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Newman-Toker DE, Sharfstein JM. The Role for Policy in AI-Assisted Medical Diagnosis. JAMA Health Forum 2024; 5:e241339. [PMID: 38635262 DOI: 10.1001/jamahealthforum.2024.1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
This JAMA Forum discusses the promise and pitfalls of using large language models and artificial intelligence (AI) in the diagnosis of patients.
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Affiliation(s)
- David E Newman-Toker
- Armstrong Institute Center for Diagnostic Excellence, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joshua M Sharfstein
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Kotwal S, Singh A, Tackett S, Bery AK, Omron R, Gold D, Newman-Toker DE, Wright SM. Assessing clinical reasoning skills following a virtual patient dizziness curriculum. Diagnosis (Berl) 2024; 11:73-81. [PMID: 38079609 DOI: 10.1515/dx-2023-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/09/2023] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Dizziness is a common medical symptom that is frequently misdiagnosed. While virtual patient (VP) education has been shown to improve diagnostic accuracy for dizziness as assessed by VPs, trainee performance has not been assessed on human subjects. The study aimed to assess whether internal medicine (IM) interns after training on a VP-based dizziness curriculum using a deliberate practice framework would demonstrate improved clinical reasoning when assessed in an objective structured clinical examination (OSCE). METHODS All available interns volunteered and were randomized 2:1 to intervention (VP education) vs. control (standard clinical teaching) groups. This quasi-experimental study was conducted at one academic medical center from January to May 2021. Both groups completed pre-posttest VP case assessments (scored as correct diagnosis across six VP cases) and participated in an OSCE done 6 weeks later. The OSCEs were recorded and assessed using a rubric that was systematically developed and validated. RESULTS Out of 21 available interns, 20 participated. Between intervention (n=13) and control (n=7), mean pretest VP diagnostic accuracy scores did not differ; the posttest VP scores improved for the intervention group (3.5 [SD 1.3] vs. 1.6 [SD 0.8], p=0.007). On the OSCE, the means scores were higher in the intervention (n=11) compared to control group (n=4) for physical exam (8.4 [SD 4.6] vs. 3.9 [SD 4.0], p=0.003) and total rubric score (43.4 [SD 12.2] vs. 32.6 [SD 11.3], p=0.04). CONCLUSIONS The VP-based dizziness curriculum resulted in improved diagnostic accuracy among IM interns with enhanced physical exam skills retained at 6 weeks post-intervention.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amteshwar Singh
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Tackett
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anand K Bery
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Gold
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M Wright
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Newman-Toker DE, Nassery N, Schaffer AC, Yu-Moe CW, Clemens GD, Wang Z, Zhu Y, Saber Tehrani AS, Fanai M, Hassoon A, Siegal D. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf 2024; 33:109-120. [PMID: 37460118 PMCID: PMC10792094 DOI: 10.1136/bmjqs-2021-014130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 06/24/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Diagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. We previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. OBJECTIVE We sought to estimate the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. METHODS Cross-sectional analysis of US-based nationally representative observational data. We estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). Annual new cancers were taken from US-based registries (2014). Years were selected for coding consistency with prior literature. Disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories) were multiplied by literature-based rates to derive diagnostic errors and serious harms. We calculated uncertainty estimates using Monte Carlo simulations. Validity checks included sensitivity analyses and comparison with prior published estimates. RESULTS Annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers. Per 'Big Three' dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), we estimated total serious harms annually in the USA to be 795 000 (plausible range 598 000-1 023 000). Sensitivity analyses using more conservative assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. The 15 dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%. CONCLUSION An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Najlla Nassery
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Adam C Schaffer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Chihwen Winnie Yu-Moe
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Gwendolyn D Clemens
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yuxin Zhu
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ali S Saber Tehrani
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mehdi Fanai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ahmed Hassoon
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dana Siegal
- Candello, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
- Department of Risk Management & Analytics, Coverys, Boston, Massachusetts, USA
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Liberman AL, Wang Z, Zhu Y, Hassoon A, Choi J, Austin JM, Johansen MC, Newman-Toker DE. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Diagnosis (Berl) 2023; 10:225-234. [PMID: 37018487 PMCID: PMC10659025 DOI: 10.1515/dx-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023]
Abstract
Diagnostic errors in medicine represent a significant public health problem but continue to be challenging to measure accurately, reliably, and efficiently. The recently developed Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach measures misdiagnosis related harms using electronic health records or administrative claims data. The approach is clinically valid, methodologically sound, statistically robust, and operationally viable without the requirement for manual chart review. This paper clarifies aspects of the SPADE analysis to assure that researchers apply this method to yield valid results with a particular emphasis on defining appropriate comparator groups and analytical strategies for balancing differences between these groups. We discuss four distinct types of comparators (intra-group and inter-group for both look-back and look-forward analyses), detailing the rationale for choosing one over the other and inferences that can be drawn from these comparative analyses. Our aim is that these additional analytical practices will improve the validity of SPADE and related approaches to quantify diagnostic error in medicine.
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Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Justin Choi
- Department of Internal Medicine, Weill Cornell Medicine
| | - J. Matthew Austin
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine and the Armstrong Institute Center for Diagnostic Excellence
| | - Michelle C. Johansen
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - David E. Newman-Toker
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
- The Johns Hopkins Bloomberg School of Public Health, Departments of Epidemiology and Health Policy & Management
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Tarnutzer AA, Gold D, Wang Z, Robinson KA, Kattah JC, Mantokoudis G, Tehrani ASS, Zee DS, Edlow JA, Newman-Toker DE. Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome - A Meta-Analysis. Ann Neurol 2023; 94:295-308. [PMID: 37038843 PMCID: PMC10524166 DOI: 10.1002/ana.26661] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes. METHODS We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness/vertigo ("acute vestibular syndrome" [AVS]). Diagnostic test properties were calculated for findings. Results were stratified by examiner type and stroke location. RESULTS We identified 6,089 citations and included 14 articles representing 10 study cohorts (n = 800). The Head Impulse, Nystagmus, Test of Skew (HINTS) eye movement battery had high sensitivity 95.3% (95% confidence interval [CI] = 92.5-98.1) and specificity 92.6% (95% CI = 88.6-96.5). Sensitivity was similar by examiner type (subspecialists 94.3% [95% CI = 88.2-100.0] vs non-subspecialists 95.0% [95% CI = 91.2-98.9], p = 0.55), but specificity was higher among subspecialists (97.6% [95% CI = 94.9-100.0] vs 89.1% [95% CI = 83.0-95.2], p = 0.007). HINTS sensitivity was lower in anterior cerebellar artery (AICA) than posterior inferior cerebellar artery (PICA) strokes (84.0% [95% CI = 65.3-93.6] vs 97.7% [95% CI = 93.3-99.2], p = 0.014) but was "rescued" by the addition of bedside hearing tests (HINTS+). Severe (grade 3) gait/truncal instability had high specificity 99.2% (95% CI = 97.8-100.0) but low sensitivity 35.8% (95% CI = 5.2-66.5). Early magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI; within 24-48 hours) was falsely negative in 15% of strokes (sensitivity 85.1% [95% CI = 79.2-91.0]). INTERPRETATION In AVS, HINTS examination by appropriately trained clinicians can differentiate peripheral from central causes and has higher diagnostic accuracy for stroke than MRI-DWI in the first 24-48 hours. These techniques should be disseminated to all clinicians evaluating dizziness/vertigo. ANN NEUROL 2023;94:295-308.
