1
|
Hoagland A, Kantarevic J, Stutely J, Wijeysundera HC. Importance of Direct Exposure in Continuing Medical Education: Primary Care Physician Learning Through Patients With Transcatheter Aortic Valve Implantation. Can J Cardiol 2024; 40:637-639. [PMID: 37995906 DOI: 10.1016/j.cjca.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/31/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023] Open
Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jasmin Kantarevic
- Research and Analytics, Ontario Medical Association, Toronto, Ontario, Canada
| | - James Stutely
- Research and Analytics, Ontario Medical Association, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Department of Cardiology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Naseralallah L, Stewart D, Price M, Paudyal V. Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. Int J Clin Pharm 2023; 45:1359-1377. [PMID: 37682400 PMCID: PMC10682158 DOI: 10.1007/s11096-023-01626-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/12/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Medication errors are common events that compromise patient safety. Outpatient and ambulatory settings enhance access to healthcare which has been linked to favorable outcomes. While medication errors have been extensively researched in inpatient settings, there is dearth of literature from outpatient settings. AIM To synthesize the peer-reviewed literature on the prevalence, nature, contributory factors, and interventions to minimize medication errors in outpatient and ambulatory settings. METHOD A systematic review was conducted using Medline, Embase, CINAHL, and Google Scholar which were searched from 2011 to November 2021. Quality assessment was conducted using the quality assessment checklist for prevalence studies tool. Data related to contributory factors were synthesized according to Reason's accident causation model. RESULTS Twenty-four articles were included in the review. Medication errors were common in outpatient and ambulatory settings (23-92% of prescribed drugs). Prescribing errors were the most common type of errors reported (up to 91% of the prescribed drugs, high variations in the data), with dosing errors being most prevalent (up to 41% of the prescribed drugs). Latent conditions, largely due to inadequate knowledge, were common contributory factors followed by active failures. The seven studies that discussed interventions were of poor quality and none used a randomized design. CONCLUSION Medication errors (particularly prescribing errors and dosing errors) in outpatient settings are prevalent, although reported prevalence range is wide. Future research should be informed by behavioral theories and should use high quality designs. These interventions should encompass system-level strategies, multidisciplinary collaborations, effective integration of pharmacists, health information technology, and educational programs.
Collapse
Affiliation(s)
- Lina Naseralallah
- School of Pharmacy, College of Medical and Dental Science, Institute of Clinical Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Derek Stewart
- Clinical Pharmacy and Practice Department, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Malcom Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Science, Institute of Clinical Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| |
Collapse
|
3
|
Kanter MH, Ghobadi A, Lurvey LD, Liang S, Litman K, Au M. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl) 2022; 9:430-436. [PMID: 36151610 DOI: 10.1515/dx-2022-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 08/16/2022] [Indexed: 12/29/2022]
Abstract
Solving diagnostic errors is difficult and progress on preventing those errors has been slow since the 2015 National Academy of Medicine report. There are several methods used to improve diagnostic and other errors including voluntary reporting; malpractice claims; patient complaints; physician surveys, random quality reviews and audits, and peer review data which usually evaluates single cases and not the systems that allowed the error. Additionally, manual review of charts is often labor intensive and reviewer dependent. In 2010 we developed an e-Autopsy/e-Biopsy (eA/eB) methodology to aggregate cases with quality/safety/diagnostic issues, focusing on a specific population of patients and conditions. By performing a hybrid review process (cases are first filtered using administrative data followed by standardized manual chart reviews) we can efficiently identify patterns of medical and diagnostic error leading to opportunities for system improvements that have improved care for future patients. We present a detailed methodology for eA/eB studies and describe results from three successful studies on different diagnoses (ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer) that illustrate our eA/eB process and how it reveals insights into creating systems that reduce diagnostic and other errors. The eA/eB process is innovative and transferable to other healthcare organizations and settings to identify trends in diagnostic error and other quality issues resulting in improved systems of care.
Collapse
Affiliation(s)
- Michael H Kanter
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Ali Ghobadi
- Department of Emergency Medicine, Southern California Permanente Medical Group, Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Lawrence D Lurvey
- Department of Obstetrics & Gynecology, Southern California Permanente Medical Group Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sophia Liang
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Kerry Litman
- Department of Family Medicine, Southern California Permanente Medical Group, Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Maverick Au
- Southern California Permanente Medical Group, Pasadena, CA, USA
| |
Collapse
|
4
|
Deans AM, Basilious A, Hutnik CM. Assessing the Performance of a Novel Bayesian Algorithm at Point of Care for Red Eye Complaints. VISION (BASEL, SWITZERLAND) 2022; 6:vision6040064. [PMID: 36412645 PMCID: PMC9680424 DOI: 10.3390/vision6040064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
The current diagnostic aids for red eye are static flowcharts that do not provide dynamic, stepwise workups. The diagnostic accuracy of a novel dynamic Bayesian algorithm for red eye was tested. Fifty-seven patients with red eye were evaluated by an emergency medicine physician who completed a questionnaire about symptoms/findings (without requiring extensive slit lamp findings). An ophthalmologist then attributed an independent "gold-standard diagnosis". The algorithm used questionnaire data to suggest a differential diagnosis. The referrer's diagnostic accuracy was 70.2%, while the algorithm's accuracy was 68.4%, increasing to 75.4% with the algorithm's top two diagnoses included and 80.7% with the top three included. In urgent cases of red eye (n = 26), the referrer diagnostic accuracy was 76.9%, while the algorithm's top diagnosis was 73.1% accurate, increasing to 84.6% (top two included) and 88.5% (top three included). The algorithm's sensitivity for urgent cases was 76.9% (95% CI: 56-91%) using its top diagnosis, with a specificity of 93.6% (95% CI: 79-99%). This novel algorithm provides dynamic workups using clinical symptoms, and may be used as an adjunct to clinical judgement for triaging the urgency of ocular causes of red eye.
