina G McCoy
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca S Lipner
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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Mamede S, Goeijenbier M, Schuit SCE, de Carvalho Filho MA, Staal J, Zwaan L, Schmidt HG. Specific Disease Knowledge as Predictor of Susceptibility to Availability Bias in Diagnostic Reasoning: a Randomized Controlled Experiment. J Gen Intern Med 2021; 36:640-646. [PMID: 32935315 PMCID: PMC7947124 DOI: 10.1007/s11606-020-06182-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bias in reasoning rather than knowledge gaps has been identified as the origin of most diagnostic errors. However, the role of knowledge in counteracting bias is unclear. OBJECTIVE To examine whether knowledge of discriminating features (findings that discriminate between look-alike diseases) predicts susceptibility to bias. DESIGN Three-phase randomized experiment. Phase 1 (bias-inducing): Participants were exposed to a set of clinical cases (either hepatitis-IBD or AMI-encephalopathy). Phase 2 (diagnosis): All participants diagnosed the same cases; 4 resembled hepatitis-IBD, 4 AMI-encephalopathy (but all with different diagnoses). Availability bias was expected in the 4 cases similar to those encountered in phase 1. Phase 3 (knowledge evaluation): For each disease, participants decided (max. 2 s) which of 24 findings was associated with the disease. Accuracy of decisions on discriminating features, taken as a measure of knowledge, was expected to predict susceptibility to bias. PARTICIPANTS Internal medicine residents at Erasmus MC, Netherlands. MAIN MEASURES The frequency with which higher-knowledge and lower-knowledge physicians gave biased diagnoses based on phase 1 exposure (range 0-4). Time to diagnose was also measured. KEY RESULTS Sixty-two physicians participated. Higher-knowledge physicians yielded to availability bias less often than lower-knowledge physicians (0.35 vs 0.97; p = 0.001; difference, 0.62 [95% CI, 0.28-0.95]). Whereas lower-knowledge physicians tended to make more of these errors on subjected-to-bias than on not-subjected-to-bias cases (p = 0.06; difference, 0.35 [CI, - 0.02-0.73]), higher-knowledge physicians resisted the bias (p = 0.28). Both groups spent more time to diagnose subjected-to-bias than not-subjected-to-bias cases (p = 0.04), without differences between groups. CONCLUSIONS Knowledge of features that discriminate between look-alike diseases reduced susceptibility to bias in a simulated setting. Reflecting further may be required to overcome bias, but succeeding depends on having the appropriate knowledge. Future research should examine whether the findings apply to real practice and to more experienced physicians.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands. .,Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Marco Goeijenbier
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephanie C E Schuit
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marco Antonio de Carvalho Filho
- Centre for Educational Research and Development in Health Professions, University Medical Centre, Groningen, The Netherlands.,Internal Medicine Department, School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - Justine Staal
- Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Henk G Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Prokop TR. Calibration and Academic Performance in Students of Health Sciences. HEALTH PROFESSIONS EDUCATION 2020. [DOI: 10.1016/j.hpe.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Nutrition Information in Oncology - Extending the Electronic Patient-Record Data Set. J Med Syst 2020; 44:191. [PMID: 32986139 PMCID: PMC7520877 DOI: 10.1007/s10916-020-01649-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Abstract
Electronic health records (EHRs) present extensive patient information and may be used as a tool to improve health care. However, the oncology context presents a complex content that increases the difficulties of EHR application. This study aimed at developing openEHR-archetypes representing clinical concepts in cancer nutrition-care, as well as to develop an openEHR-template including the aforementioned archetypes. The study involved the following stages: 1) a thorough literature review, followed by an expert’s (nutrition guideline authors) survey, aiming to identify the main statements of published clinical guidelines on nutrition in cancer patients that were not included on the Clinical Knowledge Manager (CKM) repository; 2) modelling of the archetypes using the Ocean Archetype Software and submission to the CKM repository; 3) creating an example template with Template Designer; and 4) automatic conversion of the openEHR-template into a readily usable EHR using VCIntegrator. The clinical concepts (among 17 clinical concepts not yet available in the CKM repository) chosen for further development were: body composition, diet plan, dietary nutrients, dietary supplements, dietary intake assessment, and Malnutrition Screening Tool (MST). So far, four archetypes were accepted for review in the CKM repository and a template was created and converted into an EHR. This study designed new openEHR-archetypes for nutrition management in cancer patients. These archetypes can be included in EHR. Future studies are needed to assess their applicability in other areas and their practical impact on data quality, system interoperability and, ultimately, on clinical practice and research.