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Affiliation(s)
- Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Daniel Gold
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD
| | - Karen A. Robinson
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | | | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali S. Saber Tehrani
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - David S. Zee
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - David E. Newman-Toker
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Otero-Millan J, Parker TM, Badihian S, Hassoon A, Tehrani ASS, Farrell N, Newman-Toker DE. Eye and head movement recordings using smartphone: measurements of accuracy and precision. J Vis 2022. [DOI: 10.1167/jov.22.14.3239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Jorge Otero-Millan
- Herbert Wertheim School of Optometry and Vision Science, University of California, Berkeley, Berkeley, CA, USA
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - T Maxwell Parker
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Shervin Badihian
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Nathan Farrell
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Liberman AL, Zhang C, Lipton RB, Kamel H, Parikh NS, Navi BB, Segal AZ, Razzak J, Newman-Toker DE, Merkler AE. Short-term stroke risk after emergency department treat-and-release headache visit. Headache 2022; 62:1198-1206. [PMID: 36073865 PMCID: PMC10041409 DOI: 10.1111/head.14387] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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Wagle N, Morkos J, Liu J, Reith H, Greenstein J, Gong K, Gangan I, Pakhomov D, Hira S, Komogortsev OV, Newman-Toker DE, Winslow R, Zee DS, Otero-Millan J, Green KE. aEYE: A deep learning system for video nystagmus detection. Front Neurol 2022; 13:963968. [PMID: 36034311 PMCID: PMC9403604 DOI: 10.3389/fneur.2022.963968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Nystagmus identification and interpretation is challenging for non-experts who lack specific training in neuro-ophthalmology or neuro-otology. This challenge is magnified when the task is performed via telemedicine. Deep learning models have not been heavily studied in video-based eye movement detection. Methods We developed, trained, and validated a deep-learning system (aEYE) to classify video recordings as normal or bearing at least two consecutive beats of nystagmus. The videos were retrospectively collected from a subset of the monocular (right eye) video-oculography (VOG) recording used in the Acute Video-oculography for Vertigo in Emergency Rooms for Rapid Triage (AVERT) clinical trial (#NCT02483429). Our model was derived from a preliminary dataset representing about 10% of the total AVERT videos (n = 435). The videos were trimmed into 10-sec clips sampled at 60 Hz with a resolution of 240 × 320 pixels. We then created 8 variations of the videos by altering the sampling rates (i.e., 30 Hz and 15 Hz) and image resolution (i.e., 60 × 80 pixels and 15 × 20 pixels). The dataset was labeled as "nystagmus" or "no nystagmus" by one expert provider. We then used a filtered image-based motion classification approach to develop aEYE. The model's performance at detecting nystagmus was calculated by using the area under the receiver-operating characteristic curve (AUROC), sensitivity, specificity, and accuracy. Results An ensemble between the ResNet-soft voting and the VGG-hard voting models had the best performing metrics. The AUROC, sensitivity, specificity, and accuracy were 0.86, 88.4, 74.2, and 82.7%, respectively. Our validated folds had an average AUROC, sensitivity, specificity, and accuracy of 0.86, 80.3, 80.9, and 80.4%, respectively. Models created from the compressed videos decreased in accuracy as image sampling rate decreased from 60 Hz to 15 Hz. There was only minimal change in the accuracy of nystagmus detection when decreasing image resolution and keeping sampling rate constant. Conclusion Deep learning is useful in detecting nystagmus in 60 Hz video recordings as well as videos with lower image resolutions and sampling rates, making it a potentially useful tool to aid future automated eye-movement enabled neurologic diagnosis.
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Affiliation(s)
- Narayani Wagle
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
| | - John Morkos
- The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jingyan Liu
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Henry Reith
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Joseph Greenstein
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
| | - Kirby Gong
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Indranuj Gangan
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Daniil Pakhomov
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
| | - Sanchit Hira
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Oleg V. Komogortsev
- Department of Computer Science, Texas State University, San Marcos, TX, United States
| | - David E. Newman-Toker
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Ophthalmology and Otolaryngology, The John Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Emergency Medicine, The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Raimond Winslow
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Electrical and Computer Engineering, The John Hopkins University, Baltimore, MD, United States
| | - David S. Zee
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Electrical and Computer Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Neurosciences, The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jorge Otero-Millan
- Department of Neurosciences, The John Hopkins University School of Medicine, Baltimore, MD, United States
- School of Optometry University of California–Berkeley, Berkeley, CA, United States
| | - Kemar E. Green
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
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10
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Edlow JA, Agrawal Y, Newman-Toker DE. Correct Diagnosis for the Proper Treatment of Acute Vertigo-Putting the Diagnostic Horse Before the Therapeutic Cart. JAMA Neurol 2022; 79:841-843. [PMID: 35849406 DOI: 10.1001/jamaneurol.2022.1493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuri Agrawal
- Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Armstrong Institute Center for Diagnostic Excellence, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Affiliation(s)
- Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine, Peoria.,Department of Neurosurgery, University of Illinois College of Medicine, Peoria
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology-Head & Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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12
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Kim JS, Newman-Toker DE, Kerber KA, Jahn K, Bertholon P, Waterston J, Lee H, Bisdorff A, Strupp M. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32:205-222. [PMID: 35367974 PMCID: PMC9249306 DOI: 10.3233/ves-210169] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.
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Affiliation(s)
- Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan Health System, Ann Arbor, USA
| | - Klaus Jahn
- Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | | | - John Waterston
- Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia
| | - Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
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13
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Parker TM, Badihian S, Hassoon A, Saber Tehrani AS, Farrell N, Newman-Toker DE, Otero-Millan J. Eye and Head Movement Recordings Using Smartphones for Telemedicine Applications: Measurements of Accuracy and Precision. Front Neurol 2022; 13:789581. [PMID: 35370913 PMCID: PMC8975177 DOI: 10.3389/fneur.2022.789581] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Smartphones have shown promise in the assessment of neuro-ophthalmologic and vestibular disorders. We have shown that the head impulse test results recorded using our application are comparable with measurements from clinical video-oculography (VOG) goggles. The smartphone uses ARKit's capability to acquire eye and head movement positions without the need of performing a calibration as in most eye-tracking devices. Here, we measure the accuracy and precision of the eye and head position recorded using our application. Methods We enrolled healthy volunteers and asked them to direct their eyes, their heads, or both to targets on a wall at known eccentricities while recording their head and eye movements with our smartphone application. We measured the accuracy as the error between the eye or head movement measurement and the location of each target and the precision as the standard deviation of the eye or head position for each of the target positions. Results The accuracy of head recordings (15% error) was overall better than the accuracy of eye recordings (23% error). We also found that the accuracy for horizontal eye movements (17% error) was better than for vertical (27% error). Precision was also better for head movement (0.8 degrees) recordings than eye movement recordings (1.3 degrees) and variability tended to increase with eccentricity. Conclusion Our results provide basic metrics evaluating the utility of smartphone applications in the quantitative assessment of head and eye movements. While the new method may not replace the more accurate dedicated VOG devices, they provide a more accessible quantitative option. It may be advisable to include a calibration recording together with any planned clinical test to improve the accuracy.
