Development and Validation of Trigger Algorithms to Identify Delays in Diagnostic Evaluation of Gastroenterological Cancer

A Virtual Breakthrough Series Collaborative for Missed Test Results: A Stepped-Wedge Cluster-Randomized Clinical Trial

Importance

Missed test results, defined as test results not followed up within an appropriate time frame, are common and lead to delays in diagnosis and treatment.

Objective

To evaluate the effect of a quality improvement collaborative, the Virtual Breakthrough Series (VBTS), on the follow-up rate of 2 types of test results prone to being missed: chest imaging suspicious for lung cancer and laboratory findings suggestive of colorectal cancer.

Design, Setting, and Participants

This stepped-wedge cluster-randomized clinical trial was conducted between February 2020 and March 2022 at 12 Department of Veterans Affairs (VA) medical centers, with a predefined 3-cohort roll-out. Each cohort was exposed to 3 phases: preintervention, action, and continuous improvement. Follow-up ranged from 0 to 12 months, depending on cohort. Teams at each site were led by a project leader and included diverse interdisciplinary representation, with a mix of clinical and technical experts, senior leaders, nursing champions, and other interdisciplinary team members. Analysis was conducted per protocol, and data were analyzed from April 2022 to March 2024.

Intervention

All teams participated in a VBTS, which included instruction on reducing rates of missed test results at their site.

Main Outcomes and Measures

The primary outcome was changes in the percentage of abnormal test result follow-up, comparing the preintervention phase with the action phase. Secondary outcomes were effects across cohorts and the intervention's effect on sites with the highest and lowest preintervention follow-up rates. Previously validated electronic algorithms measured abnormal imaging and laboratory test result follow-up rates.

Results

A total of 11 teams completed the VBTS and implemented 47 (mean, 4 per team; range, 3-8 per team; mode, 3 per team) unique interventions to improve missed test results. A total of 40 027 colorectal cancer-related tests were performed, with 5130 abnormal results, of which 1286 results were flagged by the electronic trigger (e-trigger) algorithm as being missed. For lung cancer-related studies, 376 765 tests were performed, with 7314 abnormal results and 2436 flagged by the e-trigger as being missed. There was no significant difference in the percentage of abnormal test results followed up by study phase, consistent across all 3 cohorts. The estimated mean difference between the preintervention and action phases was -0.78 (95% CI, -6.88 to 5.31) percentage points for the colorectal e-trigger and 0.36 (95% CI, -5.19 to 5.9) percentage points for the lung e-trigger. However, there was a significant effect of the intervention by site, with the site with the lowest follow-up rate at baseline increasing its follow-up rate from 27.8% in the preintervention phase to 55.6% in the action phase.

Conclusions and Relevance

In this cluster-randomized clinical trial of the VBTS intervention, there was no improvement in the percentage of test results receiving follow-up. However, the VBTS may offer benefits for sites with low baseline performance.

Trial Registration

ClinicalTrials.gov Identifier: NCT04166240.

Defining and Understanding Diagnostic Delays Among Pancreatic Cancer Patients: A Retrospective Cohort Study

BACKGROUND AND AIMS

Pancreatic cancer is a lethal cancer of increasing incidence, presenting with several clinically detectable signals allowing for earlier diagnosis. However, there are limited data related to diagnostic process, including prevalence of diagnostic delays and their contributing factors. We aimed to develop a standardized definition of diagnostic delay, evaluate its prevalence, and identify its contributing factors among pancreatic cancer patients.

METHODS

We convened an expert panel who defined diagnostic delay among pancreatic cancer patients. We then conducted a retrospective cohort study among pancreatic adenocarcinoma patients consecutively diagnosed from 2007 to 2019 at a tertiary care Veterans Affairs medical center. We manually reviewed diagnostic delay instances for contributing factors. Secondary analyses, using multivariate logistic regression and Cox proportional hazards models, explored associations between diagnostic delays and cancer outcomes.