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Mamede S, Hautz WE, Berendonk C, Hautz SC, Sauter TC, Rotgans J, Zwaan L, Schmidt HG. Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1223-1229. [PMID: 31972673 DOI: 10.1097/acm.0000000000003153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Diagnostic errors have been attributed to failure to sufficiently reflect on initial diagnoses. However, evidence of the benefits of reflection is conflicting. This study examined whether reflection upon initial diagnoses on difficult cases improved diagnostic accuracy and whether reflection triggered by confrontation with case evidence was more beneficial than simply revising initial diagnoses. METHOD Participants were physicians in Bern, Switzerland, registered for the 2018 Swiss internal medicine certification exam. They diagnosed written clinical cases, providing an initial diagnosis by following the same instructions and returning to the case to provide a final diagnosis. The latter required different types of reflection depending on the physician's experimental condition: return without instructions, identify confirmatory evidence, identify contradictory evidence, or identify both confirmatory and contradictory evidence. The authors examined diagnostic accuracy scores (range 0-1) as a function of diagnostic phase and reflection type. RESULTS One hundred and sixty-seven physicians participated. Diagnostic accuracy scores did not significantly differ between the 4 groups of physicians in the initial (I) or the final (F) diagnostic phase (mean [95% CI]: return without instructions, I: 0.21 [0.17, 0.26], F: 0.23 [0.18, 0.28]; confirmatory evidence, I: 0.24 [0.19, 0.29], F: 0.31 [0.25, 0.37]; contradictory evidence, I: 0.22 [0.17, 0.26], F: 0.26 [0.22, 0.30]; confirmatory and contradictory evidence, I: 0.19 [0.15, 0.23], F: 0.25 [0.20, 0.31]). Regardless of type of reflection employed while revising the case, accuracy increased significantly between initial and final diagnosis, I: 0.22 (0.19, 0.24) vs F: 0.26 (0.24, 0.29); P < .001. CONCLUSIONS Physicians' diagnostic accuracy improved after reflecting upon initial diagnoses provided for difficult cases, independently of the evidence searched for while reflecting. The findings support the importance attributed to reflection in clinical teaching. Future research should investigate whether revising the case can become more beneficial by triggering additional reflection.
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Affiliation(s)
- Sílvia Mamede
- S. Mamede is associate professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, Rotterdam, the Netherlands; ORCID: https://orcid.org/0000-0003-1187-2392
| | - Wolf E Hautz
- W.E. Hautz is assistant professor of medical education and chief of service, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-2445-984X
| | - Christoph Berendonk
- C. Berendonk is deputy head, Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-3740-9358
| | - Stefanie C Hautz
- S.C. Hautz is educational consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0003-4715-8465
| | - Thomas C Sauter
- T.C. Sauter is senior consultant, Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland; ORCID: https://orcid.org/0000-0002-6646-5789
| | - Jerome Rotgans
- J. Rotgans is assistant professor, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Laura Zwaan
- L. Zwaan is assistant professor, Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, the Netherlands
| | - Henk G Schmidt
- H.G. Schmidt is professor, Institute of Medical Education Research Rotterdam, Erasmus MC, and Department of Psychology, Education & Child Studies, Erasmus University Rotterdam, the Netherlands
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11
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Richards D, Morren JA, Pioro EP. Time to diagnosis and factors affecting diagnostic delay in amyotrophic lateral sclerosis. J Neurol Sci 2020; 417:117054. [PMID: 32763509 DOI: 10.1016/j.jns.2020.117054] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive, degenerative neuromuscular disease with limited treatment options. The diagnosis of ALS can be challenging for numerous reasons, resulting in delays that may compromise optimal management and enrollment into clinical trials. Several studies have examined the process and challenges regarding the clinical diagnosis of ALS. Twenty-one studies that were almost exclusively from the English literature published between 1990 and 2020 were identified via PubMed using relevant search terms and included patient populations from the United States, Canada, Japan, Egypt, and several countries in South America and Europe. Probable or definitive ALS patients were identified using El Escorial or revised El Escorial/Airlie House Criteria. Time to diagnosis or diagnostic delay was defined as mean or median time from patient-reported first symptom onset to formal diagnosis by a physician, as recorded in medical records. The typical time to diagnosis was 10-16 months from symptom onset. Several points of delay in the diagnosis course were identified, including specialist referrals and misdiagnoses, often resulting in unnecessary procedures and surgeries. Bulbar onset was noted to significantly reduce time to ALS diagnosis. Future interventions and potential research opportunities were reviewed.