Collapse
Affiliation(s)
- Alexander M. Deans
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada
- Correspondence: ; Tel.: +226-246-8142
| | - Amy Basilious
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada
| | - Cindy M. Hutnik
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada
| |
Collapse
|
5
|
Diagnostic Agreement Among General Practitioners, Residents, and Senior Rheumatologists for Rheumatic Diseases. J Clin Rheumatol 2022; 28:293-299. [PMID: 35660703 DOI: 10.1097/rhu.0000000000001854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the concordance of the diagnoses made by senior rheumatologists and those made by residents in rheumatology and by general practitioners (GPs). METHODS In this cohort, 497 patients referred by GPs from August 1, 2018 to December 16, 2019 were evaluated first by a second-year resident in rheumatology. After clinical rounds, the diagnoses by senior rheumatologists were assumed as the criterion standard and defined the prevalence of the rheumatic diseases, divided into 5 groups: rheumatoid arthritis, spondyloarthritis, other connective tissue diseases and vasculitis, nonautoimmune rheumatic diseases, and nonrheumatic diseases. The follow-up ended on November 30, 2020. We calculated sensibility, specificity, positive predictive value, negative predictive value, and κ coefficient of the diagnosis by GPs and residents. RESULTS The diagnoses were changed for 58% of the referral letters. Diseases of low complexity, such as fibromyalgia and osteoarthritis, accounted for 50% of the diagnoses. Compared with senior rheumatologists, residents in rheumatology had κ > 0.6 for all the groups, whereas GPs had κ < 0.5, with the worst performance for nonautoimmune rheumatic disease (κ = -0.18) and nonrheumatic disease (κ = 0.15). In terms of level of complexity, 46% of the letters were inappropriate. CONCLUSIONS We found a poor level of diagnostic agreement between GPs and the rheumatology team. General practitioners had difficulties diagnosing and treating rheumatic diseases, referring patients that should be treated in the primary level of health care. One year of training in rheumatology made residents' skills comparable to those of senior rheumatologists.
Collapse
|
6
|
Basilious A, Govas CN, Deans AM, Yoganathan P, Deans RM. Evaluating the Diagnostic Accuracy of a Novel Bayesian Decision-Making Algorithm for Vision Loss. Vision (Basel) 2022; 6:vision6020021. [PMID: 35466273 PMCID: PMC9036270 DOI: 10.3390/vision6020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/23/2022] [Accepted: 04/02/2022] [Indexed: 12/03/2022] Open
Abstract
The current diagnostic aids for acute vision loss are static flowcharts that do not provide dynamic, stepwise workups. We tested the diagnostic accuracy of a novel dynamic Bayesian algorithm for acute vision loss. Seventy-nine “participants” with acute vision loss in Windsor, Canada were assessed by an emergency medicine or primary care provider who completed a questionnaire about ocular symptoms/findings (without requiring fundoscopy). An ophthalmologist then attributed an independent “gold-standard diagnosis”. The algorithm employed questionnaire data to produce a differential diagnosis. The referrer diagnostic accuracy was 30.4%, while the algorithm’s accuracy was 70.9%, increasing to 86.1% with the algorithm’s top two diagnoses included and 88.6% with the top three included. In urgent cases of vision loss (n = 54), the referrer diagnostic accuracy was 38.9%, while the algorithm’s top diagnosis was correct in 72.2% of cases, increasing to 85.2% (top two included) and 87.0% (top three included). The algorithm’s sensitivity for urgent cases using the top diagnosis was 94.4% (95% CI: 85–99%), with a specificity of 76.0% (95% CI: 55–91%). This novel algorithm adjusts its workup at each step using clinical symptoms. In doing so, it successfully improves diagnostic accuracy for vision loss using clinical data collected by non-ophthalmologists.
Collapse
Affiliation(s)
- Amy Basilious
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada; (A.B.); (A.M.D.)
| | - Chris N. Govas
- School of Medicine, Ross University, Two Mile Hill, St. Michael, Bridgetown BB11093, Barbados;
| | - Alexander M. Deans
- Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada; (A.B.); (A.M.D.)
| | - Pradeepa Yoganathan
- Department of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine, Wayne State University, 540 E. Canfield Ave., Detroit, MI 48201, USA;
- Windsor Eye Associates, Department of Ophthalmology and Vision Sciences, University of Toronto, 2224 Walker Rd #198, Windsor, ON N8W 3P6, Canada
| | - Robin M. Deans
- Department of Ophthalmology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON N6A 5C1, Canada
- Correspondence: ; Tel.: +519-980-1031
| |
Collapse
|
7
|
Zhou AY, Zghebi SS, Hodkinson A, Hann M, Grigoroglou C, Ashcroft DM, Esmail A, Chew-Graham CA, Payne R, Little P, de Lusignan S, Cherachi-Sohi S, Spooner S, Zhou AK, Kontopantelis E, Panagioti M. Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in General Practitioners working in the United Kingdom. Front Psychiatry 2022; 13:936067. [PMID: 35958644 PMCID: PMC9360551 DOI: 10.3389/fpsyt.2022.936067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND General Practitioners (GPs) report high levels of burnout, job dissatisfaction, and turnover intention. The complexity of presenting problems to general practice makes diagnostic uncertainty a common occurrence that has been linked to burnout. The interrelationship between diagnostic uncertainty with other factors such as burnout, job satisfaction and turnover intention have not been previously examined. OBJECTIVES To examine associations between diagnostic uncertainty, emotional exhaustion (EE), depersonalization (DP), job satisfaction, and turnover intention in GPs. METHODS Seventy general practices in England were randomly selected through the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP-RSC). A total of 348 GPs within 67 these practices completed a 10-item online questionnaire which included questions on GP characteristics, work-life balance, job satisfaction, sickness presenteeism, diagnostic uncertainty, turnover intention as well as EE and DP. Associations between diagnostic uncertainty and each of EE, DP, job satisfaction, and turnover intention were evaluated in multivariate mixed-effect ordinal logistic regressions whilst adjusting for covariates, to account for the correlation in the three outcomes of interest. RESULTS Almost one-third of GPs (n = 101; 29%) reported experiencing >10% of diagnostic uncertainty in their day-to-day practice over the past year. GPs reporting greater diagnostic uncertainty had higher levels of EE [OR = 3.90; 95% CI = (2.54, 5.99)], job dissatisfaction [OR = 2.01; 95% CI = (1.30, 3.13)] and turnover intention [OR = 4.51; 95% CI = (2.86, 7.11)]. GPs with no sickness presenteeism had lower levels of EE [OR = 0.53; 95% CI = (0.35, 0.82)], job dissatisfaction [OR = 0.56; 95% CI = (0.35, 0.88)], and turnover intention [OR = 0.61; 95% CI = (0.41, 0.91)]. CONCLUSION Diagnostic uncertainty may not only negatively impact on the wellbeing of GPs, but could also have adverse implications on workforce retention in primary care.