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Affiliation(s)
- T. Maxwell Parker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
| | - Shervin Badihian
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ali S. Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nathan Farrell
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E. Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jorge Otero-Millan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Herbert Wertheim School of Optometry and Vision Science, University of California, Berkeley, Berkeley, CA, United States
- *Correspondence: Jorge Otero-Millan
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14
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Yousef EA, Sutcliffe KM, McDonald KM, Newman-Toker DE. Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles. Hum Factors 2022; 64:6-20. [PMID: 33657891 DOI: 10.1177/0018720821996187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers. BACKGROUND Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered. METHOD We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers. RESULTS Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them. CONCLUSION The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved. APPLICATION The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.
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Affiliation(s)
- Elham A Yousef
- 24575 University Hospitals, Cleveland Medical Center. Case Western Reserve University, Ohio, USA
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15
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Liberman AL, Hassoon A, Fanai M, Badihian S, Rupani H, Peterson SM, Sebestyen K, Wang Z, Zhu Y, Lipton RB, Newman-Toker DE. Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study. Acad Emerg Med 2022; 29:41-50. [PMID: 34309135 PMCID: PMC8766867 DOI: 10.1111/acem.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. METHODS We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05. RESULTS Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03). CONCLUSION We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.
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Affiliation(s)
- Ava L. Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Mehdi Fanai
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Shervin Badihian
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Hetal Rupani
- The Johns Hopkins University School of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Susan M. Peterson
- The Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland, USA
| | - Krisztian Sebestyen
- The Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, Maryland, USA
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Richard B. Lipton
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - David E. Newman-Toker
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology,The Johns Hopkins University School of Medicine, Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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16
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Sharp AL, Pallegadda R, Baecker A, Park S, Nassery N, Hassoon A, Peterson S, Pitts SI, Wang Z, Zhu Y, Newman-Toker DE. Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department? Ann Emerg Med 2021; 79:93-101. [PMID: 34607739 DOI: 10.1016/j.annemergmed.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/14/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To assess if having a mental health and/or substance use disorder is associated with a missed acute myocardial infarction diagnosis in the emergency department (ED). METHODS This was a retrospective cohort analysis (2009 to 2017) of adult ED encounters at Kaiser Permanente Southern California. We used the validated symptom-disease pair analysis of diagnostic error methodological approach to "look back" and "look forward" and identify missed acute myocardial infarctions within 30 days of a treat-and-release ED visit. We use adjusted logistic regression to report the odds of missed acute myocardial infarction among patients with a history of mental health and/or substance use disorders. RESULTS The look-back analysis identified 44,473 acute myocardial infarction hospital encounters; 574 (1.3%) diagnoses were missed. The odds of missed diagnoses were higher in patients with mental health disorders (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.23 to 1.77) but not in those with substance abuse disorders (OR 1.22, 95% CI 0.91 to 1.62). The highest risk was observed in those with co-occurring disorders (OR 1.90, 95% CI 1.30 to 2.76). The look-forward analysis identified 325,088 chest pain/dyspnea ED encounters; 508 (0.2%) were missed acute myocardial infarctions. No significant associations of missed acute myocardial infarction were revealed in either group (mental health disorder: OR 0.92, 95% CI 0.71 to 1.18; substance use disorder: OR 1.22, 95% CI 0.80 to 1.85). CONCLUSION The look-back analysis identified patients with mental illness at increased risk of missed acute myocardial infarction diagnosis, with the highest risk observed in those with a history of comorbid substance abuse. Having substance use disorders alone did not increase this risk in either cohort. The look-forward analysis revealed challenges in prospectively identifying high-risk patients to target for improvement.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
| | - Rani Pallegadda
- Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Najlla Nassery
- Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha I Pitts
- Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD
| | - Yuxin Zhu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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17
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Green KE, Pogson JM, Otero-Millan J, Gold DR, Tevzadze N, Saber Tehrani AS, Zee DS, Newman-Toker DE, Kheradmand A. Author Response: Opinion and Special Articles: Remote Evaluation of Acute Vertigo Strategies and Technological Considerations. Neurology 2021; 97:652. [PMID: 34580187 DOI: 10.1212/wnl.0000000000012630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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18
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Ellenbogen MI, Prichett L, Newman-Toker DE, Brotman DJ. Characterizing the relationship between diagnostic intensity and quality of care. Diagnosis (Berl) 2021; 9:123-126. [PMID: 34261203 PMCID: PMC10642069 DOI: 10.1515/dx-2021-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The relationship between diagnostic intensity and quality of care has not been well-characterized at the hospital level. We performed an exploratory analysis to better delineate this relationship using a hospital-level diagnostic overuse index and accepted hospital quality metrics (readmissions and mortality). METHODS We previously developed and published a hospital-level diagnostic overuse index. A hospital's overuse index value (which ranges from 0 to 0.986, with larger numbers indicating more overuse) was our predictor variable of interest. The outcome variables were excess readmission ratios and mortality rates for common medical conditions, which CMS publicly reports. The model controlled for Elixhauser comorbidity score, hospital bed size, hospital teaching status, and random effects that vary by state. RESULTS We did not find a statistically significant relationship between our overuse index and the quality measures we evaluated. CONCLUSIONS The lack of a significant relationship between diagnostic intensity and quality, at least as measured by our overuse index and the tested quality metrics, suggests that well-targeted efforts to reduce diagnostic overuse in hospitals may not adversely impact quality of care.
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Affiliation(s)
- Michael I Ellenbogen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Hopkins Business of Health Initiative, Johns Hopkins University, Baltimore, MD, USA
| | - Laura Prichett
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Armstrong Institute Center for Diagnostic Excellence, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel J Brotman
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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19
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Chang TP, Bery AK, Wang Z, Sebestyen K, Ko YH, Liberman AL, Newman-Toker DE. Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods. ACTA ACUST UNITED AC 2021; 9:96-106. [PMID: 34147048 DOI: 10.1515/dx-2020-0124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly "benign dizziness" between general and specialty care settings. METHODS This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event). RESULTS We analyzed 144,355 patients discharged with "benign dizziness" (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for "benign dizziness" 24.9 [95% CI 18.6-31.2] in general care and 10.6 [95% CI 6.3-14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5-3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9-1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching. CONCLUSIONS Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.