RESULTS

Diagnostic delay was defined as cancer diagnosis made ≥60 days after first clinical presence of predefined red flag(s). Among 197 pancreatic adenocarcinoma patients, 38.6% experienced a diagnostic delay. Among delay cases, the most common primary contributing factor was related to the patient-provider encounter (44.7% with lack of recognition of objective weight loss). Patients with delays were more likely to be diagnosed at advanced stage disease (adjusted odds ratio, 1.62; 95% confidence interval, 0.79-3.30) and less likely to receive potentially curative treatment (adjusted odds ratio, 0.72; 95% confidence interval, 0.28-1.84), although these trends did not reach statistical significance.

CONCLUSIONS

Over one-third of pancreatic cancer patients experienced a diagnostic delay, mostly due to inadequate recognition of red flag findings. Results can inform targeted interventions to reduce preventable diagnostic delays among pancreatic cancer patients.

Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration

Importance

Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs' (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially also improve timely follow-up of abnormal test results. PACT was implemented nationally in the VA between 2010 and 2012.

Objective

To evaluate the long-term association between PACT implementation and timely follow-up of abnormal test results related to the diagnosis of 5 different cancers.

Design, Setting, and Participants

This multiyear retrospective cohort study used 14 years of VA data (2006-2019), which were analyzed using panel data-based random-effects linear regressions. The setting included all VA clinics and facilities. The participants were adult patients who underwent diagnostic testing related to 5 different cancers and had abnormal test results. Data extraction and statistical analyses were performed from September 2021 to December 2023.

Exposure

Calendar years denoting preperiods and postperiods of PACT implementation, and the PACT Implementation Progress Index Score denoting the extent of implementation in each VA clinic and facility.

Main Outcome and Measure

Percentage of potentially missed timely follow-ups of abnormal test results.

Results

This study analyzed 6 data sets representing 5 different types of cancers. During the initial years of PACT implementation (2010 to 2013), percentage of potentially missed timely follow-ups decreased between 3 to 7 percentage points for urinalysis suggestive of bladder cancer, 12 to 14 percentage points for mammograms suggestive of breast cancer, 19 to 22 percentage points for fecal tests suggestive of colorectal cancer, and 6 to 13 percentage points for iron deficiency anemia laboratory tests suggestive of colorectal cancer, with no statistically significant changes for α-fetoprotien tests and lung cancer imaging. However, these beneficial reductions were not sustained over time. Better PACT implementation scores were associated with a decrease in potentially missed timely follow-up percentages for urinalysis (0.3-percentage point reduction [95% CI, -0.6 to -0.1] with 1-point increase in the score), and laboratory tests suggestive of iron deficiency anemia (0.5-percentage point reduction [95% CI,-0.8 to -0.2] with 1-point increase in the score).

Conclusions and Relevance

This cohort study found that implementation of PACT in the VA was associated with a potential short-term improvement in the quality of follow-up for certain test results. Additional multifaceted sustained interventions to reduce missed test results are required to prevent care delays.

Developing electronic clinical quality measures to assess the cancer diagnostic process

OBJECTIVE

Measures of diagnostic performance in cancer are underdeveloped. Electronic clinical quality measures (eCQMs) to assess quality of cancer diagnosis could help quantify and improve diagnostic performance.

MATERIALS AND METHODS

We developed 2 eCQMs to assess diagnostic evaluation of red-flag clinical findings for colorectal (CRC; based on abnormal stool-based cancer screening tests or labs suggestive of iron deficiency anemia) and lung (abnormal chest imaging) cancer. The 2 eCQMs quantified rates of red-flag follow-up in CRC and lung cancer using electronic health record data repositories at 2 large healthcare systems. Each measure used clinical data to identify abnormal results, evidence of appropriate follow-up, and exclusions that signified follow-up was unnecessary. Clinicians reviewed 100 positive and 20 negative randomly selected records for each eCQM at each site to validate accuracy and categorized missed opportunities related to system, provider, or patient factors.

RESULTS

We implemented the CRC eCQM at both sites, while the lung cancer eCQM was only implemented at the VA due to lack of structured data indicating level of cancer suspicion on most chest imaging results at Geisinger. For the CRC eCQM, the rate of appropriate follow-up was 36.0% (26 746/74 314 patients) in the VA after removing clinical exclusions and 41.1% at Geisinger (1009/2461 patients; P < .001). Similarly, the rate of appropriate evaluation for lung cancer in the VA was 61.5% (25 166/40 924 patients). Reviewers most frequently attributed missed opportunities at both sites to provider factors (84 of 157).