Collapse
Affiliation(s)
- Anli Yue Zhou
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Salwa S Zghebi
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alexander Hodkinson
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Mark Hann
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Christos Grigoroglou
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Institute for Health Policy and Organisation (IHPO), Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Darren M Ashcroft
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, United Kingdom
| | - Aneez Esmail
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | | | - Rupert Payne
- Centre for Academic Primary Care Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Simon de Lusignan
- Medical Sciences Division, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.,Royal College of General Practitioners Research and Surveillance Centre, London, United Kingdom
| | - Sudeh Cherachi-Sohi
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Sharon Spooner
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew K Zhou
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Evangelos Kontopantelis
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- National Institute for Health and Care Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
8
|
Okpere A, Samuel S, King-Shier K, Hamiwka L, Elliott MJ. The Diagnostic Journey of Childhood Idiopathic Nephrotic Syndrome: Perspectives of Children and Their Caregivers. Can J Kidney Health Dis 2022; 9:20543581221139025. [DOI: 10.1177/20543581221139025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Childhood nephrotic syndrome is a rare kidney disease characterized by sudden onset of edema, massive proteinuria, and hypoalbuminemia. Rare diseases can have a long and difficult trajectory to diagnosis. Objective: We aimed to explore the experiences of children with nephrotic syndrome and their caregivers in their search of a nephrotic syndrome diagnosis. Design: An exploratory, qualitative descriptive study design. Setting: The Alberta Children’s Hospital outpatient nephrology program in Calgary, Alberta, Canada. Sample: Children aged 9 to 18 years with steroid-sensitive nephrotic syndrome and their caregivers. Methods: We undertook semi-structured interviews with children (alone or with a caregiver present) and their caregivers using a question guide suitable to their age and role. We used a thematic analysis approach to inductively code the data and characterize themes related to our research question. Results: Participants included 10 children aged 9 to 18 years (6 boys and 4 girls) and 18 caregivers (8 men and 10 women). We characterized 3 themes related to participants’ experiences in search of a diagnosis of nephrotic syndrome: (1) unexpected and distressing symptom onset, (2) elusiveness of a diagnosis, and (3) encountering a diagnosis. Children with nephrotic syndrome and their caregivers described experiencing initial anxiety due to their unusual and unexpected symptom onset and lack of awareness about the disease. Perceived diagnostic delays and incorrect diagnosis early in the course of the disease contributed to multiple consultations with a variety of care providers. Overall, participants expressed a desire to move past their diagnosis, learn about nephrotic syndrome, and engage in their treatment plans. Limitations: The views expressed by participants may not reflect those of individuals from other settings. The time elapsed since participants’ nephrotic syndrome diagnosis may have influenced their recall of events and reactions to this diagnosis. Conclusions: In characterizing the diagnostic experiences of children and their caregivers, our study provides insight into how patients with nephrotic syndrome and their caregivers can be supported by the healthcare team along this journey. Focused strategies to increase awareness and understanding of nephrotic syndrome among healthcare providers are needed to improve patients’ and families’ diagnostic experiences.
Collapse
Affiliation(s)
- Augustina Okpere
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Susan Samuel
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | | | - Lorraine Hamiwka
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Meghan J. Elliott
- Department of Community Health Sciences, University of Calgary, AB, Canada
- Department of Medicine, University of Calgary, AB, Canada
| |
Collapse
|
9
|
Liu C, Wang D, Duan L, Zhang X, Liu C. Coping With Diagnostic Uncertainty in Antibiotic Prescribing: A Latent Class Study of Primary Care Physicians in Hubei China. Front Public Health 2021; 9:741345. [PMID: 34957007 PMCID: PMC8695689 DOI: 10.3389/fpubh.2021.741345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Misuse of antibiotics is prevalent worldwide and primary care is a major contributor. Although a clear diagnosis is fundamental for rational antibiotic use, primary care physicians often struggle with diagnostic uncertainty. However, we know little about how physicians cope with this situation and its association with antibiotic prescribing. Methods: A total of 583 primary care physicians were surveyed using the Dealing with Uncertainty Questionnaire. Their prescriptions (n = 949,181) over the year 2018 were retrieved retrospectively. Two categories of behavioral patterns of participants were identified based on latent class analyses (high vs. low openness and collaborativeness) in responding to diagnostic uncertainty. Multi-level logistic regression models were established to determine the associations between these behavioral patterns and antibiotic prescribing (overall and broad-spectrum antibiotics) for illness without an indication for antibiotics and those with a conditional indication for antibiotics, respectively, after adjustment for variations of patient (level one) and physician (level two) characteristics. Results: Most physicians reported open communications with their patients (80.96%), collected further information (85.08%), and referred patients to specialists (68.95%) in dealing with diagnostic uncertainly. More than half (56.95%) sought help from colleagues. Less than 20% acted on intuition or adopted a “wait and see” strategy. About 40% participants (n = 238) were classified into the group of low openness and collaborativeness in coping with diagnostic uncertainty. They were more likely to prescribe antibiotics for the recorded illness without an indication for antibiotics (AOR = 1.013 for all antibiotics, p = 0.024; AOR = 1.047 for broad-spectrum antibiotics, p < 0.001), as well as for the recorded illness with a conditional indication for antibiotics (AOR = 1.226 for all antibiotic, p < 0.001; AOR = 1.257 for broad-spectrum antibiotics, p < 0.001). Conclusion: Low tolerance with diagnostic uncertainty is evident in primary care. Inappropriate and over antibiotic prescribing is shaped by physicians' coping methods of diagnostic uncertainty. Physicians' openness and collaborativeness in responding to diagnostic uncertainty is associated with lower antibiotic prescribing in primary care. Interventions targeting on better management of diagnostic uncertainty may offer a promising approach in reducing antibiotic use in primary care.
Collapse
Affiliation(s)
- Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Lixia Duan
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
10
|
Liberman AL, Cheng NT, Friedman BW, Gerstein MT, Moncrieffe K, Labovitz DL, Lipton RB. Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study. Diagnosis (Berl) 2021; 9:225-235. [PMID: 34855312 DOI: 10.1515/dx-2021-0125] [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: 09/05/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We sought to understand the knowledge, attitudes, and beliefs of emergency medicine (EM) physicians towards non-specific neurological conditions and the use of clinical decision support (CDS) to improve diagnostic accuracy. METHODS We conducted semi-structured interviews of EM physicians at four emergency departments (EDs) affiliated with a single US healthcare system. Interviews were conducted until thematic saturation was achieved. Conventional content analysis was used to identify themes related to EM physicians' perspectives on acute diagnostic neurology; directed content analysis was used to explore views regarding CDS. Each interview transcript was independently coded by two researchers using an iteratively refined codebook with consensus-based resolution of coding differences. RESULTS We identified two domains regarding diagnostic safety: (1) challenges unique to neurological complaints and (2) challenges in EM more broadly. Themes relevant to neurology included: (1) knowledge gaps and uncertainty, (2) skepticism about neurology, (3) comfort with basic as opposed to detailed neurological examination, and (4) comfort with non-neurological diseases. Themes relevant to diagnostic decision making in the ED included: (1) cognitive biases, (2) ED system/environmental issues, (3) patient barriers, (4) comfort with diagnostic uncertainty, and (5) concerns regarding diagnostic error identification and measurement. Most participating EM physicians were enthusiastic about the potential for well-designed CDS to improve diagnostic accuracy for non-specific neurological complaints. CONCLUSIONS Physicians identified diagnostic challenges unique to neurological diseases as well as issues related more generally to diagnostic accuracy in EM. These physician-reported issues should be accounted for when designing interventions to improve ED diagnostic accuracy.
