quick ?

robert bell rmsbell at ESEDONA.NET
Fri Apr 25 20:46:43 UTC 2014


David, Edward,

Agree, and this also tied to cost effectiveness, which in turn is linked to services available - there may not even be a CT scanner available.

Doesn't it get complex?

Rob


On Apr 25, 2014, at 12:34 PM, Hoffer, Edward P.,M.D. <EHOFFER at MGH.HARVARD.EDU> wrote:

> Excellent point, to which I would like to add that Dr. A will find all sorts of "incidentalomas" on the CT scans, which will require FURTHER testing, most of no avail to the patient.
>  
> Ed
> Edward P Hoffer MD, FACC, FACP
> From: David Gordon, M.D. [davidc.gordon at DUKE.EDU]
> Sent: Friday, April 25, 2014 1:11 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
> 
> I am SO GLAD to see Eric's and Manoj's comments appear because they highlight a really important piece of the puzzle.
> 
> If all we focus on is the miss or delay rate, we will fail to appreciate the harm that can come by over diagnosis and over treatment. Take a theoretical and extreme example for illustrative purposes:
> --Doctor A obtains a CT scan on every patient with RLQ pain across the board to make sure appendicitis is not missed. Still may miss a case or 2 over the course of several years due to the intrinsic miss rate of CTs
> --Doctor B does a selective approach. Using his judgment and sometimes guided by labs, he sometimes will do a CT, sometimes will recommend a clinical recheck the next day, or sometimes tells the patient everything looks fine today and come back as needed for worsening.  In doing this, he may miss a few more cases of appendicitis over the years than Doctor A but avoids hundreds of unnecessary CT scans.
> 
> So if the only variable studied is how often a diagnosis is missed, Doctor A will always come out on top when in the more complete picture his overtesting and overtreating style can lead to greater public harm not only through greater cost but also through radiation exposure, adverse medication reactions, drug resistance, and so on.  
> 
> I am sure we are going to see an explosion of studies looking at how often diagnoses are missed or delayed. I gather the majority will be retrospective studies - at least in these early phases. My fear is that retrospective analysis has many limitations and unmeasured variables, yet it is going to be the results rather than the limitations that will receive greater public attention. Ultimately, this evolving science about how to improve diagnostic efficacy is going to have to balance the harm that can come by both under and over diagnosis. I hope the caution expressed by Eric that we are a long way from safely implementing performance metrics and regulations is heard widely and embraced strongly.
> 
> Thanks
> David
> 
> 
> 
> 
> David Gordon, MD
> Associate Professor
> Undergraduate Education Director
> Division of Emergency Medicine
> Duke University
>  
> The information in this electronic mail is sensitive, protected information intended only for the addressee(s). Any other person, including anyone who believes he/she might have received it due to an addressing error, is requested to notify the sender immediately by return electronic mail, and to delete it without further reading or retention. The information is not to be forwarded to or shared unless in compliance with Duke Medicine policies on confidentiality and/or with the approval of the sender.
> From: Mittal, Manoj K [MITTAL at EMAIL.CHOP.EDU]
> Sent: Friday, April 25, 2014 10:50 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
> 
> Thanks, Eric.
> That is a useful definition. 
> What concerns me a little bit is that we are labeling events as diagnostic errors based on retrospective review of the chart. This may lead to over-diagnosis of diagnostic errors.
> 
> It is far easier to see something as a missed opportunity when one knows the future.
> When you are with a patient in the office or in the emergency department, though, and the case is not straightforward, there may be some pointers to the final diagnosis, but the trick is to find the signal amongst all the noise. 
> 
> It will be useful to test the various differential diagnosis list generators, such as Isabel, prospectively, to see how much they help, and at what cost (in terms of increased testing, imaging, increasing LOS, false positive tests, etc.).
> 
> Regards,
> Manoj Mittal, MD
> From: Thomas, Eric [Eric.Thomas at UTH.TMC.EDU]
> Sent: Friday, April 25, 2014 9:51 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
> 
> Steve and Colleagues,
>  