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Affiliation(s)
- Danielle Richards
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John A Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Erik P Pioro
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Mamede S, de Carvalho-Filho MA, de Faria RMD, Franci D, Nunes MDPT, Ribeiro LMC, Biegelmeyer J, Zwaan L, Schmidt HG. 'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf 2020; 29:550-559. [PMID: 31988257 PMCID: PMC7362774 DOI: 10.1136/bmjqs-2019-010079] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/24/2019] [Accepted: 01/16/2020] [Indexed: 12/14/2022]
Abstract
Background Diagnostic errors have often been attributed to biases in physicians’ reasoning. Interventions to ‘immunise’ physicians against bias have focused on improving reasoning processes and have largely failed. Objective To investigate the effect of increasing physicians’ relevant knowledge on their susceptibility to availability bias. Design, settings and participants Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. Interventions Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. Main outcome measurements Diagnostic accuracy, measured by test score (range 0–1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. Results Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference −0.05 (95% CI −0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference −0.17 (95% CI −0.28 to −0.05); p=0.005); immunised physicians’ accuracy did not differ (p=0.56). Conclusions An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians’ susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. Trial registration number 68745917.1.1001.0068.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands .,Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Marco Antonio de Carvalho-Filho
- Internal Medicine, State University of Campinas, Campinas, Brazil.,Center for Education Development and Research in the Health Professions, University of Groningen, Groningen, The Netherlands
| | - Rosa Malena Delbone de Faria
- Propeudeutics, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Education and Research Center, Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Franci
- Internal Medicine, State University of Campinas, Campinas, Brazil
| | | | | | | | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Henk G Schmidt
- Institute of Medical Education Research Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands.,Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
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13
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Pace LE, Percac-Lima S, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:1146-1153. [PMID: 31011969 PMCID: PMC6614558 DOI: 10.1007/s11606-019-05003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 11/06/2018] [Accepted: 03/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions. OBJECTIVES To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion. DESIGN A retrospective cohort study using explicit chart abstraction methods. PARTICIPANTS Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016. MAIN MEASURES Rates and timing of test ordering and completion and patterns of visits and communications. KEY RESULTS At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS The study relied on documented care, and findings may be most generalizable to academically affiliated institutions. CONCLUSIONS Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.
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Affiliation(s)
- Lydia E Pace
- Harvard Medical School, Boston, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, OBC 3-34, 75 Francis Street, Boston, MA, 02115-9950, USA.
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanford University School of Medicine and Graduate School of Business, Stanford, CA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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14
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Browne AM, Deutsch ES, Corwin K, Davis DH, Teets JM, Apkon M. An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. Am J Med Qual 2019; 34:569-576. [PMID: 30739459 DOI: 10.1177/1062860618820687] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Errors in thinking contribute to harm, delays in diagnosis, incorrect treatments, or failures to recognize clinical changes. Models of cognition are useful in understanding error occurrence and avoidance. Intra-team conflict can represent failures in joint cognitive processing. The authors developed training focused on recognizing and managing cognitive bias and resolving conflicts. The program provides context and introduces models of cognition, concepts of bias, team cognition, conflict resolution, and 2 tools. "IDEA" incorporates 4 de-biasing strategies: Identify assumptions; Don't assume correctness; Explore expectations; Assess alternatives. "TLA" presents strategies for resolving conflicts: Tell your thoughts; Listen actively, and Ask questions. A total of 4941 care providers participated in training using didactic presentations, group discussion, and simulation. Learners rated training effectiveness at 4.68 on a scale of 1 to 5 (5 as optimum) and perceived improvement in recognizing or managing errors. Nonphysician caregivers reported greatest improvement. Training to improve critical thinking is feasible, well received, and effective.