CONCLUSIONS

We implemented 2 eCQMs to evaluate the diagnostic process in cancer at 2 large health systems. Health care organizations can use these eCQMs to monitor diagnostic performance related to cancer.

Using Natural Language Processing to Automatically Identify Dysplasia in Pathology Reports for Patients With Barrett's Esophagus

BACKGROUND & AIMS

Identifying dysplasia of Barrett's esophagus (BE) in the electronic medical record (EMR) requires manual abstraction of unstructured data. Natural language processing (NLP) creates structure to unstructured free text. We aimed to develop and validate an NLP algorithm to identify dysplasia in BE patients on histopathology reports with varying report formats in a large integrated EMR system.

METHODS

We randomly selected 600 pathology reports for NLP development and 400 reports for validation from patients with suspected BE in the national Veterans Affairs databases. BE and dysplasia were verified by manual review of the pathology reports. We used NLP software (Clinical Language Annotation, Modeling, and Processing Toolkit; Melax Tech, Houston, TX) to develop an algorithm to identify dysplasia using findings. The algorithm performance characteristics were calculated as recall, precision, accuracy, and F-measure.

RESULTS

In the development set of 600 patients, 457 patients had confirmed BE (60 with dysplasia). The NLP identified dysplasia with 98.0% accuracy, 91.7% recall, and 93.2% precision, with an F-measure of 92.4%. All 7 patients with confirmed high-grade dysplasia were classified by the algorithm as having dysplasia. Among the 400 patients in the validation cohort, 230 had confirmed BE (39 with dysplasia). Compared with manual review, the NLP algorithm identified dysplasia with 98.7% accuracy, 92.3% recall, and 100.0% precision, with an F-measure of 96.0%.

CONCLUSIONS

NLP yielded a high degree of sensitivity and accuracy for identifying dysplasia from diverse types of pathology reports for patients with BE. The application of this algorithm would facilitate research and clinical care in an EMR system with text reports in large data repositories.

Cancer Evaluations During the COVID-19 Pandemic: An Observational Study Using National Veterans Affairs Data

INTRODUCTION

Fewer cancer diagnoses have been made during the COVID-19 pandemic. Pandemic-related delays in cancer diagnosis could occur from limited access to care or patient evaluation delays (e.g., delayed testing after abnormal results). Follow-up of abnormal test results warranting evaluation for cancer was examined before and during the pandemic.

METHODS

Electronic trigger algorithms were applied to the Department of Veterans Affairs electronic health record data to assess follow-up of abnormal test results before (March 10, 2019-March 7, 2020) and during (March 8, 2020-March 6, 2021) the pandemic.

RESULTS

Electronic triggers were applied to 8,021,406 veterans' electronic health records to identify follow-up delays for abnormal results warranting evaluation for 5 cancers: bladder (urinalysis with high-grade hematuria), breast (abnormal mammograms), colorectal (positive fecal occult blood tests/fecal immunochemical tests or results consistent with iron deficiency anemia), liver (elevated alpha-fetoprotein), and lung (chest imaging suggestive of malignancy) cancers. Between prepandemic and pandemic periods, test quantities decreased by 12.6%-27.8%, and proportions of abnormal results lacking follow-up decreased for urinalyses (-0.8%), increased for fecal occult blood tests/fecal immunochemical test (+2.3%) and chest imaging (+1.8%), and remained constant for others. Follow-up times decreased for most tests; however, control charts suggested increased delays at 2 stages: early (pandemic beginning) for urinalyses, mammograms, fecal occult blood tests/fecal immunochemical test, iron deficiency anemia, and chest imaging and late (30-45 weeks into pandemic) for mammograms, fecal occult blood tests/fecal immunochemical test, and iron deficiency anemia.

CONCLUSIONS

Although early pandemic delays in follow-up may have led to reduced cancer rates, the significant decrease in tests performed is likely a large driver of these reductions. Future emergency preparedness efforts should bolster essential follow-up and testing procedures to facilitate timely cancer diagnosis.

Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies' Report Improving Diagnosis in Health Care

BACKGROUND

Standards for accurate and timely diagnosis are ill-defined. In 2015, the National Academies of Science, Engineering, and Medicine (NASEM) committee published a landmark report, Improving Diagnosis in Health Care , and proposed a new definition of diagnostic error, "the failure to ( a ) establish an accurate and timely explanation of the patient's health problem(s) or ( b ) communicate that explanation to the patient."

OBJECTIVE

This study aimed to explore how researchers operationalize the NASEM's definition of diagnostic error with relevance to accuracy, timeliness, and/or communication in peer-reviewed published literature.

METHODS

Using the Arskey and O'Malley's framework framework, we identified published literature from October 2015 to February 2021 using Medline and Google Scholar. We also conducted subject matter expert interviews with researchers.

RESULTS

Of 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by theme: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies indicated using the NASEM definition. Of those, 5 studies also operationalized with existing definitions proposed before the NASEM report. Four studies operationalized the components of the NASEM definition and did not cite existing definitions. Three studies operationalized error using existing definitions only. Subject matter experts indicated that the NASEM definition functions as foundation for researchers to conceptualize diagnostic error.

CONCLUSIONS

The NASEM report produced a common understanding of diagnostic error that includes accuracy, timeliness, and communication. In recent peer-reviewed literature, most researchers continue to use pre-NASEM report definitions to operationalize accuracy and timeliness. The report catalyzed the use of patient-centered concepts in the definition, resulting in emerging studies focused on examining errors related to communicating diagnosis to patients.

Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations

OBJECTIVE

To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data.

RESULTS

Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions.

CONCLUSIONS

Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.

Understanding barriers to diagnosis in a rare, genetic disease: Delays and errors in diagnosing schwannomatosis

Diagnosis of rare, genetic diseases is challenging, but conceptual frameworks of the diagnostic process can guide quality improvement initiatives. Using the National Academy of Medicine diagnostic framework, we assessed the extent of, and reasons for diagnostic delays and diagnostic errors in schwannomatosis, a neurogenetic syndrome characterized by nerve sheath tumors and chronic pain. We reviewed the medical records of 97 people with confirmed or probable schwannomatosis seen in two US tertiary care clinics. Time-to-event analysis revealed a median time from first symptom to diagnosis of 16.7 years (95% CI, 7.5-26.0 years) and median time from first medical consultation to diagnosis of 9.8 years (95% CI, 3.5-16.2 years). Factors associated with longer times to diagnosis included initial signs/symptoms that were intermittent, non-specific, or occurred at younger ages (p < 0.05). Thirty-six percent of patients were misdiagnosed; misdiagnoses were of underlying genetic condition (18.6%), pain etiology (16.5%), and nerve sheath tumor presence/pathology (11.3%) (non-mutually exclusive categories). One-fifth (19.6%) of patients had a clear missed opportunity for genetics workup that could have led to an earlier schwannomatosis diagnosis. These results suggest that interventions in clinician education, genetic testing availability, expert review of pathology findings, and automatic triggers for genetics referrals may improve diagnosis of schwannomatosis.

Cancer risk in persons with new-onset anaemia: a population-based cohort study in Denmark

Background

The time interval from first symptom and sign until a cancer diagnosis significantly affects the prognosis. Therefore, recognising and acting on signs of cancer, such as anaemia, is essential. Evidence is sparse on the overall risk of cancer and the risk of specific cancer types in persons with new-onset anaemia detected in an unselected general practice population. We aimed to assess the risk of cancer in persons with new-onset anaemia detected in general practice, both overall and for selected cancer types.

Methods

This observational population-based cohort study used individually linked electronic data from laboratory information systems and nationwide healthcare registries in Denmark. We included persons aged 40–90 years without a prior history of cancer and with new-onset anaemia (no anaemia during the previous 15 months) detected in general practice in 2014–2018. We measured the incidence proportion and standardised incidence ratios of a new cancer diagnosis (all cancers except for non-melanoma skin cancers) during 12 months follow-up.