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Affiliation(s)
- Tzu-Pu Chang
- Department of Neurology/Neuro-Medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Anand K Bery
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krisztian Sebestyen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yu-Hung Ko
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins Hospital, Pathology Building 2-221, 600 North Wolfe Street, Baltimore, MD 21287-6921, USA
- Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sharp AL, Baecker A, Nassery N, Park S, Hassoon A, Lee MS, Peterson S, Pitts S, Wang Z, Zhu Y, Newman-Toker DE. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berl) 2021; 8:177-186. [PMID: 32701479 DOI: 10.1515/dx-2020-0049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method. METHODS Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events). RESULTS A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%). CONCLUSIONS The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Najlla Nassery
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ming-Sum Lee
- Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samantha Pitts
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuxin Zhu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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21
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Horberg MA, Nassery N, Rubenstein KB, Certa JM, Shamim EA, Rothman R, Wang Z, Hassoon A, Townsend JL, Galiatsatos P, Pitts SI, Newman-Toker DE. Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system. ACTA ACUST UNITED AC 2021; 8:479-488. [PMID: 33894108 DOI: 10.1515/dx-2020-0145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/16/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Delays in sepsis diagnosis can increase morbidity and mortality. Previously, we performed a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) "look-back" analysis to identify symptoms at risk for delayed sepsis diagnosis. We found treat-and-release emergency department (ED) encounters for fluid and electrolyte disorders (FED) and altered mental status (AMS) were associated with downstream sepsis hospitalizations. In this "look-forward" analysis, we measure the potential misdiagnosis-related harm rate for sepsis among patients with these symptoms. METHODS Retrospective cohort study using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (2013-2018). Patients ≥18 years with ≥1 treat-and-release ED encounter for FED or AMS were included. Observed greater than expected sepsis hospitalizations within 30 days of ED treat-and-release encounters were considered potential misdiagnosis-related harms. Temporal analyses were employed to differentiate case and comparison (superficial injury/contusion ED encounters) cohorts. RESULTS There were 4,549 treat-and-release ED encounters for FED or AMS, 26 associated with a sepsis hospitalization in the next 30 days. The observed (0.57%) minus expected (0.13%) harm rate was 0.44% (absolute) and 4.5-fold increased over expected (relative). There was a spike in sepsis hospitalizations in the week following FED/AMS ED visits. There were fewer sepsis hospitalizations and no spike in admissions in the week following superficial injury/contusion ED visits. Potentially misdiagnosed patients were older and more medically complex. CONCLUSIONS Potential misdiagnosis-related harms from sepsis are infrequent but measurable using SPADE. This look-forward analysis validated our previous look-back study, demonstrating the SPADE approach can be used to study infectious disease syndromes.
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Affiliation(s)
- Michael A Horberg
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.,Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Najlla Nassery
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Diagnostic Excellence, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Kevin B Rubenstein
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Julia M Certa
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Ejaz A Shamim
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA.,Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmed Hassoon
- Center for Diagnostic Excellence, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer L Townsend
- Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samantha I Pitts
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Center for Diagnostic Excellence, Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Kotwal S, Fanai M, Fu W, Wang Z, Bery AK, Omron R, Tevzadze N, Gold D, Garibaldi BT, Wright SM, Newman-Toker DE. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study. ACTA ACUST UNITED AC 2021; 8:489-496. [PMID: 33675203 DOI: 10.1515/dx-2020-0127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diagnostic errors are pervasive in medicine and most often caused by clinical reasoning failures. Clinical presentations characterized by nonspecific symptoms with broad differential diagnoses (e.g., dizziness) are especially prone to such errors. METHODS We hypothesized that novice clinicians could achieve proficiency diagnosing dizziness by training with virtual patients (VPs). This was a prospective, quasi-experimental, pretest-posttest study (2019) at a single academic medical center. Internal medicine interns (intervention group) were compared to second/third year residents (control group). A case library of VPs with dizziness was developed from a clinical trial (AVERT-NCT02483429). The approach (VIPER - Virtual Interactive Practice to build Expertise using Real cases) consisted of brief lectures combined with 9 h of supervised deliberate practice. Residents were provided dizziness-related reading and teaching modules. Both groups completed pretests and posttests. RESULTS For interns (n=22) vs. residents (n=18), pretest median diagnostic accuracy did not differ (33% [IQR 18-46] vs. 31% [IQR 13-50], p=0.61) between groups, while posttest accuracy did (50% [IQR 42-67] vs. 20% [IQR 17-33], p=0.001). Pretest median appropriate imaging did not differ (33% [IQR 17-38] vs. 31% [IQR 13-38], p=0.89) between groups, while posttest appropriateness did (65% [IQR 52-74] vs. 25% [IQR 17-36], p<0.001). CONCLUSIONS Just 9 h of deliberate practice increased diagnostic skills (both accuracy and testing appropriateness) of medicine interns evaluating real-world dizziness 'in silico' more than ∼1.7 years of residency training. Applying condensed educational experiences such as VIPER across a broad range of common presentations could significantly enhance diagnostic education and translate to improved patient care.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mehdi Fanai
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wei Fu
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zheyu Wang
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anand K Bery
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Rodney Omron
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nana Tevzadze
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Gold
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian T Garibaldi
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND Diagnostic error is prevalent and costly, occurring in up to 15% of US medical encounters and affecting up to 5% of the US population. One-third of malpractice payments are related to diagnostic error. A complex and specialized diagnostic process makes neuro-ophthalmologic conditions particularly vulnerable to diagnostic error. EVIDENCE ACQUISITION English-language literature on diagnostic errors in neuro-ophthalmology and neurology was identified through electronic search of PubMed and Google Scholar and hand search. RESULTS Studies investigating diagnostic error of neuro-ophthalmologic conditions have revealed misdiagnosis rates as high as 60%-70% before evaluation by a neuro-ophthalmology specialist, resulting in unnecessary tests and treatments. Correct performance and interpretation of the physical examination, appropriate ordering and interpretation of neuroimaging tests, and generation of a differential diagnosis were identified as pitfalls in the diagnostic process. Most studies did not directly assess patient harms or financial costs of diagnostic error. CONCLUSIONS As an emerging field, diagnostic error in neuro-ophthalmology offers rich opportunities for further research and improvement of quality of care.
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Affiliation(s)
- Leanne Stunkel
- Departments of Ophthalmology and Visual Sciences (LS) and Neurology (LS), Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Neurology (DEN-T), The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Departments of Ophthalmology (NJN, VB), Neurology (NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia
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Nassery N, Horberg MA, Rubenstein KB, Certa JM, Watson E, Somasundaram B, Shamim E, Townsend JL, Galiatsatos P, Pitts SI, Hassoon A, Newman-Toker DE. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. ACTA ACUST UNITED AC 2021; 8:469-478. [PMID: 33650389 DOI: 10.1515/dx-2020-0140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach. METHODS SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared. RESULTS There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits. CONCLUSIONS Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.