Collapse
Affiliation(s)
- Ava L Liberman
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Khadean Moncrieffe
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L Labovitz
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
11
|
Meyer AND, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions. PATIENT EDUCATION AND COUNSELING 2021; 104:2606-2615. [PMID: 34312032 DOI: 10.1016/j.pec.2021.07.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate and timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing (1) where patients and clinicians experience uncertainty within the diagnostic process, (2) how uncertainty affects the diagnostic process, (3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and (4) strategies to manage uncertainty. DISCUSSION Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined. CONCLUSION Scientific knowledge on diagnostic uncertainty, while previously elusive, is now becoming more clearly defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
Collapse
Affiliation(s)
- Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Lubna Khawaja
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| |
Collapse
|
12
|
Matulis JC, Kok SN, Dankbar EC, Majka AJ. A survey of outpatient Internal Medicine clinician perceptions of diagnostic error. ACTA ACUST UNITED AC 2021; 7:107-114. [PMID: 31913847 DOI: 10.1515/dx-2019-0070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/05/2019] [Indexed: 11/15/2022]
Abstract
Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.
Collapse
Affiliation(s)
- John C Matulis
- Division of Community Internal Medicine, Mayo Clinic, Rochester, USA
| | - Susan N Kok
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eugene C Dankbar
- The Division of Management, Engineering and Internal Consulting, Mayo Clinic, Rochester, MN, USA
| | - Andrew J Majka
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Wang D, Liu C, Zhang X, Liu C. Does diagnostic uncertainty increase antibiotic prescribing in primary care? NPJ Prim Care Respir Med 2021; 31:17. [PMID: 33767206 PMCID: PMC7994848 DOI: 10.1038/s41533-021-00229-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/17/2021] [Indexed: 01/05/2023] Open
Abstract
This study aimed to determine the association between factors relevant to diagnostic uncertainty and physicians' antibiotic-prescribing behaviour in primary care. A questionnaire survey was conducted on 327 physicians that measured their diagnostic ability, perceived frequency of diagnostic uncertainty, tolerance, and perceived patient tolerance of uncertainty. Physician antibiotic-prescribing behaviours were assessed based on their prescriptions (n = 207,804) of three conditions: upper respiratory tract infections (URTIs, antibiotics not recommended), acute tonsillitis (cautious use of antibiotics), and pneumonia (antibiotics recommended). A two-level logistic regression model determined the association between diagnostic uncertainty factors and physician antibiotic prescribing. Physicians perceived a higher frequency of diagnostic uncertainty resulting in higher antibiotic use for URTIs and less antibiotic use for pneumonia. Higher antibiotic use for acute tonsillitis was related to a low tolerance of uncertainty of physicians and patients. This study suggests that reducing diagnostic uncertainty and improving physician and patient uncertainty management could reduce antibiotic use.
Collapse
Affiliation(s)
- Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| |
Collapse
|
14
|
Wallace EJC, Liberman AL. Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes. Neuropsychiatr Dis Treat 2021; 17:1469-1480. [PMID: 34017173 PMCID: PMC8129915 DOI: 10.2147/ndt.s275750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/08/2021] [Indexed: 12/14/2022] Open
Abstract
Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.
Collapse
Affiliation(s)
- Emma J C Wallace
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
| | - Ava L Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
| |
Collapse
|
15
|
Berenson R, Singh H. Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error. Health Aff (Millwood) 2019; 37:1828-1835. [PMID: 30395510 DOI: 10.1377/hlthaff.2018.0714] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnostic accuracy is essential for treatment decisions but is largely unaccounted for by payers, including in fee-for-service Medicare and proposed Alternative Payment Models (APMs). We discuss three payment-related approaches to reducing diagnostic error. First, coding changes in the Medicare Physician Fee Schedule could facilitate the more effective use of teamwork and information technology in the diagnostic process and better support the cognitive work and time commitment that physicians make in the quest for diagnostic accuracy, especially in difficult or uncertain cases. Second, new APMs could be developed to focus on improving diagnostic accuracy in challenging cases and make available support resources for diagnosis, including condition-specific centers of diagnostic expertise or general diagnostic centers of excellence that provide second (or even third) opinions. Performing quality improvement activities that promote safer diagnosis should be a part of the accountability of APM recipients. Third, the accuracy of diagnoses that trigger APM payments and establish payment amounts should be confirmed by APM recipients. Implementation of these multipronged approaches can make current payment models more accountable for addressing diagnostic error and position diagnostic performance as a critical component of quality-based payment.
Collapse
Affiliation(s)
- Robert Berenson
- Robert Berenson ( ) is an institute fellow at the Urban Institute, in Washington, D.C
| | - Hardeep Singh
- Hardeep Singh is chief of the Health Policy, Quality, and Informatics Program, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and a professor of medicine at the Baylor College of Medicine, both in Houston, Texas
| |
Collapse
|
16
|
de Wet C, Bowie P, O'Donnell C. 'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice. BMC FAMILY PRACTICE 2018; 19:83. [PMID: 29885654 PMCID: PMC5994252 DOI: 10.1186/s12875-018-0772-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/21/2018] [Indexed: 12/04/2022]
Abstract
Background Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks. Methods A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed. Results Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment. Conclusion The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so.
