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Mangus CW, James TG, Parker SJ, Duffy E, Chandanabhumma PP, Cassady CM, Bellolio F, Pasupathy KS, Manojlovich M, Singh H, Mahajan P. Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study. Jt Comm J Qual Patient Saf 2024; 50:480-491. [PMID: 38643047 DOI: 10.1016/j.jcjq.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews. RESULTS The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused. CONCLUSION Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.
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Bergl PA, Shukla N, Shah J, Khan M, Patel JJ, Nanchal RS. Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study. Diagnosis (Berl) 2024; 11:31-39. [PMID: 38018397 DOI: 10.1515/dx-2023-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 11/02/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES Diagnostic errors are a source of morbidity and mortality in intensive care unit (ICU) patients. However, contextual factors influencing clinicians' diagnostic performance have not been studied in authentic ICU settings. We sought to determine the accuracy of ICU clinicians' diagnostic impressions and to characterize how various contextual factors, including self-reported stress levels and perceptions about the patient's prognosis and complexity, impact diagnostic accuracy. We also explored diagnostic calibration, i.e. the balance of accuracy and confidence, among ICU clinicians. METHODS We conducted an observational cohort study in an academic medical ICU. Between June and August 2019, we interviewed ICU clinicians during routine care about their patients' diagnoses, their confidence, and other contextual factors. Subsequently, using adjudicated final diagnoses as the reference standard, two investigators independently rated clinicians' diagnostic accuracy and on each patient on a given day ("patient-day") using 5-point Likert scales. We conducted analyses using both restrictive and conservative definitions of clinicians' accuracy based on the two reviewers' ratings of accuracy. RESULTS We reviewed clinicians' responses for 464 unique patient-days, which included 255 total patients. Attending physicians had the greatest diagnostic accuracy (77-90 %, rated as three or higher on 5-point Likert scale) followed by the team's primary fellow (73-88 %). Attending physician and fellows were also least affected by contextual factors. Diagnostic calibration was greatest among ICU fellows. CONCLUSIONS Additional studies are needed to better understand how contextual factors influence different clinicians' diagnostic reasoning in the ICU.
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Affiliation(s)
- Paul A Bergl
- Department of Critical Care, Gundersen Health System, La Crosse, WI, USA
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Neehal Shukla
- Cleveland Clinic Foundation, Internal Medicine Residency Program, Cleveland, OH, USA
| | - Jatan Shah
- University of Pittsburgh Medical Centre Chautauqua, Jamestown, NY, USA
| | - Marium Khan
- Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rahul S Nanchal
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Herasevich S, Soleimani J, Huang C, Pinevich Y, Dong Y, Pickering BW, Murad MH, Barwise AK. Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. BMJ Qual Saf 2023; 32:676-688. [PMID: 36972982 DOI: 10.1136/bmjqs-2022-015038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms. METHODS We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies. CONCLUSIONS This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations. TRIAL REGISTRATION NUMBER The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chanyan Huang
- Department of Anaesthesiology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad H Murad
- Center for Science of Healthcare Delivery, Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
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Herasevich S, Pinevich Y, Lindroth HL, Herasevich V, Pickering BW, Barwise AK. Who needs clinician attention first? A qualitative study of critical care clinicians' needs that enable the prioritization of care for populations of acutely ill patients. Int J Med Inform 2023; 177:105118. [PMID: 37295137 PMCID: PMC10527757 DOI: 10.1016/j.ijmedinf.2023.105118] [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: 03/10/2023] [Revised: 05/15/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND To adequately care for groups of acutely ill patients, clinicians maintain situational awareness to identify the most acute needs within the entire intensive care unit (ICU) population through constant reappraisal of patient data from electronic medical record and other information sources. Our objective was to understand the information and process requirements of clinicians caring for multiple ICU patients and how this information is used to support their prioritization of care among populations of acutely ill