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Affiliation(s)
- Najlla Nassery
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Kevin B Rubenstein
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Julia M Certa
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Eric Watson
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Brinda Somasundaram
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Ejaz Shamim
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Jennifer L Townsend
- Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samantha I Pitts
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmed Hassoon
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David E Newman-Toker
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Newman-Toker DE, Schaffer AC, Yu-Moe CW, Nassery N, Saber Tehrani AS, Clemens GD, Wang Z, Zhu Y, Fanai M, Siegal D. Corrigendum to: Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2021; 8:127-128. [DOI: 10.1515/dx-2020-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- David E. Newman-Toker
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore , MD , USA
- Director of the Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University School of Medicine , Baltimore , MD , USA
- Professor, Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Adam C. Schaffer
- Sr. Clinical Analytics Specialist, Patient Safety-Advanced Data Analytics and Coding , CRICO, Boston , MA, USA
- Assistant Professor of Medicine, Part-time, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston , MA , USA
| | - C. Winnie Yu-Moe
- Program Director, Patient Safety-Advanced Data Analytics and Coding, CRICO , Boston , MA , USA
| | - Najlla Nassery
- Department of Medicine , The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Ali S. Saber Tehrani
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Gwendolyn D. Clemens
- Department of Biostatistics , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Zheyu Wang
- Department of Biostatistics , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
- Department of Oncology, The Johns Hopkins University School of Medicine , Baltimore , MD, USA
| | - Yuxin Zhu
- Department of Biostatistics , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
- Department of Oncology, The Johns Hopkins University School of Medicine , Baltimore , MD, USA
| | - Mehdi Fanai
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Dana Siegal
- Director of Patient Safety, CRICO Strategies , Boston , USA
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Green KE, Pogson JM, Otero-Millan J, Gold DR, Tevzadze N, Saber Tehrani AS, Zee DS, Newman-Toker DE, Kheradmand A. Opinion and Special Articles: Remote Evaluation of Acute Vertigo: Strategies and Technological Considerations. Neurology 2021; 96:34-38. [PMID: 33004609 PMCID: PMC7884977 DOI: 10.1212/wnl.0000000000010980] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with acute vestibular disorders are often a diagnostic challenge for neurologists, especially when the evaluation must be conducted remotely. The clinical dilemma remains: Does the patient have a benign peripheral inner ear problem or a worrisome central vestibular disorder, such as a stroke? The use of a focused history and the virtual HINTS (head impulse test, nystagmus evaluation, and test of skew) examination are key steps towards correctly diagnosing and triaging the acute vertiginous patient. When looking for signs of vestibulo-ocular dysfunction, there are important technological and practical considerations for an effective clinical interpretation.
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Affiliation(s)
- Kemar E Green
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley.
| | - Jacob M Pogson
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - Jorge Otero-Millan
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - Daniel R Gold
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - Nana Tevzadze
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - Ali S Saber Tehrani
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - David S Zee
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - David E Newman-Toker
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
| | - Amir Kheradmand
- From the Departments of Neurology (K.E.G., J.M.P., J.O.-M., D.R.G., N.T., A.S.S.T., D.S.Z., D.E.N.-T., A.K.), Otolaryngology-Head and Neck Surgery (D.R.G., D.S.Z., D.E.N.-T., A.K.), Ophthalmology (D.R.G., D.S.Z., D.E.N.-T.), Emergency Medicine (D.R.G.), Neurosurgery & Medicine (D.R.G.), and Neuroscience (D.S.Z.), The Johns Hopkins University School of Medicine, Baltimore, MD; and School of Optometry (J.O.-M.), University of California, Berkeley
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Parker TM, Farrell N, Otero-Millan J, Kheradmand A, McClenney A, Newman-Toker DE. Proof of Concept for an "eyePhone" App to Measure Video Head Impulses. Digit Biomark 2020; 5:1-8. [PMID: 33615116 DOI: 10.1159/000511287] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Differentiating benign from dangerous causes of dizziness or vertigo presents a major diagnostic challenge for many clinicians. Bedside presentations of peripheral vestibular disorders and posterior fossa strokes are often indistinguishable other than by a few subtle vestibular eye movements. The most challenging of these to interpret is the head impulse test (HIT) of vestibulo-ocular reflex (VOR) function. There have been major advances in portable video-oculography (VOG) quantification of the video HIT (vHIT), but these specialized devices are not routinely available in most clinical settings. As a first step towards smartphone-based diagnosis of strokes in patients presenting vestibular symptoms, we sought proof of concept that we could use a smartphone application ("app") to accurately record the vHIT. Methods This was a cross-sectional agreement study comparing a novel index test (smartphone-based vHIT app) to an accepted reference standard test (VOG-based vHIT) for measuring VOR function. We recorded passive (examiner-performed) vHIT sequentially with both methods in a convenience sample of patients visiting an otoneurology clinic. We quantitatively correlated VOR gains (ratio of eye to head movements during the HIT) from each side/ear and experts qualitatively assessed the physiologic traces by the two methods. Results We recruited 11 patients; 1 patient's vHIT could not be reliably quantified with either device. The novel and reference test VOR gain measurements for each ear (n = 20) were highly correlated (Pearson's r = 0.9, p = 0.0000001) and, qualitatively, clinically equivalent. Conclusions This preliminary study provides proof of concept that an "eyePhone" app could be used to measure vHIT and eventually developed to diagnose vestibular strokes by smartphone.
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Affiliation(s)
- T Maxwell Parker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nathan Farrell
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jorge Otero-Millan
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Optometry and Vision Science, University of California, Berkeley, Berkeley, California, USA
| | - Amir Kheradmand
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ayodele McClenney
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
| | - David E Newman-Toker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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Liberman AL, Skillings J, Greenberg P, Newman-Toker DE, Siegal D. Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. ACTA ACUST UNITED AC 2020; 7:37-43. [PMID: 31535831 DOI: 10.1515/dx-2019-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/10/2019] [Indexed: 11/15/2022]
Abstract
Background Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy. Methods We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO's proprietary taxonomy. Results A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases. Conclusions Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY 10467, USA
| | | | | | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Departments of Epidemiology and Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Gold DR, Newman-Toker DE. Reader response: Questionnaire-based diagnosis of benign paroxysmal positional vertigo. Neurology 2020; 95:887-888. [DOI: 10.1212/wnl.0000000000010935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Zamaro E, Saber Tehrani AS, Kattah JC, Eibenberger K, Guede CI, Armando L, Caversaccio MD, Newman-Toker DE, Mantokoudis G. VOR gain calculation methods in video head impulse recordings. J Vestib Res 2020; 30:225-234. [PMID: 32804110 PMCID: PMC9037838 DOI: 10.3233/ves-200708] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND: International consensus on best practices for calculating and reporting vestibular function is lacking. Quantitative vestibulo-ocular reflex (VOR) gain using a video head impulse test (HIT) device can be calculated by various methods. OBJECTIVE: To compare different gain calculation methods and to analyze interactions between artifacts and calculation methods. METHODS: We analyzed 1300 horizontal HIT traces from 26 patients with acute vestibular syndrome and calculated the ratio between eye and head velocity at specific time points (40 ms, 60 ms) after HIT onset (‘velocity gain’), ratio of velocity slopes (‘regression gain’), and ratio of area under the curves after de-saccading (‘position gain’). RESULTS: There was no mean difference between gain at 60 ms and position gain, both showing a significant correlation (r2 = 0.77, p < 0.001) for artifact-free recordings. All artifacts reduced high, normal-range gains modestly (range –0.06 to –0.11). The impact on abnormal, low gains was variable (depending on the artifact type) compared to artifact-free recordings. CONCLUSIONS: There is no clear superiority of a single gain calculation method for video HIT testing. Artifacts cause small but significant reductions of measured VOR gains in HITs with higher, normal-range gains, regardless of calculation method. Artifacts in abnormal HITs with low gain increased measurement noise. A larger number of HITs should be performed to confirm abnormal results, regardless of calculation method.