Results

A total of 48,925 persons (median [interquartile interval] age, 69 [55–78] years; 55.5% men) were included in the study. In total, 7.9% (95% confidence interval (CI): 7.6 to 8.2) of men and 5.2% (CI: 4.9 to 5.5) of women were diagnosed with cancer during 12 months. Across selected anaemia types, the highest cancer incidence proportion was seen in women with ‘anaemia of inflammation’ (15.3%, CI: 13.1 to 17.5) (ferritin > 100 ng/mL and increased C-reactive protein (CRP)) and in men with ‘combined inflammatory iron deficiency anaemia’ (19.3%, CI: 14.5 to 24.1) (ferritin < 100 ng/mL and increased CRP). For these two anaemia types, the cancer incidence across cancer types was 10- to 30-fold higher compared to the general population.

Conclusions

Persons with new-onset anaemia detected in general practice have a high cancer risk; and markedly high for ‘combined inflammatory iron deficiency anaemia’ and ‘anaemia of inflammation’. Anaemia is a sign of cancer that calls for increased awareness and action. There is a need for research on how to improve the initial pathway for new-onset anaemia in general practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09912-7.

The use of electronic health records to inform cancer surveillance efforts: a scoping review and test of indicators for public health surveillance of cancer prevention and control

INTRODUCTION

State cancer prevention and control programs rely on public health surveillance data to set objectives to improve cancer prevention and control, plan interventions, and evaluate state-level progress towards achieving those objectives. The goal of this project was to evaluate the validity of using electronic health records (EHRs) based on common data model variables to generate indicators for surveillance of cancer prevention and control for these public health programs.

METHODS

Following the methodological guidance from the PRISMA Extension for Scoping Reviews, we conducted a literature scoping review to assess how EHRs are used to inform cancer surveillance. We then developed 26 indicators along the continuum of the cascade of care, including cancer risk factors, immunizations to prevent cancer, cancer screenings, quality of initial care after abnormal screening results, and cancer burden. Indicators were calculated within a sample of patients from the New York City (NYC) INSIGHT Clinical Research Network using common data model EHR data and were weighted to the NYC population using post-stratification. We used prevalence ratios to compare these estimates to estimates from the raw EHR of NYU Langone Health to assess quality of information within INSIGHT, and we compared estimates to results from existing surveillance sources to assess validity.

RESULTS

Of the 401 identified articles, 15% had a study purpose related to surveillance. Our indicator comparisons found that INSIGHT EHR-based measures for risk factor indicators were similar to estimates from external sources. In contrast, cancer screening and vaccination indicators were substantially underestimated as compared to estimates from external sources. Cancer screenings and vaccinations were often recorded in sections of the EHR that were not captured by the common data model. INSIGHT estimates for many quality-of-care indicators were higher than those calculated using a raw EHR.

CONCLUSION

Common data model EHR data can provide rich information for certain indicators related to the cascade of care but may have substantial biases for others that limit their use in informing surveillance efforts for cancer prevention and control programs.

Why Test Results Are Still Getting "Lost" to Follow-up: a Qualitative Study of Implementation Gaps

BACKGROUND

Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm.

OBJECTIVE

As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff.

DESIGN

We used a semi-structured interview guide to collect qualitative data from Veterans Affairs (VA) facility staff who had experience with test results management and patient safety.

SETTING

Twelve VA facilities across the USA.

PARTICIPANTS

Facility staff members (n = 27), including clinicians, lab and imaging professionals, nursing staff, patient safety professionals, and leadership.

APPROACH

We conducted a content analysis of interview transcripts to identify perceived barriers and high-risk areas for effective test result management, as well as recommendations for improvement.

RESULTS

We identified seven themes to guide further development of interventions to improve test result follow-up. Themes related to trainees, incidental findings, tracking systems for electronic health record notifications, outdated contact information, referrals, backup or covering providers, and responsibility for test results pending at discharge. Participants provided recommendations for improvement within each theme.