patients. Additionally, we wanted to gather insights on the organization of an Acute care multi-patient viewer (AMP) dashboard. METHODS We conducted and audio-recorded semi-structured interviews of ICU clinicians who had worked with the AMP in three quaternary care hospitals. The transcripts were analyzed with open, axial, and selective coding. Data was managed using NVivo 12 software. RESULTS We interviewed 20 clinicians and identified 5 main themes following data analysis: (1) strategies used to enable patient prioritization, (2) strategies used for optimizing task organization, (3) information and factors helpful for situational awareness within the ICU, (4) unrecognized or missed critical events and information, and (5) suggestions for AMP organization and content. Prioritization of critical care was largely determined by severity of illness and trajectory of patient clinical status. Important sources of information were communication with colleagues from the previous shift, bedside nurses, and patients, data from the electronic medical record and AMP, and physical presence and availability in the ICU. CONCLUSIONS This qualitative study explored ICU clinicians' information and process requirements to enable the prioritization of care among populations of acutely ill patients. Timely recognition of patients who need priority attention and intervention provides opportunities for improvement of critical care and for preventing catastrophic events in the ICU.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Republican Clinical Medical Center, Minsk, Belarus
| | - Heidi L Lindroth
- Department of Nursing, Mayo Clinic, Rochester, MN; Center for Health Innovation and Implementation Science, Center for Aging Research, School of Medicine, Indiana University, Indianapolis, IN
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Bioethics Research Program, Mayo Clinic, Rochester, MN
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Lucas S, Chauhan A, Garg M. Letter: delays to diagnosis of IBD-Challenges requiring a systematic approach. Aliment Pharmacol Ther 2023; 57:1477-1478. [PMID: 37243457 DOI: 10.1111/apt.17521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Sarah Lucas
- Northern Health, Melbourne, Victoria, Australia
| | | | - Mayur Garg
- Northern Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Herasevich S, Pinevich Y, Lipatov K, Barwise AK, Lindroth HL, LeMahieu AM, Dong Y, Herasevich V, Pickering BW. Evaluation of Digital Health Strategy to Support Clinician-Led Critically Ill Patient Population Management: A Randomized Crossover Study. Crit Care Explor 2023; 5:e0909. [PMID: 37151891 PMCID: PMC10158897 DOI: 10.1097/cce.0000000000000909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
To investigate whether a novel acute care multipatient viewer (AMP), created with an understanding of clinician information and process requirements, could reduce time to clinical decision-making among clinicians caring for populations of acutely ill patients compared with a widely used commercial electronic medical record (EMR). DESIGN Single center randomized crossover study. SETTING Quaternary care academic hospital. SUBJECTS Attending and in-training critical care physicians, and advanced practice providers. INTERVENTIONS AMP. MEASUREMENTS AND MAIN RESULTS We compared ICU clinician performance in structured clinical task completion using two electronic environments-the standard commercial EMR (Epic) versus the novel AMP in addition to Epic. Twenty subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the tasks on two ICUs (7-10 beds each) and eight individual patients. The adjusted time for assessment of the entire ICU and the adjusted total time to task completion were significantly lower using AMP versus standard commercial EMR (-6.11; 95% CI, -7.91 to -4.30 min and -5.38; 95% CI, -7.56 to -3.20 min, respectively; p < 0.001). The adjusted time for assessment of individual patients was similar using both the EMR and AMP (0.73; 95% CI, -0.09 to 1.54 min; p = 0.078). AMP was associated with a significantly lower adjusted task load (National Aeronautics and Space Administration-Task Load Index) among clinicians performing the task versus the standard EMR (22.6; 95% CI, -32.7 to -12.4 points; p < 0.001). There was no statistically significant difference in adjusted total errors when comparing the two environments (0.68; 95% CI, 0.36-1.30; p = 0.078). CONCLUSIONS When compared with the standard EMR, AMP significantly reduced time to assessment of an entire ICU, total time to clinical task completion, and clinician task load. Additional research is needed to assess the clinicians' performance while using AMP in the live ICU setting.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
- Department of Anesthesiology, Republican Clinical Medical Center, Minsk, Belarus
| | - Kirill Lipatov
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Health Systems, Eau Claire, WI