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Affiliation(s)
- Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali S. Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jorge C. Kattah
- Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Karin Eibenberger
- Boston University, Department of Psychology and Brain Sciences, Boston, MA, USA
| | - Cynthia I. Guede
- Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Lenz Armando
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marco D. Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David E. Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Newman-Toker DE, Wang Z, Zhu Y, Nassery N, Saber Tehrani AS, Schaffer AC, Yu-Moe CW, Clemens GD, Fanai M, Siegal D. Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”. Diagnosis (Berl) 2020; 8:67-84. [DOI: 10.1515/dx-2019-0104] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 02/12/2020] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Missed vascular events, infections, and cancers account for ~75% of serious harms from diagnostic errors. Just 15 diseases from these “Big Three” categories account for nearly half of all serious misdiagnosis-related harms in malpractice claims. As part of a larger project estimating total US burden of serious misdiagnosis-related harms, we performed a focused literature review to measure diagnostic error and harm rates for these 15 conditions.
Methods
We searched PubMed, Google, and cited references. For errors, we selected high-quality, modern, US-based studies, if available, and best available evidence otherwise. For harms, we used literature-based estimates of the generic (disease-agnostic) rate of serious harms (morbidity/mortality) per diagnostic error and applied claims-based severity weights to construct disease-specific rates. Results were validated via expert review and comparison to prior literature that used different methods. We used Monte Carlo analysis to construct probabilistic plausible ranges (PPRs) around estimates.
Results
Rates for the 15 diseases were drawn from 28 published studies representing 91,755 patients. Diagnostic error (false negative) rates ranged from 2.2% (myocardial infarction) to 62.1% (spinal abscess), with a median of 13.6% [interquartile range (IQR) 9.2–24.7] and an aggregate mean of 9.7% (PPR 8.2–12.3). Serious misdiagnosis-related harm rates per incident disease case ranged from 1.2% (myocardial infarction) to 35.6% (spinal abscess), with a median of 5.5% (IQR 4.6–13.6) and an aggregate mean of 5.2% (PPR 4.5–6.7). Rates were considered face valid by domain experts and consistent with prior literature reports.
Conclusions
Diagnostic improvement initiatives should focus on dangerous conditions with higher diagnostic error and misdiagnosis-related harm rates.
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Affiliation(s)
- David E. Newman-Toker
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Director, Armstrong Institute Center for Diagnostic Excellence , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Professor, Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Zheyu Wang
- Department of Oncology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Yuxin Zhu
- Department of Oncology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Najlla Nassery
- Department of Medicine , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Ali S. Saber Tehrani
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Adam C. Schaffer
- Department of Patient Safety, CRICO , Boston, MA , USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School , Boston, MA , USA
| | | | - Gwendolyn D. Clemens
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
| | - Mehdi Fanai
- Department of Neurology , The Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | - Dana Siegal
- Director of Patient Safety, CRICO Strategies , Boston, MA , USA
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Kattah JC, Tehrani AS, du Lac S, Newman-Toker DE, Zee DS. Conversion of upbeat to downbeat nystagmus in Wernicke encephalopathy. Neurology 2019; 91:790-796. [PMID: 30348852 DOI: 10.1212/wnl.0000000000006385] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/27/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explain (1) why an initial upbeat nystagmus (UBN) converts to a permanent downbeat nystagmus (DBN) in Wernicke encephalopathy (WE) and (2) why convergence and certain vestibular provocative maneuvers may transiently switch UBN to DBN. METHODS Following a literature review and study of our 2 patients, we develop hypotheses for the unusual patterns of vertical nystagmus in WE. RESULTS Our overarching hypothesis is that there is a selective vulnerability and a selective recovery from thiamine deficiency of neurons within brainstem gaze-holding networks. Furthermore, since the circuits affected in WE are commonly paraventricular, especially medially, just under the floor of the fourth ventricle where lie structures important for control of vertical gaze, we suggest the patterns of involvement in WE also reflect a breakdown in vulnerable areas of the blood-brain barrier. Many of the initial deficits of our patients improved over time, but their DBN did not. Irreversible changes in paramedian tract neurons, which project to the cerebellar flocculus, may be the cause. Here we suggest that conversion of UBN to permanent DBN points to thiamine deficiency and may argue for a chronic, nonprogressive DBN/truncal ataxia syndrome. Finally, we posit that the transient switch of UBN to DBN reflects abnormal processing of otolith information about linear acceleration, and often points to a diagnosis of WE. CONCLUSION Recognizing the unusual patterns of transient switching and then permanent conversion of UBN to DBN in WE is vital since long-term disability from WE may be prevented by timely, parenteral high-dose thiamine.
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Affiliation(s)
- Jorge C Kattah
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD.
| | - Ali Saber Tehrani
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - Sascha du Lac
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - David S Zee
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
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Newman-Toker DE, Schaffer AC, Yu-Moe CW, Nassery N, Saber Tehrani AS, Clemens GD, Wang Z, Zhu Y, Fanai M, Siegal D. Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2019; 6:227-240. [DOI: 10.1515/dx-2019-0019] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/28/2019] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms.
Methods
We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)’s Comparative Benchmarking System (CBS) database (2006–2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the “Big Three”), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6–9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale.
Results
From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36–60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0–88.8%).
Conclusions
The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.
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Tarnutzer AA, Gold D, Blitz AM, Kattah JC, Newman-Toker DE. Reader response: Teaching Video NeuroImages: Vestibulo-ocular reflex defect in cerebellar stroke. Neurology 2019; 93:367-368. [DOI: 10.1212/wnl.0000000000007982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Eggers SD, Bisdorff A, von Brevern M, Zee DS, Kim JS, Perez-Fernandez N, Welgampola MS, Della Santina CC, Newman-Toker DE. Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements. J Vestib Res 2019; 29:57-87. [PMID: 31256095 PMCID: PMC9249296 DOI: 10.3233/ves-190658] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Bárány Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations. View accompanying videos at http://www.jvr-web.org/ICVD.html
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Affiliation(s)
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael von Brevern
- Private Practice of Neurology and Department of Neurology, Charité, Berlin, Germany
| | - David S. Zee
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | | | - Miriam S. Welgampola
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, Australia
| | - Charles C. Della Santina
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E. Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Gleason KT, Peterson S, Kasda E, Rusz D, Adler-Kirkley A, Wang Z, Newman-Toker DE. Capturing diagnostic errors in incident reporting systems: value of a specific “DX Tile” for diagnosis-related concerns. Diagnosis (Berl) 2018; 5:249-251. [DOI: 10.1515/dx-2018-0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/10/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Kelly T. Gleason
- School of Nursing , Johns Hopkins University , Baltimore, MD , USA
| | - Susan Peterson
- School of Medicine , Johns Hopkins University , Baltimore, MD , USA
| | - Eileen Kasda
- Armstrong Institute for Patient Safety , Johns Hopkins University , Baltimore, MD , USA
| | - Diana Rusz
- Society to Improve Diagnosis Medicine , Evanston, IL , USA
| | - Anna Adler-Kirkley
- Armstrong Institute for Patient Safety , Johns Hopkins University , Baltimore, MD , USA
| | - Zheyu Wang
- School of Medicine , Johns Hopkins University , Baltimore, MD , USA
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Affiliation(s)
- Peter J Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland (P.J.P.)
| | - Julie Miller
- Johns Hopkins University, Baltimore, Maryland (J.M., D.E.N.)
| | | | - Lisa Ishii
- Johns Hopkins Medicine, Baltimore, Maryland (L.I.)
| | - Albert W Wu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (A.W.W.)