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Affiliation(s)
| | - Ellen S Deutsch
- The Children's Hospital of Philadelphia, Philadelphia, PA.,Pennsylvania Patient Safety Authority and ECRI Institute, Plymouth Meeting, PA
| | | | - Daniela H Davis
- The Children's Hospital of Philadelphia, Philadelphia, PA.,University of Pennsylvania, Philadelphia, PA
| | | | - Michael Apkon
- The Hospital for Sick Children, Toronto, ON, Canada.,The University of Toronto School of Medicine, Toronto, ON, Canada
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15
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Hardie RA, Moore D, Holzhauser D, Legg M, Georgiou A, Badrick T. Informatics External Quality Assurance (IEQA) Down Under: evaluation of a pilot implementation. ACTA ACUST UNITED AC 2018. [DOI: 10.1515/labmed-2018-0050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractExternal quality assurance (EQA) provides ongoing evaluation to verify that laboratory medicine results conform to quality standards expected for patient care. While attention has focused predominantly on test accuracy, the diagnostic phases, consisting of pre- and post-laboratory phases of testing, have thus far lagged in the development of an appropriate diagnostic-phase EQA program. One of the challenges faced by Australian EQA has been a lack of standardisation or “harmonisation” resulting from variations in reporting between different laboratory medicine providers. This may introduce interpretation errors and misunderstanding of results by clinicians, resulting in a threat to patient safety. While initiatives such as the Australian Pathology Information, Terminology and Units Standardisation (PITUS) program have produced Standards for Pathology Informatics in Australia (SPIA), conformity to these requires regular monitoring to maintain integrity of data between sending (laboratory medicine providers) and receiving (physicians, MyHealth Record, registries) organisations’ systems. The PITUS 16 Informatics EQA (IEQA) Project together with the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) has created a system to perform quality assurance on the electronic laboratory message when the laboratory sends a result back to the EQA provider. The purpose of this study was to perform a small scale pilot implementation of an IEQA protocol, which was performed to test the suitability of the system to check compliance of existing Health Level-7 (HL7 v2.4) reporting standards localised and constrained by the RCPA SPIA. Here, we present key milestones from the implementation, including: (1) software development, (2) installation, and verification of the system and communication services, (3) implementation of the IEQA program and compliance testing of the received HL7 v2.4 report messages, (4) compilation of a draft Informatics Program Survey Report for each laboratory and (5) review consisting of presentation of a report showing the compliance checking tool to each participating laboratory.
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16
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Nicholson BD, Goyder CR, Bankhead CR, Toftegaard BS, Rose PW, Thulesius H, Vedsted P, Perera R. Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data. Br J Gen Pract 2018; 68:e323-e332. [PMID: 29686134 PMCID: PMC5916079 DOI: 10.3399/bjgp18x695813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/05/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained. AIM To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions. DESIGN AND SETTING A secondary analysis of survey data from the International Cancer Benchmarking Partnership. METHOD The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach. RESULTS PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility. CONCLUSION The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Goyder
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Peter W Rose
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Växjö, Sweden
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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17
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Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding. J Gen Intern Med 2018; 33:415-422. [PMID: 29302885 PMCID: PMC5880768 DOI: 10.1007/s11606-017-4273-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
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Affiliation(s)
- Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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18
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Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol 2018; 15:287-295. [PMID: 29102539 DOI: 10.1016/j.jacr.2017.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE We previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography. METHODS An algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger's performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed. RESULTS Of 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result. CONCLUSIONS Care delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.
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19
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Referring Provider Perceptions of Standardized Reporting for Possible Abdominal Cancer. J Am Coll Radiol 2017; 14:654-658.e3. [DOI: 10.1016/j.jacr.2016.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 11/23/2022]
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20
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Weingart SN, Stoffel EM, Chung DC, Sequist TD, Lederman RI, Pelletier SR, Shields HM. Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. Jt Comm J Qual Patient Saf 2016; 43:32-40. [PMID: 28334584 DOI: 10.1016/j.jcjq.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding. METHODS In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance. RESULTS Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented. CONCLUSION Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.