Collapse
Affiliation(s)
- Carl de Wet
- Medical Directorate, NHS Education for Scotland, Glasgow, UK. .,General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland. .,School of Medicine, Griffith University, Southport, Gold Coast, Australia.
| | - Paul Bowie
- Medical Directorate, NHS Education for Scotland, Glasgow, UK.,General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland
| | - Catherine O'Donnell
- General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland
| |
Collapse
|
17
|
Pekez-Pavliško T, Račić M, Jurišić D. A Questionnaire Study on the Attitudes and Previous Experience of Croatian Family Physicians toward their Preparedness for Disaster Management. Bull Emerg Trauma 2018; 6:162-168. [PMID: 29719848 DOI: 10.29252/beat-060211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To explore family physicians' attitudes, previous experience and self-assessed preparedness to respond or to assist in mass casualty incidents in Croatia. Methods The cross-sectional survey was carried out during January 2017. Study participants were recruited through a Facebook group that brings together family physicians from Croatia. They were asked to complete the questionnaire, which was distributed via google.docs. Knowledge and attitudes toward disaster preparedness were evaluated by 18 questions. Analysis of variance, Student t test and Kruskal-Wallis test t were used for statistical analysis. Results Risk awareness of disasters was high among respondents (M = 4.89, SD=0.450). Only 16.4 of respondents have participated in the management of disaster at the scene. The majority (73.8%) of physicians have not been participating in any educational activity dealing with disaster over the past two years. Family physicians believed they are not well prepared to participate in national (M = 3.02, SD=0.856) and local community emergency response system for disaster (M = 3.16, SD=1.119). Male physicians scored higher preparedness to participate in national emergency response system for disaster (p=0.012), to carry out accepted triage principles used in the disaster situation (p=0.003) and recognize differences in health assessments indicating potential exposure to specific agents (p=0,001) compared to their female colleagues. Conclusion Croatian primary healthcare system attracts many young physicians, who can be an important part of disaster and emergency management. However, the lack of experience despite a high motivation indicates a need for inclusion of disaster medicine training during undergraduate studies and annual educational activities.
Collapse
Affiliation(s)
| | - Maja Račić
- Department for Primary Health Care and Public Health, Faculty of Medicine, University of East Sarajevo, Foca, Bosnia and Herzegovina
| | | |
Collapse
|
18
|
Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care. J Pediatr Health Care 2018; 32:53-62. [PMID: 28916249 DOI: 10.1016/j.pedhc.2017.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies. METHODS A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records. RESULTS Knowledge related to diagnostic errors statistically improved from the pretest to posttest scores with sustained 60-day differences (p < .025). Although there was a decline in the proportion of patients returning with the same chief complaint within 14 days, this was not statistically significant (p < .15). When providers were confronted with an unrecognizable clinical presentation, they reported an increased use of a "diagnostic timeout" (p < .038). DISCUSSION Providers developed an increased awareness of the presence of diagnostic errors in the primary care setting, the contributing risk factors for a diagnostic error, and possible strategies to reduce diagnostic errors. These factors had an unexpected impact on changing the primary care practice model to enhance the continuity of patient care.
Collapse
|
19
|
Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review. J Gen Intern Med 2018; 33:103-115. [PMID: 28936618 PMCID: PMC5756158 DOI: 10.1007/s11606-017-4164-1] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/26/2017] [Accepted: 08/11/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Physicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice. METHODS We searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty. KEY RESULTS We identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation-for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient-clinician encounter (such as by reviews of medical records, transcripts of patient-clinician communication and observation), and (3) experimental techniques (patient vignette studies). CONCLUSIONS The term "diagnostic uncertainty" lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a "subjective perception of an inability to provide an accurate explanation of the patient's health problem." Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.
Collapse
Affiliation(s)
- Viraj Bhise
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Suja S Rajan
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
- UT-Memorial Hermann Center for Health Care Quality and Safety, Houston, TX, USA
| | - Robert O Morgan
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Pooja Chaudhary
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
20
|
Newman-Toker DE, Austin JM, Derk J, Danforth M, Graber ML. Are health care provider organizations ready to tackle diagnostic error? A survey of Leapfrog-participating hospitals. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2016-0048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:A 2015 National Academy of Medicine report on improving diagnosis in health care made recommendations for direct action by hospitals and health systems. Little is known about how health care provider organizations are addressing diagnostic safety/quality.Methods:This study is an anonymous online survey of safety professionals from US hospitals and health systems in July–August 2016. The survey was sent to those attending a Leapfrog Group webinar on misdiagnosis (n=188). The instrument was focused on knowledge, attitudes, and capability to address diagnostic errors at the institutional level.Results:Overall, 61 (32%) responded, including community hospitals (42%), integrated health networks (25%), and academic centers (21%). Awareness was high, but commitment and capability were low (31% of leaders understand the problem; 28% have sufficient safety resources; and 25% have made diagnosis a top institutional safety priority). Ongoing efforts to improve diagnostic safety were sparse and mostly included root cause analysis and peer review feedback around diagnostic errors. The top three barriers to addressing diagnostic error were lack of awareness of the problem, lack of measures of diagnostic accuracy and error, and lack of feedback on diagnostic performance. The top two tools viewed as critically important for locally tackling the problem were routine feedback on diagnostic performance and culture change to emphasize diagnostic safety.Conclusions:Although hospitals and health systems appear to be aware of diagnostic errors as a major safety imperative, most organizations (even those that appear to be making a strong commitment to patient safety) are not yet doing much to improve diagnosis. Going forward, efforts to activate health care organizations will be essential to improving diagnostic safety.
Collapse
|
21
|
Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017; 26:484-494. [PMID: 27530239 PMCID: PMC5502242 DOI: 10.1136/bmjqs-2016-005401] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/15/2016] [Accepted: 07/13/2016] [Indexed: 12/20/2022]
Abstract
Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.
Collapse
Affiliation(s)
- Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Gordon D Schiff
- General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark L Graber
- RTI International, Research Triangle Park, North Carolina, USA
- SUNY Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | |
Collapse
|
22
|
Car LT, Papachristou N, Urch C, Majeed A, El-Khatib M, Aylin P, Atun R, Car J, Vincent C. Preventing delayed diagnosis of cancer: clinicians' views on main problems and solutions. J Glob Health 2017; 6:020901. [PMID: 28028437 PMCID: PMC5140077 DOI: 10.7189/jogh.06.020901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Delayed diagnosis is a major contributing factor to the UK’s lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In this study, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians. Methods We developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care. Results Clinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly on the delays during referrals from primary to secondary care. Conclusions Many identified priorities were feasible, affordable and converged around common themes such as public awareness, care continuity and length of consultation. As a timely, proactive and scalable priority–setting approach, PRIORITZE could be implemented as a routine preventative system for determining patient safety issues by frontline staff.
