Impact of dx accuracy on antimicrobial therapy appropriateness

Jason Maude Jason.Maude at ISABELHEALTHCARE.COM
Mon Nov 11 09:30:13 UTC 2013

The issue here is that 2 things are going on-the accuracy of the diagnosis
and impact of CDS. When they looked the appropriateness of CDS versus non
CDS where the initial diagnosis was correct then figures were 67% using
CDS compared to 55% non CDS. OK, only a 12 point increase versus 11 but
now at least with the help of CDS the therapy is appropriate in 2/3 of
patients rather than just under 1/2. I assume that would have a relatively
bigger impact in tackling future AM resistance?

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890 <>

On 10/11/2013 15:28, "Bates, David Westfall,M.D." <DBATES at PARTNERS.ORG>

>This is about average for how much difference CDS makes--is typically
>only 10-15% at margin for a bunch of domains (prevention, chronic disease
>management).  But across a population this is still a big win (on the one
>hand).  On the other, obvious opportunity to do a lot better--a big thing
>we need to learn about CDS is how to get more juice from it.
>David Bates
>-----Original Message-----
>From: Harold Lehmann [mailto:lehmann at JHMI.EDU]
>Sent: Saturday, November 09, 2013 10:29 PM
>Subject: Re: [IMPROVEDX] Impact of dx accuracy on antimicrobial therapy
>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 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
>>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
>>Date: Fri, 8 Nov 2013 10:58:41 -0500
>>Subject: [IMPROVEDX] Impact of dx accuracy on antimicrobial therapy
>>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.
>>Key facts that jumped out were that:
>> 1.  Initial provider diagnosis was considered correct in only 55% of
>> 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
>> 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
>>Jason Maude
>>Founder and CEO Isabel Healthcare
>>Tel: +44 1428 644886
>>Tel: +1 703 879 1890
>> <>

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