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Edlow JA, Gurley KL, Newman-Toker DE. A New Diagnostic Approach to the Adult Patient with Acute Dizziness. J Emerg Med 2018; 54:469-483. [PMID: 29395695 PMCID: PMC6049818 DOI: 10.1016/j.jemermed.2017.12.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/21/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. OBJECTIVE OF THE REVIEW This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. DISCUSSION Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. CONCLUSIONS The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Kiersten L Gurley
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
| | - David E Newman-Toker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, Otolaryngology, and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Saber Tehrani AS, Kattah JC, Kerber KA, Gold DR, Zee DS, Urrutia VC, Newman-Toker DE. Diagnosing Stroke in Acute Dizziness and Vertigo: Pitfalls and Pearls. Stroke 2018; 49:788-795. [PMID: 29459396 PMCID: PMC5829023 DOI: 10.1161/strokeaha.117.016979] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Ali S Saber Tehrani
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jorge C Kattah
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin A Kerber
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel R Gold
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David S Zee
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor C Urrutia
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD.
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Mantokoudis G, Saber Tehrani AS, Wozniak A, Eibenberger K, Kattah JC, Guede CI, Zee DS, Newman-Toker DE. Impact of artifacts on VOR gain measures by video-oculography in the acute vestibular syndrome. J Vestib Res 2018; 26:375-385. [PMID: 27814312 DOI: 10.3233/ves-160587] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The video head impulse test (HIT) measures vestibular function (vestibulo-ocular reflex [VOR] gain - ratio of eye to head movement), and, in principle, could be used to make a distinction between central and peripheral causes of vertigo. However, VOG recordings contain artifacts, so using unfiltered device data might bias the final diagnosis, limiting application in frontline healthcare settings such as the emergency department (ED). We sought to assess whether unfiltered data (containing artifacts) from a video-oculography (VOG) device have an impact on VOR gain measures in acute vestibular syndrome (AVS). METHODS This cross-sectional study compared VOG HIT results 'unfiltered' (standard device output) versus 'filtered' (artifacts manually removed) and relative to a gold standard final diagnosis (neuroimaging plus clinical follow-up) in 23 ED patients with acute dizziness, nystagmus, gait disturbance and head motion intolerance. RESULTS Mean VOR gain assessment alone (unfiltered device data) discriminated posterior inferior cerebellar artery (PICA) strokes from vestibular neuritis with 91% accuracy in AVS. Optimal stroke discrimination cut points were bilateral VOR gain >0.7099 (unfiltered data) versus >0.7041 (filtered data). For PICA stroke sensitivity and specificity, there was no clinically-relevant difference between unfiltered and filtered data-sensitivity for PICA stroke was 100% for both data sets and specificity was almost identical (87.5% unfiltered versus 91.7% filtered). More impulses increased gain precision. CONCLUSIONS The bedside HIT remains the single best method for discriminating between vestibular neuritis and PICA stroke in patients presenting AVS. Quantitative VOG HIT testing in the ED is associated with frequent artifacts that reduce precision but not accuracy. At least 10-20 properly-performed HIT trials per tested ear are recommended for a precise VOR gain estimate.
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Affiliation(s)
- Georgios Mantokoudis
- University Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Switzerland.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali S Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Wozniak
- Johns Hopkins Biostatistics Center, Baltimore, MD, USA
| | - Karin Eibenberger
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jorge C Kattah
- Department of Neurology, Illinois Neurologic Institute, University of Illinois, College of Medicine, Peoria, IL, USA
| | - Cynthia I Guede
- Department of Neurology, Illinois Neurologic Institute, University of Illinois, College of Medicine, Peoria, IL, USA
| | - David S Zee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 2018; 27:557-566. [PMID: 29358313 DOI: 10.1136/bmjqs-2017-007032] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 12/04/2017] [Accepted: 12/14/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND The public health burden associated with diagnostic errors is likely enormous, with some estimates suggesting millions of individuals are harmed each year in the USA, and presumably many more worldwide. According to the US National Academy of Medicine, improving diagnosis in healthcare is now considered 'a moral, professional, and public health imperative.' Unfortunately, well-established, valid and readily available operational measures of diagnostic performance and misdiagnosis-related harms are lacking, hampering progress. Existing methods often rely on judging errors through labour-intensive human reviews of medical records that are constrained by poor clinical documentation, low reliability and hindsight bias. METHODS Key gaps in operational measurement might be filled via thoughtful statistical analysis of existing large clinical, billing, administrative claims or similar data sets. In this manuscript, we describe a method to quantify and monitor diagnostic errors using an approach we call 'Symptom-Disease Pair Analysis of Diagnostic Error' (SPADE). RESULTS We first offer a conceptual framework for establishing valid symptom-disease pairs illustrated using the well-known diagnostic error dyad of dizziness-stroke. We then describe analytical methods for both look-back (case-control) and look-forward (cohort) measures of diagnostic error and misdiagnosis-related harms using 'big data'. After discussing the strengths and limitations of the SPADE approach by comparing it to other strategies for detecting diagnostic errors, we identify the sources of validity and reliability that undergird our approach. CONCLUSION SPADE-derived metrics could eventually be used for operational diagnostic performance dashboards and national benchmarking. This approach has the potential to transform diagnostic quality and safety across a broad range of clinical problems and settings.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Epidemiology and Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Gleason KT, Davidson PM, Tanner EK, Baptiste D, Rushton C, Day J, Sawyer M, Baker D, Paine L, Himmelfarb CRD, Newman-Toker DE. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractNurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.
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Berger ZD, Brito JP, Ospina NS, Kannan S, Hinson JS, Hess EP, Haskell H, Montori VM, Newman-Toker DE. Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice. BMJ 2017; 359:j4218. [PMID: 29092826 DOI: 10.1136/bmj.j4218] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Zackary D Berger
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | | | - Naykky Singh Ospina
- Division of Endocrinology, University of Florida School of Medicine, Gainesville, FL, USA
| | - Suraj Kannan
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | - Jeremiah S Hinson
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
| | | | | | | | - David E Newman-Toker
- Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, 601 N Caroline St Suite 7143, Baltimore, MD 21287 US
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Chang TP, Wang Z, Winnick AA, Chuang HY, Urrutia VC, Carey JP, Newman-Toker DE. Sudden Hearing Loss with Vertigo Portends Greater Stroke Risk Than Sudden Hearing Loss or Vertigo Alone. J Stroke Cerebrovasc Dis 2017; 27:472-478. [PMID: 29102540 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/20/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Because it is unknown whether sudden hearing loss (SHL) in acute vertigo is a "benign" sign (reflecting ear disease) or a "dangerous" sign (reflecting stroke), we sought to compare long-term stroke risk among patients with (1) "SHL with vertigo," (2) "SHL alone," and (3) "vertigo alone" using a large national health-care database. METHODS Patients with first-incident SHL (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] 388.2) or vertigo (ICD-9-CM 386.x, 780.4) were identified from the National Health Insurance Research Database of Taiwan (2002-2009). We defined SHL with vertigo as a vertigo-related diagnosis ±30 days from the index SHL event. SHL without a temporally proximate vertigo diagnosis was considered SHL alone. The vertigo-alone group had no SHL diagnosis. All the patients were followed up until stroke, death, withdrawal from the database, or current end of the database (December 31, 2012) for a minimum period of 3 years. The hazards of stroke were compared across groups. RESULTS We studied 218,656 patients (678 SHL with vertigo, 1998 with SHL alone, and 215,980 with vertigo alone). Stroke rates at study end were 5.5% (SHL with vertigo), 3.0% (SHL alone), and 3.9% (vertigo alone). Stroke hazards were higher in SHL with vertigo than in SHL alone (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.28-2.91) and in vertigo alone (HR, 1.63; 95% CI, 1.18-2.25). Defining a narrower window between SHL and vertigo (±3 days) increased the hazards. CONCLUSIONS The combination of SHL plus vertigo in close temporal proximity is associated with increased subsequent stroke risk over SHL alone and vertigo alone. This suggests that SHL in patients with vertigo is not necessarily a benign peripheral vestibular sign.