Collapse
Affiliation(s)
- Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
| | - Nikolaos Papachristou
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
| | - Catherine Urch
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
| | - Mona El-Khatib
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
| | - Rifat Atun
- Department of Global Health and Population & Department of Health Policy and Management, Harvard School of Public Health, Harvard, Boston, USA
| | - Josip Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK; Health Services and Outcomes Research Programme, LKCMedicine, Nanyang Technological University, Singapore
| | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, UK
| |
Collapse
|
23
|
Mücke U, Klemann C, Baumann U, Meyer-Bahlburg A, Kortum X, Klawonn F, Lechner WM, Grigull L. Patient's Experience in Pediatric Primary Immunodeficiency Disorders: Computerized Classification of Questionnaires. Front Immunol 2017; 8:384. [PMID: 28424699 PMCID: PMC5380667 DOI: 10.3389/fimmu.2017.00384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/17/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Primary immunodeficiency disorders (PIDs) are a heterogeneous group of more than 200 rare diseases. Timely diagnosis is of uttermost importance. Therefore, we aimed to develop a diagnostic questionnaire with computerized pattern-recognition in order to support physicians to identify suspicious patient histories. Materials and methods Standardized interviews were conducted with guardians of children with PID. The questionnaire based on parental observations was developed using Colaizzis’ framework for content analysis. Answers from 64 PID patients and 62 controls were analyzed by data mining methods in order to make a diagnostic prediction. Performance was evaluated by k-fold stratified cross-validation. Results The diagnostic support tool achieved a diagnostic sensitivity of up to 98%. The analysis of 12 interviews revealed 26 main phenomena observed by parents in the pre-diagnostic period. The questions were systematically phrased and selected resulting in a 36-item questionnaire. This was answered by 126 patients with or without PID to evaluate prediction. Item analysis revealed significant questions. Discussion Our approach proved suitable for recognizing patterns and thus differentiates between observations of PID patients and control groups. These findings provide the basis for developing a tool supporting physicians to consider a PID with a questionnaire. These data support the notion that patient’s experience is a cornerstone in the diagnostic process.
Collapse
Affiliation(s)
- Urs Mücke
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Christian Klemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Department of Pediatric Pulmonology, Hannover Medical School, Hannover, Germany
| | | | - Xiaowei Kortum
- Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Frank Klawonn
- Helmholtz Centre for Infection Research, Braunschweig, Germany.,Ostfalia University of Applied Sciences, Wolfenbuettel, Germany
| | | | - Lorenz Grigull
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
24
|
Chase HS, Mitrani LR, Lu GG, Fulgieri DJ. Early recognition of multiple sclerosis using natural language processing of the electronic health record. BMC Med Inform Decis Mak 2017; 17:24. [PMID: 28241760 PMCID: PMC5329909 DOI: 10.1186/s12911-017-0418-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/10/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diagnostic accuracy might be improved by algorithms that searched patients' clinical notes in the electronic health record (EHR) for signs and symptoms of diseases such as multiple sclerosis (MS). The focus this study was to determine if patients with MS could be identified from their clinical notes prior to the initial recognition by their healthcare providers. METHODS An MS-enriched cohort of patients with well-established MS (n = 165) and controls (n = 545), was generated from the adult outpatient clinic. A random sample cohort was generated from randomly selected patients (n = 2289) from the same adult outpatient clinic, some of whom had MS (n = 16). Patients' notes were extracted from the data warehouse and signs and symptoms mapped to UMLS terms using MedLEE. Approximately 1000 MS-related terms occurred significantly more frequently in MS patients' notes than controls'. Synonymous terms were manually clustered into 50 buckets and used as classification features. Patients were classified as MS or not using Naïve Bayes classification. RESULTS Classification of patients known to have MS using notes of the MS-enriched cohort entered after the initial ICD9[MS] code yielded an ROC AUC, sensitivity, and specificity of 0.90 [0.87-0.93], 0.75[0.66-0.82], and 0.91 [0.87-0.93], respectively. Similar classification accuracy was achieved using the notes from the random sample cohort. Classification of patients not yet known to have MS using notes of the MS-enriched cohort entered before the initial ICD9[MS] documentation identified 40% [23-59%] as having MS. Manual review of the EHR of 45 patients of the random sample cohort classified as having MS but lacking an ICD9[MS] code identified four who might have unrecognized MS. CONCLUSIONS Diagnostic accuracy might be improved by mining patients' clinical notes for signs and symptoms of specific diseases using NLP. Using this approach, we identified patients with MS early in the course of their disease which could potentially shorten the time to diagnosis. This approach could also be applied to other diseases often missed by primary care providers such as cancer. Whether implementing computerized diagnostic support ultimately shortens the time from earliest symptoms to formal recognition of the disease remains to be seen.
Collapse
Affiliation(s)
- Herbert S Chase
- Department of Biomedical Informatics, Columbia University Medical Center, PH-20, 622 West 168th street, New York, NY, 10032, USA.
| | - Lindsey R Mitrani
- Department of Biomedical Informatics, Columbia University Medical Center, PH-20, 622 West 168th street, New York, NY, 10032, USA
| | - Gabriel G Lu
- Department of Biomedical Informatics, Columbia University Medical Center, PH-20, 622 West 168th street, New York, NY, 10032, USA
| | - Dominick J Fulgieri
- Department of Biomedical Informatics, Columbia University Medical Center, PH-20, 622 West 168th street, New York, NY, 10032, USA
| |
Collapse
|
25
|
Tudor Car L, El-Khatib M, Perneczky R, Papachristou N, Atun R, Rudan I, Car J, Vincent C, Majeed A. Prioritizing problems in and solutions to homecare safety of people with dementia: supporting carers, streamlining care. BMC Geriatr 2017; 17:26. [PMID: 28103810 PMCID: PMC5244548 DOI: 10.1186/s12877-017-0415-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dementia care is predominantly provided by carers in home settings. We aimed to identify the priorities for homecare safety of people with dementia according to dementia health and social care professionals using a novel priority-setting method. METHODS The project steering group determined the scope, the context and the criteria for prioritization. We then invited 185 North-West London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to homecare safety of people with dementia. 76 clinicians submitted their suggestions which were thematically synthesized into a composite list of 27 distinct problems and 30 solutions. A group of 49 clinicians arbitrarily selected from the initial cohort ranked the composite list of suggestions using predetermined criteria. RESULTS Inadequate education of carers of people with dementia (both family and professional) is seen as a key problem that needs addressing in addition to challenges of self-neglect, social isolation, medication nonadherence. Seven out of top 10 problems related to patients and/or carers signalling clearly where help and support are needed. The top ranked solutions focused on involvement and education of family carers, their supervision and continuing support. Several suggestions highlighted a need for improvement of recruitment, oversight and working conditions of professional carers and for different home safety-proofing strategies. CONCLUSIONS Clinicians identified a range of suggestions for improving homecare safety of people with dementia. Better equipping carers was seen as fundamental for ensuring homecare safety. Many of the identified suggestions are highly challenging and not easily changeable, yet there are also many that are feasible, affordable and could contribute to substantial improvements to dementia homecare safety.