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Bioethics Research Program, Mayo Clinic, Rochester, MN
| | - Heidi L Lindroth
- Department of Nursing, Mayo Clinic, Rochester, MN
- Center for Health Innovation and Implementation Science, Center for Aging Research, School of Medicine, Indiana University, Indianapolis, IN
| | | | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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VanSpronsen AD, Zychla L, Turley E, Villatoro V, Yuan Y, Ohinmaa A. Causes of Inappropriate Laboratory Test Ordering from the Perspective of Medical Laboratory Technical Professionals: Implications for Research and Education. Lab Med 2023; 54:e18-e23. [PMID: 35801961 DOI: 10.1093/labmed/lmac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Inappropriate laboratory test ordering is a significant and persistent problem. Many causes have been identified and studied. Medical laboratory professionals (MLPs) are technical staff within clinical laboratories who are uniquely positioned to comment on why inappropriate ordering occurs. We aimed to characterize existing MLP perceptions in this domain to reveal new or underemphasized interventional targets. METHODS We developed and disseminated a self-administered survey to MLPs in Canada, including open-ended responses to questions about the causes of inappropriate laboratory test ordering. RESULTS Four primary themes were identified from qualitative analysis: ordering-provider factors, communication factors, existing test-ordering processes, and patient factors. Although these factors can largely be found in previous literature, some are under-studied. CONCLUSION MLP insights into nonphysician triage ordering and poor result communication provide targets for further investigation. A heavy focus on individual clinician factors suggests that current understandings and interprofessional skills in the MLP population can be improved.
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Affiliation(s)
- Amanda D VanSpronsen
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Laura Zychla
- Research, Canadian Association for Medical Radiation Technologists, Ottawa, Ontario, Canada
| | - Elona Turley
- Coagulation Medicine, Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Valentin Villatoro
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Yan Yuan
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Redmond S, Barwise A, Zornes S, Dong Y, Herasevich S, Pinevich Y, Soleimani J, LeMahieu A, Leppin A, Pickering B. Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders. Health Serv Insights 2022; 15:11786329221123540. [PMID: 36119635 PMCID: PMC9476244 DOI: 10.1177/11786329221123540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.
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Affiliation(s)
- Sarah Redmond
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Zornes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN, USA
| | - Aaron Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit (KER), Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Anderson LK, Lane KR. The diagnostic journey in adults with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. J Am Assoc Nurse Pract 2021; 34:639-648. [PMID: 34739411 DOI: 10.1097/jxx.0000000000000672] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Researchers have identified lengthy diagnosis delays in patients with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders (hEDS/HSD), but the reason for these delays is unclear. OBJECTIVE This review seeks to synthesize the existing qualitative research about hEDS/HSD to understand the reasons for diagnosis delay. DATA SOURCES We searched PubMed, Scopus, CINAHL, Google Scholar, and Dissertations and Theses databases for all qualitative studies about hEDS/HSD that mentioned the diagnosis process. A total of 283 studies were retrieved, from which we identified 13 studies to include in this synthesis. CONCLUSIONS The reviewers identified and organized diagnosis delay themes under four overarching categories: disease, patient, provider, and system. Disease factors included the nature of the symptoms and lack of a confirmatory test. Patient factors included psychological and emotional responses, seeing multiple providers, and receiving multiple diagnoses. Provider factors related to limited knowledge and attitudes. System factors included silo-based health care systems and bureaucratic barriers. IMPLICATIONS FOR PRACTICE Diagnosis delays result from complex, overlapping, and interacting factors. Nurse practitioners have a critical role in improving care and reducing diagnosis delays in patients with hEDS/HSD. Further research is needed to understand the causes and consequences of diagnosis delays in hEDS/HSD.
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Affiliation(s)
- Linda K Anderson
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, Missouri
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