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21
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Murphy DR, Meyer AN, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest 2016; 150:613-20. [PMID: 27178786 DOI: 10.1016/j.chest.2016.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/14/2016] [Accepted: 05/02/2016] [Indexed: 02/08/2023] Open
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22
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Abstract
IMPORTANCE Patients are increasingly being given access to their test results, but little is known about how preferences vary with the test under consideration or the results of the test (normal or abnormal). OBJECTIVE This study was conducted to examine preferences for test result communication. DESIGN, SETTING, AND PARTICIPANTS We surveyed adults to explore their preferences for test result notification for three common diagnostic tests of varying "emotional impact" (dual-energy x-ray absorptiometry [DXA], genital herpes, and cancer biopsy) when test results were 1) normal and 2) abnormal. We conducted our survey between June and August 2012 on the campus of an academic medical center. For each scenario, subjects were asked to rank seven methods that might be used to communicate test results (letter, unsecured email, secured email, text message, telephone call, secure Web portal, office visit) in order of acceptability. MAIN OUTCOME MEASURES The main measures were the percentage of respondents who ranked a particular test result notification method favorably and the percentage who ranked it as unacceptable. RESULTS When test results were normal, subjects' notification preferences were generally similar for DXA, herpes and cancer biopsy, with telephone and letter ranked most favorably for all three tests. Conversely, text message and unsecured email were viewed as unacceptable notification methods for normal results by 45.0-55.0 % of subjects across all three tests. When test results were abnormal, office visits became more popular. A higher proportion of subjects ranked office visits as their most preferred notification method for our test with high "emotional impact" (cancer biopsy) (38.4 %) as compared to DXA (28.2 %) and herpes (27.9 %) (P = 0.02). For most test scenarios, younger subjects appeared to rank electronic communication modalities (secure email or Web portal) higher than older subjects, though this difference did not reach statistical significance (P = 0.29). CONCLUSIONS Preferences for test result notification can differ substantially depending upon the test under consideration and results of the test. Providers and health care systems should consider these factors when deciding how to communicate results to patients.
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23
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Murphy DR, Thomas EJ, Meyer AND, Singh H. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings. Radiology 2015; 277:81-7. [PMID: 25961634 DOI: 10.1148/radiol.2015142530] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.
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Affiliation(s)
- Daniel R Murphy
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Eric J Thomas
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Ashley N D Meyer
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Hardeep Singh
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
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Sloan CE, Chadalavada SC, Cook TS, Langlotz CP, Schnall MD, Zafar HM. Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports? Acad Radiol 2014; 21:1579-86. [PMID: 25179562 DOI: 10.1016/j.acra.2014.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVES To understand the reasons leading to potentially inappropriate management of imaging findings concerning for malignancy and identify optimal methods for communicating these findings to providers. MATERIALS AND METHODS We identified all abdominal imaging examinations with findings of possible cancer performed on six randomly selected days in August to December 2013. Electronic medical records (EMR) of one patient group were reviewed 3 months after the index examination to determine whether management was appropriate (completed follow-up or documented reason for no follow-up) or potentially inappropriate (no follow-up or no documented reason). Providers of a second patient group were contacted 5-6 days after imaging examinations to determine notification preferences. RESULTS Among 43 patients in the first group, five (12%) received potentially inappropriate management. Reasons included patient loss to follow-up and provider failure to review imaging results, document known imaging findings, or communicate findings to providers outside the health system. Among 16 providers caring for patients in the second group, 33% were unaware of the findings, 75% preferred to be notified of abnormal findings via e-mail or EMR, 56% wanted an embedded hyperlink enabling immediate follow-up order entry, and only 25% had a system to monitor whether patients had completed ordered testing. CONCLUSIONS One in eight patients did not receive potentially necessary follow-up care within 3 months of imaging findings of possible cancer. Automated notification of imaging findings and follow-up monitoring not only is desired by providers but can also address many of the reasons we found for inappropriate management.
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Affiliation(s)
- Caroline E Sloan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Seetharam C Chadalavada
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tessa S Cook
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Curtis P Langlotz
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mitchell D Schnall
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Murphy DR, Laxmisan A, Reis BA, Thomas EJ, Esquivel A, Forjuoh SN, Parikh R, Khan MM, Singh H. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf 2013; 23:8-16. [PMID: 23873756 DOI: 10.1136/bmjqs-2013-001874] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis. METHODS We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV). RESULTS The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers. CONCLUSIONS EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.
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Affiliation(s)
- Daniel R Murphy
- Houston VA Health Services Research & Development Center of Excellence, and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research and Development, , Houston, Texas, USA
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Kravitz RL. Bending the arc of the health care universe through systems improvement. J Gen Intern Med 2012; 27:1395-6. [PMID: 22936290 PMCID: PMC3475832 DOI: 10.1007/s11606-012-2205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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