Collapse
Affiliation(s)
- Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Mona El-Khatib
- Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Robert Perneczky
- Neuroepidemiology and Ageing Research Unit, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany
| | - Nikolaos Papachristou
- Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, UK
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh Medical School, Edinburg, UK
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| |
Collapse
|
26
|
Price EL, Sewell JL, Chen AH, Sarkar U. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf 2017; 42:341-54. [PMID: 27456415 DOI: 10.1016/s1553-7250(16)42048-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments. METHODS All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available. RESULTS Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm. CONCLUSION Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.
Collapse
|
27
|
Car LT, Papachristou N, Bull A, Majeed A, Gallagher J, El-Khatib M, Aylin P, Rudan I, Atun R, Car J, Vincent C. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC FAMILY PRACTICE 2016; 17:131. [PMID: 27613564 PMCID: PMC5017013 DOI: 10.1186/s12875-016-0530-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/01/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Delayed diagnosis in primary care is a common, harmful and costly patient safety incident. Its measurement and monitoring are underdeveloped and underutilised. We created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. METHODS We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were thematically grouped and synthesized into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the Average Expert Agreement. RESULTS The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients' medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts. CONCLUSIONS The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can be largely prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in prioritization of scarce healthcare resources.
Collapse
Affiliation(s)
- Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Nikolaos Papachristou
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Adrian Bull
- Imperial College Health Partners, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Joseph Gallagher
- gHealth Research Group, UCD Conway Institute, University College Dublin School of Medicine, Dublin, Ireland
| | - Mona El-Khatib
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh Medical School, Edinburgh, UK
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, USA
| | - Josip Car
- Health Services and Outcomes Research Programme, LKCMedicine, Nanyang Technological University, Singapore, Singapore
| | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford, UK
| |
Collapse
|
28
|
Brami J, Amalberti R, Wensing M. Patient safety and the control of time in primary care: A review of the French tempos framework by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract 2016; 21 Suppl:45-9. [PMID: 26339836 PMCID: PMC4828602 DOI: 10.3109/13814788.2015.1043733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The tempos framework provides GPs with a flexible and practical guide to reflect on their organization and practices in the analysis of adverse events and supplement existing classification systems. The tempos framework specifies five timescales that need to be managed by physicians: the disease's tempo (unexpected rapid changes, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, and emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. Objective: This paper reviews the tempos framework and two studies that underpin its conceptual development. Methods: Two databases were used. Results: The use of the framework as a mechanism for analysing insurance claims is described. A comparison of using the tempos framework and standard patient safety classifications for analysing insurance claims is also described and showed that the concordance among coders was better for the tempos framework. The tempos framework fits closely with key principles of general practice and has potentially high relevance for analysing a patient's journey and continuity of care. The tempos framework seems most useful for GPs when analysing adverse events in their practice. Conclusion: Further work needs to be done to assess its generalizability and to formally assess its validity and reliability.
Collapse
Affiliation(s)
- Jean Brami
- a Mission pour la Sécurité du Patient (MSP), Haute Autorité de Santé , Saint Denis la Plaine , France
| | | | | |
Collapse
|
29
|
Carpenter CR, Raja AS, Brown MD. Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine. Acad Emerg Med 2015; 22:1484-92. [PMID: 26568269 DOI: 10.1111/acem.12820] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 12/15/2022]
Abstract
Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.
Collapse
Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Ali S. Raja
- Department of Emergency Medicine; Brigham & Women's Hospital; Boston MA
| | - Michael D. Brown
- Emergency Medicine; Michigan State University College of Medicine; Grand Rapids MI
| |
Collapse
|
30
|
Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial. J Clin Oncol 2015; 33:3560-7. [PMID: 26304875 PMCID: PMC4622097 DOI: 10.1200/jco.2015.61.1301] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer. METHODS We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months. RESULTS We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58). CONCLUSION Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.
Collapse
Affiliation(s)
- Daniel R Murphy
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Louis Wu
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Eric J Thomas
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Samuel N Forjuoh
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Ashley N D Meyer
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Hardeep Singh
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX.
| |
Collapse
|
31
|
Sarkar U, Simchowitz B, Bonacum D, Strull W, Lopez A, Rotteau L, Shojania KG. A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors. Jt Comm J Qual Patient Saf 2014; 40:461-1. [PMID: 26111306 DOI: 10.1016/s1553-7250(14)40059-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis. METHODS As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis. RESULTS A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors. CONCLUSIONS Multiple themes relating to each of the participants in the diagnostic process-health system, provider, and patient-emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.
Collapse
Affiliation(s)
- Urmimala Sarkar
- Center for Vulnerable Populations, Division of General Internal Medicine, University of California, San Francisco, USA
| | | | | | | | | | | | | |
Collapse
|
32
|
Singh H. Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Jt Comm J Qual Patient Saf 2014; 40:99-101. [PMID: 24730204 DOI: 10.1016/s1553-7250(14)40012-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
33
|
The Evolving Role of the Radiologist: The Vancouver Workload Utilization Evaluation Study. J Am Coll Radiol 2013; 10:764-9. [DOI: 10.1016/j.jacr.2013.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022]
|
34
|
Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? A health economics perspective. BMJ Qual Saf 2013; 22 Suppl 2:ii11-ii20. [PMID: 24048914 PMCID: PMC3786645 DOI: 10.1136/bmjqs-2012-001616] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 12/31/2022]
Affiliation(s)
- David E Newman-Toker
- Department of Neurology,Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn M McDonald
- Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, Stanford, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - David O Meltzer
- Department of Medicine, Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
35
|
Giardina TD, King BJ, Ignaczak A, Paull DE, Hoeksema L, Mills PD, Neily J, Hemphill RR, Singh H. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff (Millwood) 2013; 32:1368-75. [PMID: 23918480 PMCID: PMC3822525 DOI: 10.1377/hlthaff.2013.0130] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005-12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision-making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.