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Affiliation(s)
- Tzu-Pu Chang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology/Neuro-medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; Department of Medicine, Tzu Chi University, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Zheyu Wang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biostatistics, Johns Hopkins University School of Public Health, Baltimore, Maryland
| | - Ariel A Winnick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hsun-Yang Chuang
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John P Carey
- Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Liberman AL, Prabhakaran S, Newman-Toker DE. Letter by Liberman et al Regarding Article, "Psychiatric Hospitalization Increases Short-Term Risk of Stroke". Stroke 2017; 48:e260. [PMID: 28775141 DOI: 10.1161/strokeaha.117.018391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ava L Liberman
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD
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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] [What about the content of this article? (0)] [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.
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Rao G, Epner P, Bauer V, Solomonides A, Newman-Toker DE. Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2016-0049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractDiagnostic error is a serious public health problem to which knowledge gaps and associated cognitive error contribute significantly. Identifying diagnostic approaches to common problems in ambulatory care associated with more timely and accurate diagnosis and lower cost and harm associated with diagnostic evaluation is an important priority for health care systems, clinicians, and of course patients. Unfortunately, guidance on how best to approach diagnosis in patients with common presenting complaints such as abdominal pain, dizziness, and fatigue is lacking. Exploring diagnostic practice variation and patterns of diagnostic evaluation is a potentially valuable approach to identifying best current diagnostic practices. A “diagnostic path” is the sequence of actions taken to evaluate a new complaint from first presentation until a diagnosis is established, or the evaluation ends for other reasons. A “big data” approach to identifying diagnostic paths from electronic health records can be used to identify practice variation and best practices from a large number of patients. Limitations of this approach include incompleteness and inaccuracy of electronic medical record data, the fact that diagnostic paths may not represent clinician thinking, and the fact that diagnostic paths may be used to identify best current practices, rather than optimal practices.
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Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology 2017; 88:1468-1477. [PMID: 28356464 DOI: 10.1212/wnl.0000000000003814] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/12/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE With the emergency department (ED) being a high-risk site for diagnostic errors, we sought to estimate ED diagnostic accuracy for identifying acute cerebrovascular events. METHODS MEDLINE and Embase were searched for studies (1995-2016) reporting ED diagnostic accuracy for ischemic stroke, TIA, or subarachnoid hemorrhage (SAH). Two independent reviewers determined inclusion. We identified 1,693 unique citations, examined 214 full articles, and analyzed 23 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted. We prospectively defined clinical presentation subgroups to compare odds of misdiagnosis. RESULTS Included studies reported on 15,721 patients. Studies were at low risk of bias. Overall sensitivity (91.3% [95% confidence interval (CI) 90.7-92.0]) and specificity (92.7% [91.7-93.7]) for a cerebrovascular etiology was high, but there was significant variation based on clinical presentation. Misdiagnosis was more frequent among subgroups with milder (SAH with normal vs abnormal mental state; false-negative rate 23.8% vs 4.2%, odds ratio [OR] 7.03 [4.80-10.31]), nonspecific (dizziness vs motor findings; false-negative rate 39.4% vs 4.4%, OR 14.22 [9.76-20.74]), or transient (TIA vs ischemic stroke; false discovery rate 59.7% vs 11.7%, OR 11.21 [6.66-18.89]) symptoms. CONCLUSIONS Roughly 9% of cerebrovascular events are missed at initial ED presentation. Risk of misdiagnosis is much greater when presenting neurologic complaints are mild, nonspecific, or transient (range 24%-60%). This difference suggests that many misdiagnoses relate to symptom-specific factors. Future research should emphasize studying causes and designing error-reduction strategies in symptom-specific subgroups at greatest risk of misdiagnosis.
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Affiliation(s)
- Alexander Andrea Tarnutzer
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Seung-Han Lee
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Karen A Robinson
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Zheyu Wang
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jonathan A Edlow
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David E Newman-Toker
- From the Department of Neurology (A.A.T.), University Hospital Zurich, Switzerland; Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; Department of Oncology and Department of Biostatistics (Z.W.), Johns Hopkins University, Baltimore, MD; and Department of Emergency Medicine (J.A.E.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Thomas DB, Newman-Toker DE. Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors: A case study on the role of a vestibular therapist in diagnosing dizziness. ACTA ACUST UNITED AC 2016; 3:49-59. [PMID: 28758055 DOI: 10.1515/dx-2016-0009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Diagnostic errors are the most common, most costly, and most catastrophic of medical errors. Interdisciplinary teamwork has been shown to reduce harm from therapeutic errors, but sociocultural barriers may impact the engagement of allied health professionals (AHPs) in the diagnostic process. METHODS A qualitative case study of the experience at a single institution around involvement of an AHP in the diagnostic process for acute dizziness and vertigo. We detail five diagnostic error cases in which the input of a physical therapist was central to correct diagnosis. We further describe evolution of the sociocultural milieu at the institution as relates to AHP engagement in diagnosis. RESULTS Five patients with acute vestibular symptoms were initially misdiagnosed by physicians and then correctly diagnosed based on input from a vestibular physical therapist. These included missed labyrinthine concussion and post-traumatic benign paroxysmal positional vertigo (BPPV); BPPV called gastroenteritis; BPPV called stroke; stroke called BPPV; and multiple sclerosis called BPPV. As a consequence of surfacing these diagnostic errors, initial resistance to physical therapy input to aid medical diagnosis has gradually declined, creating a more collaborative environment for 'team diagnosis' of patients with dizziness and vertigo at the institution. CONCLUSIONS Barriers to AHP engagement in 'team diagnosis' include sociocultural norms that establish medical diagnosis as something reserved only for physicians. Drawing attention to the valuable diagnostic contributions of AHPs may help facilitate cultural change. Future studies should seek to measure diagnostic safety culture and then implement proven strategies to breakdown sociocultural barriers that inhibit effective teamwork and transdisciplinary diagnosis.
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Abstract
Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.
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Affiliation(s)
- David E Newman-Toker
- Johns Hopkins Hospital, CRB-II, Room 2M-03 North, 1550 Orleans Street, Baltimore, MD 21231, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine Administrative Offices, Beth Israel Deaconess Medical Center, West CC-2, 1 Deaconess Place, Boston, MA 02215, USA
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