Impact of dx accuracy on antimicrobial therapy appropritateness

Alan Morris Alan.Morris at IMAIL.ORG
Sun Nov 10 17:28:25 UTC 2013


Dr. Sittig is correct.

He is pointing out, I believe, that you are referring to decision-support
tools that are not adequately explicit (not adequately detailed) and are
therefore not capable of tailoring decisions to individual patient needs.
That is, they are not context sensitive.  The failure to distinguish
guidelines and ordinary protocols (both inadequately explicit) from
adequately explicit protocols is common and is a major barrier to
understanding the potential of decision-support, in my opinion.
Inadequately explicit decision-support tools lead to small increases in
clinician compliance with best evidence (30-40% is common) because they
require clinician judgment to fill in the logic gaps in the inadequately
explicit tools.  In contrast, adequately explicit protocols enable
clinician compliance of 95% across medical disciplines and across
cultures.  Adequately explicit protocols enable replicable clinician
decision in clinical research and clinical care.  Unfortunately, even the
NIH and the AHRZ are not making the distinction between adequately
explicit protocols and the inadequately explicit guidelines and protocols
that constitute well over 99% of the decision support tools currently
available.

Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com


On 11/10/13 8:31 AM, "Dean F. Sittig" <Dean.F.Sittig at UTH.TMC.EDU> wrote:

>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
>><https://urldefense.proofpoint.com/v1/url?u=http://www.isabelhealthcare
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>>c>
>>
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