CONCLUSIONS

Perceived barriers and recommendations for improving test result follow-up often reflected previously known problems and their corresponding solutions, which have not been consistently implemented in practice. Better policy solutions and improvement methods, such as quality improvement collaboratives, may bridge the implementation gaps between knowledge and practice.

Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study

BACKGROUND

Understanding pre-diagnostic test use could reveal diagnostic windows where more timely evaluation for cancer may be indicated.

AIM

To examine pre-diagnostic patterns of results of abnormal blood tests in patients with bladder and renal cancer.

DESIGN AND SETTING

A retrospective cohort study using primary care and cancer registry data on patients with bladder and renal cancer who were diagnosed between April 2012 and December 2015 in England.

METHOD

The rates of patients with a first abnormal result in the year before cancer diagnosis, for 'generic' (full blood count components, inflammatory markers, and calcium) and 'organ-specific' blood tests (creatinine and liver function test components) that may lead to subsequent detection of incidental cancers, were examined. Poisson regression was used to detect the month during which the cohort's rate of each abnormal test started to increase from baseline. The proportion of patients with a test found in the first half of the diagnostic window was examined, as these 'early' tests might represent opportunities where further evaluation could be initiated.

RESULTS

Data from 4533 patients with bladder and renal cancer were analysed. The monthly rate of patients with a first abnormal test increased towards the time of cancer diagnosis. Abnormalities of both generic (for example, high inflammatory markers) and organ-specific tests (for example, high creatinine) started to increase from 6-8 months pre-diagnosis, with 25%-40% of these patients having an abnormal test in the 'early half' of the diagnostic window.

CONCLUSION

Population-level signals of bladder and renal cancer can be observed in abnormalities in commonly performed primary care blood tests up to 8 months before diagnosis, indicating the potential for earlier diagnosis in some patients.

Learning from Missed Opportunities Through Reflective Practice

Identification of diagnostic errors is difficult but is not alone sufficient for performance improvement. Instead, cases must be reflected on to identify ways to improve decision-making in the future. There are many tools and modalities to retrospectively reflect on action to study medical decisions and outcomes and improve future performance. Reflection in action-in which diagnostic decisions are considered in real-time-may also improve medical decision-making especially through strategies such as structured reflection. Ongoing regular feedback can normalize the discussion about improving decision-making, enable reflective practice, and improve decision making.

Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians

IMPORTANCE

Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer.

OBJECTIVE

To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy.

DESIGN, SETTING, AND PARTICIPANTS

This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA.

MAIN OUTCOMES AND MEASURES

Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation.

RESULTS

Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years.

CONCLUSIONS AND RELEVANCE

In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments

OBJECTIVE

Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

METHODS

Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit.

RESULTS

We applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for "missed" = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen's kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%).

CONCLUSION

In a large national EHR repository, a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.

Factors Associated With Delay of Diagnosis of Hepatocellular Carcinoma in Patients With Cirrhosis

BACKGROUND & AIMS

We examined the frequency of and factors associated with delays in diagnosis of hepatocellular carcinoma (HCC) in a cohort of patients with cirrhosis in the Veterans Health Administration.

METHODS

In a retrospective study, we collected and analyzed data from the Veterans Health Administration's electronic health records. We used a multivariate logistic regression model to identify factors associated with a delay in diagnosis of HCC of more than 60 days following a red flag (defined as the earliest date at which a diagnosis of HCC could have been made, based on American Association for the Study of Liver Disease 2005 guidelines). We used multivariate Cox proportional hazards model to evaluate the effects of delayed diagnosis on survival, adjusting for patient and provider characteristics.

RESULTS

Among 655 patients with cirrhosis and a diagnosis of HCC from 2006 through 2011, 46.9% had a delay in diagnosis of more than 60 days following a red flag for HCC. Delays in diagnosis for more than 60 days were significantly associated with lack of provider adherence to the guidelines (adjusted odds ratio [OR], 4.82; 95% CI, 3.12-7.45), a diagnostic imaging evaluation instead of only measurement of alfa fetoprotein (adjusted OR, 2.63; 95% CI, 1.09-6.24), and diagnosis as an incidental finding during examination for an unrelated medical problem (compared with an HCC-related assessment) (adjusted OR, 2.26; 95% CI, 1.09-4.67). Diagnostic delays of 60 days or more were associated with lower mortality compared to patients without a delay in diagnosis (unadjusted hazard ratio, 0.57; 95% CI, 0.47-0.68 and adjusted hazard ratio, 0.63; 95% CI, 0.50-0.78).

