Impact of dx accuracy on antimicrobial therapy appropritateness

Dean F. Sittig Dean.F.Sittig at UTH.TMC.EDU
Sun Nov 10 15:31:15 UTC 2013


I'm struck by this sentence in the paper describing the CDSS...
The CDSS does not use patient-specific information to
tailor therapy for individual patients; this remains the responsibility
of the prescriber.

To me this is NOT the most appropriate CDSS. It is just providing information at the point of care. Which is better than nothing, but not the ultimate goal of CDSS and I believe accounts for the low rates.
dean



-----Original Message-----
From: Harold Lehmann [mailto:lehmann at JHMI.EDU] 
Sent: Saturday, November 09, 2013 9:29 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Impact of dx accuracy on antimicrobial therapy appropritateness

Thanks for pointing out this article.

I am struck that the CDSS increased the appropriateness rate only 11 percentage points (33%-->44%). I understand that this 11% represents a 33% relative improvement, but I don't want to be biased by relative rates.

Is 11% big or small?

Shouldn't we demand an appropriateness rate of like 90%? What minimum appropriateness rate would make us happy?

Harold

***************************************************************************
Harold P Lehmann, MD PhD
Professor and Interim Director
Division of Health Sciences Informatics
Johns Hopkins School of Medicine



On 11/8/13 11:53 AM, "Graber, Mark" <Mark.Graber at VA.GOV> wrote:

>Most physicians still look at me with disbelief when I talk about a 
>diagnostic error rate of 10-15%, so the figures in this paper (55%) are 
>really quite amazing.  The method they used to determine a diagnostic 
>error isn't exactly clear from reading the paper, but its from a good 
>group and this seemed to reflect the retrospective opinion from two ID 
>physicians.
>
>If we ever start using better tests to differentiate viral from 
>bacterial upper respiratory track infections, I'm guessing the error 
>rates in this setting would be similarly high.
>
>Jason said it well - quality care begins with the right diagnosis.
>
>________________________________
>From: Jason Maude <Jason.Maude at ISABELHEALTHCARE.COM>
>Reply-To: Society to Improve Diagnosis in Medicine 
><IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Jason Maude 
><Jason.Maude at ISABELHEALTHCARE.COM>
>Date: Fri, 8 Nov 2013 10:58:41 -0500
>To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>Subject: [IMPROVEDX] Impact of dx accuracy on antimicrobial therapy 
>appropritateness
>
>This is a fascinating study which adds a whole new dimension to the 
>issue of improving diagnostic accuracy. It shows how important 
>diagnostic accuracy is to appropriate antimicrobial (AM) therapy.
>
>https://urldefense.proofpoint.com/v1/url?u=http://www.jstor.org/discove
>r/10.1086/670627?uid%3D3738032%26uid%3D2%26uid%3D4%26sid%3D2&k=yYSsEqip
>9%2FcIjLHUhVwIqA%3D%3D%0A&r=%2BSR6vrjztoBl8beDtWl76UziCNT9k6Hu8dcHytqk7
>tM%3D%0A&m=bB0gssj6hwbCFiHEkXTPVtioOoErphlEPvf3Iaxz1JQ%3D%0A&s=60259dac
>b45d4862a3a7500430ea9dc3f7e2f534a41635c96f56c3cc3d5e7eef
>1102898943681
>
>Key facts that jumped out were that:
>
> 1.  Initial provider diagnosis was considered correct in only 55% of 
>cases  2.  When the initial diagnosis was correct the AM therapy was 
>considered appropriate in 62% of cases. When the initial diagnosis was 
>incorrect, uncertain, or a sign or symptom then the AM was only 
>appropriate in 11% of cases. This completely blows away the idea that 
>often it doesn't matter if the diagnosis is not made or correct as the 
>treatment would be the same anyway.
> 3.  Overall across the 500 cases, the diagnosis was not correct in 163
>(33%) of cases and in only 13 of those cases was the AM therapy 
>appropriate.
> 4.  The authors stated that "the study confirmed the tremendous impact 
>of diagnostic accuracy on AM appropriateness"
>
>This study set out to look at whether AM appropriateness improved when 
>CDSS was used but on the assumption that the initial diagnosis was 
>correct. What they found instead was that dx accuracy had much more 
>impact on AM appropriateness rather than the use of therapy CDSS.
>
>This study helps show the tremendous impact diagnostic accuracy has on 
>not just AM therapy but on so many crucial aspects of healthcare. It 
>shows the complete futility of trying to improve healthcare without 
>improving diagnosis, the first and most important decision made about 
>the patient.
>
>Regards
>Jason
>
>Jason Maude
>Founder and CEO Isabel Healthcare
>Tel: +44 1428 644886
>Tel: +1 703 879 1890
>www.isabelhealthcare.com 
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