Collapse
Affiliation(s)
- Traber Davis Giardina
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Beth J. King
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Aartee Ignaczak
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Douglas E. Paull
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Laura Hoeksema
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Peter D. Mills
- Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA
- Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at Dartmouth
| | - Julia Neily
- Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA
| | - Robin R. Hemphill
- National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, Michigan USA
| | - Hardeep Singh
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| |
Collapse
|
36
|
Smith MW, Davis Giardina T, Murphy DR, Laxmisan A, Singh H. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf 2013; 22:1006-13. [PMID: 23813210 DOI: 10.1136/bmjqs-2012-001661] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Systemic issues can adversely affect the diagnostic process. Many system-related barriers can be masked by 'resilient' actions of frontline providers (ie, actions supporting the safe delivery of care in the presence of pressures that the system cannot readily adapt to). We explored system barriers and resilient actions of primary care providers (PCPs) in the diagnostic evaluation of cancer. METHODS We conducted a secondary data analysis of interviews of PCPs involved in diagnostic evaluation of 29 lung and colorectal cancer cases. Cases covered a range of diagnostic timeliness and were analysed to identify barriers for rapid diagnostic evaluation, and PCPs' actions involving elements of resilience addressing those barriers. We rated these actions according to whether they were usual or extraordinary for typical PCP work. RESULTS Resilient actions and associated barriers were found in 59% of the cases, in all ranges of timeliness, with 40% involving actions rated as beyond typical. Most of the barriers were related to access to specialty services and coordination with patients. Many of the resilient actions involved using additional communication channels to solicit cooperation from other participants in the diagnostic process. DISCUSSION Diagnostic evaluation of cancer involves several resilient actions by PCPs targeted at system deficiencies. PCPs' actions can sometimes mitigate system barriers to diagnosis, and thereby impact the sensitivity of 'downstream' measures (eg, delays) in detecting barriers. While resilient actions might enable providers to mitigate system deficiencies in the short run, they can be resource intensive and potentially unsustainable. They complement, rather than substitute for, structural remedies to improve system performance. Measures to detect and fix system performance issues targeted by these resilient actions could facilitate diagnostic safety.
Collapse
Affiliation(s)
- Michael W Smith
- Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, , Houston, Texas, USA
| | | | | | | | | |
Collapse
|
37
|
Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf 2013; 22 Suppl 2:ii1-ii5. [PMID: 23704082 PMCID: PMC3786636 DOI: 10.1136/bmjqs-2013-001827] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite the relatively slow start in treating diagnostic error as an amenable research topic at the beginning of the patient safety movement, interest has steadily increased over the past few years in the form of solicitations for research, regularly scheduled conferences, an expanding literature and even a new professional society. Yet improving diagnostic performance increasingly is recognised as a multifaceted challenge. With the aid of a human factors perspective, this paper addresses a few of these challenges, including questions that focus on who owns the problem, treating cognitive and system shortcomings as separate issues, why knowledge in the head is not enough, and what we are learning from health information technology (IT) and the use of checklists. To encourage empirical testing of interventions that aim to improve diagnostic performance, a systems engineering approach making use of rapid-cycle prototyping and simulation is proposed. To gain a fuller understanding of the complexity of the sociotechnical space where diagnostic work is performed, a final note calls for the formation of substantive partnerships with those in disciplines beyond the clinical domain.
Collapse
Affiliation(s)
- Kerm Henriksen
- US Department of Health and Human Services, Agency for Healthcare Research and Quality, , Rockville, Maryland, USA
| | | |
Collapse
|
38
|
Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013; 173:418-25. [PMID: 23440149 PMCID: PMC3690001 DOI: 10.1001/jamainternmed.2013.2777] [Citation(s) in RCA: 317] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Diagnostic errors are an understudied aspect of ambulatory patient safety. OBJECTIVES To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions. DESIGN We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit. SETTING A large urban Veterans Affairs facility and a large integrated private health care system. PARTICIPANTS Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007. MAIN OUTCOME MEASURES Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors. RESULTS In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm. CONCLUSIONS AND RELEVANCE Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.
Collapse
Affiliation(s)
- Hardeep Singh
- Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | | | | | | | | | |
Collapse
|
39
|
Zhiheng Z, Caixia W, Jiaji W, Huajie Y, Chao W, Wannian L. The knowledge, attitude and behavior about public health emergencies and the response capacity of primary care medical staffs of Guangdong Province, China. BMC Health Serv Res 2012; 12:338. [PMID: 23009075 PMCID: PMC3489590 DOI: 10.1186/1472-6963-12-338] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 08/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care medical staffs' knowledge, attitude and behavior about health emergency and the response capacity are directly related to the control and prevention of public health emergencies. Therefore, it is of great significance for improving primary care to gain in-depth knowledge about knowledge, attitude and behavior and the response capacity of primary care medical staffs. The main objective of this study is to explore knowledge, attitude and behavior, and the response capacity of primary care medical staffs of Guangdong Province, China. METHODS Stratified clustered sample method was used in the anonymous questionnaire investigation about knowledge, attitude and behavior, and the response capacity of 3410 primary care medical staffs in 15 cities of Guangdong Province, China from July, 2010 to October 2010. The emergency response capacity was evaluated by 33 questions. The highest score of the response capacity was 100 points (full score), score of 70 was a standard. RESULTS 62.4% primary care medical staffs believed that public health emergencies would happen. Influenza (3.86 ± 0.88), food poisoning (3.35 ± 0.75), and environmental pollution events (3.23 ± 0.80) (the total score was 5) were considered most likely to occur. Among the 7 public health emergency skills, the highest self-assessment score is "public health emergency prevention skills" (2.90 ± 0.68), the lowest is "public health emergency risk management (the total score was 5)" (1.81 ± 0.40). Attitude evaluation showed 66.1% of the medical staffs believed that the community awareness of risk management were ordinary. Evaluation of response capacity of health emergency showed that the score of primary care medical staffs was 67.23 ± 10.61, and the response capacity of senior physicians, public health physicians and physicians with relatively long-term practice were significantly better (P <0.05). Multiple linear stepwise regression analysis showed gender, title, position, type of work, work experience and whether to participate relative training were the main factors affecting the health emergency response capacity. CONCLUSIONS The knowledge, attitude and behavior about public health emergencies and the response capacity of primary care medical staffs of Guangdong Province (China) were poor. Health administrative departments should strengthen the training of health emergency knowledge and skills of the primary care medical staffs to enhance their health emergency response capabilities.
Collapse
Affiliation(s)
- Zhou Zhiheng
- School of public health and family medicine, Capital medical university of China, You An Men, Beijing, PR China
| | | | | | | | | | | |
Collapse
|
40
|
|