CONCLUSIONS

Nearly half of veterans with cirrhosis have delays in diagnosis of HCC of 60 days or more after a red flag, defined by guidelines. Interventions are needed to improve timely follow-up of red flags for HCC and adherence to guidelines, to increase early detection of HCC.

Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data

IMPORTANCE

Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged.

OBJECTIVE

To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018.

MAIN OUTCOMES AND MEASURES

Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved.

RESULTS

Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.

CONCLUSIONS AND RELEVANCE

This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.

Application of electronic trigger tools to identify targets for improving diagnostic safety

Progress in reducing diagnostic errors remains slow partly due to poorly defined methods to identify errors, high-risk situations, and adverse events. Electronic trigger (e-trigger) tools, which mine vast amounts of patient data to identify signals indicative of a likely error or adverse event, offer a promising method to efficiently identify errors. The increasing amounts of longitudinal electronic data and maturing data warehousing techniques and infrastructure offer an unprecedented opportunity to implement new types of e-trigger tools that use algorithms to identify risks and events related to the diagnostic process. We present a knowledge discovery framework, the Safer Dx Trigger Tools Framework, that enables health systems to develop and implement e-trigger tools to identify and measure diagnostic errors using comprehensive electronic health record (EHR) data. Safer Dx e-trigger tools detect potential diagnostic events, allowing health systems to monitor event rates, study contributory factors and identify targets for improving diagnostic safety. In addition to promoting organisational learning, some e-triggers can monitor data prospectively and help identify patients at high-risk for a future adverse event, enabling clinicians, patients or safety personnel to take preventive actions proactively. Successful application of electronic algorithms requires health systems to invest in clinical informaticists, information technology professionals, patient safety professionals and clinicians, all of who work closely together to overcome development and implementation challenges. We outline key future research, including advances in natural language processing and machine learning, needed to improve effectiveness of e-triggers. Integrating diagnostic safety e-triggers in institutional patient safety strategies can accelerate progress in reducing preventable harm from diagnostic errors.

Low Rates of Screening for Celiac Disease Among Family Members

BACKGROUND & AIMS

Given the increased morbidity and potential mortality of celiac disease, guidelines recommend screening high-risk individuals, including first-degree relatives of patients. We assessed how commonly celiac disease testing occurs in these individuals and identified factors that influence testing.

METHODS

Relatives of 2081 patients with biopsy-diagnosed celiac disease and followed up at Columbia University Medical Center were identified using relationship inference from the electronic health record-a validated method that uses emergency contact information to identify familial relationships. We manually abstracted data from each record and performed univariate and multivariate analyses to identify factors associated with testing relatives for celiac disease.

RESULTS

Of 539 relatives identified, 212 (39.3%) were tested for celiac disease, including 50.4% (193 of 383) of first-degree relatives and 71.5% (118 of 165) of symptomatic first-degree relatives. Of the 383 first-degree relatives, only 116 (30.3%) had a documented family history of celiac disease. On multivariate analysis, testing was more likely in adults (odds ratio [OR], for 18-39 y vs younger than 18 y, 2.27; 95% CI, 1.12-4.58); relatives being seen by a gastroenterologist (OR, 15.16; 95% CI, 7.72-29.80); relatives with symptoms (OR, 3.69; 95% CI, 2.11-6.47); first-degree relatives of a patient with celiac disease (OR, 4.90, 95% CI, 2.34-10.25); and relatives with a documented family history of celiac disease (OR, 11.9, 95% CI, 5.56-25.48).

CONCLUSIONS

By using an algorithm to identify relatives of patients with celiac disease, we found that nearly 30% of symptomatic first-degree relatives of patients with celiac disease have not received the tests recommended by guidelines. Health care providers should implement strategies to identify and screen patients at increased risk for celiac disease, including methods to ensure adequate documentation of family medical history.