> In some of the research I have done with Hardeep Singh, we have tried to use definitions of diagnostic errors that allow a reliable and valid measurement to occur.  We mostly avoided the issue of diagnoses that evolve over time.  
>  
> In some of our work we used the following definition, “An error was judged to have occurred if adequate data to suggest the final, correct diagnosis were already present at the index visit or if the documented abnormal findings at the index visit should have prompted additional evaluation that would have revealed the correct, ultimate diagnosis.  Thus, errors occurred only when missed opportunities to make an earlier diagnosis occurred based on retrospective review.”  The “index visit” is the visit we sampled for review.  I won’t get into all the details here, but this definition was used for a study where we sampled primary care visits which preceded an unexpected return visit to the primary care office or the ED. 
>  
> So, when that definition is used we are pretty much eliminating the cases that are evolving over time.  We called it a dx error when all the data was there at the time of the visit to make the right dx.  As a practicing primary care doc, I am very sensitive to the fact that diagnoses evolve over time and it is often unclear what the dx is at the time of a single visit.  Our research does not label delays when all the data is not available as an error.
>  
> I agree with others that we will never know THE rate of diagnostic error.  However, with good measurement we can come to understand the frequency, types, and contributing factors of dx error within certain practice settings and for certain diseases.  I think a disease-specific and setting-specific approach will lead to the most improvement.
>  
> While I have your attention (wishful thinking, I know) I’d also say that we are a very, very long way from measures of dx error that could be useful for any external body (CMS, Leapfrog, etc) to use as some type of publically reported performance measure.  Groups like that have already gone too far with efforts to measure safety – in many organizations those externally mandated, top-down measures create cultures of accountability and even blame such that caregivers end up redefining or even hiding events so they don’t have to be reported to management.  Also, those externally mandated measures only capture a small fraction of all the harm that occurs.  What we need, especially for diagnostic errors, are cultures where learning and improvement are valued.  Externally mandated measures, especially those not based on good science, will not help us reduce diagnostic errors.
>  
> Best,
>  
> Eric
>  
> Eric J Thomas MD, MPH
> Professor of Medicine
> Associate Dean for Healthcare Quality
> Director, UT Houston-Memorial Hermann Center for Healthcare Quality and Safety
> The University of Texas Medical School at Houston
> 6410 Fannin UPB 1100.44
> Houston, TX 77030
> 713-500-7958
> www.utpatientsafety.org
>  
>  
>  
> From: Pauker, Stephen [mailto:SPauker at TUFTSMEDICALCENTER.ORG] 
> Sent: Thursday, April 24, 2014 11:15 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
>  
> Patient care and diagnoses evolve over time as things are revealed.
> So labeling something as a diagnostic error depends on when in
> the patient's course it's measured. In the course of disease evolution,
> the primary diagnosis can change. So perhaps we should not make a diagnosis
> ever but say "At this moment I think the probability of X is P". Of course, the evolving issue is
> when to treat or test with what modalities.
>  
> Steve
>  
> Stephen G. Pauker, MD, MACP, FACC, ABMH
> Professor of Medicine and Psychiatry
> ===========================
> Please note new email address;
> spauker at tuftsmedicalcenter.org
> ===========================
>  
> From: Danny Long [mailto:dannylong at EARTHLINK.NET]
> Sent: Thu 4/24/2014 8:42 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
> 
> When cover-up is the standard of care, who really knows the facts besides the ones doing the cover-up? The underlying motivation to nearly end autopsies.. just the truth.
> Statistics
> Errors related to missed or delayed diagnoses are a frequent cause of patient harm. In 2003, a systematic review of 53 autopsy studies from 1966 to 2002 was undertaken to determine the rate at which autopsies detect important, clinically missed diagnoses. Diagnostic error rates were 4.1% to 49.8% with a median error rate of 23.5%.* Furthermore, approximately 4% of these cases revealed lethal diagnostic errors for which a correct diagnosis coupled with treatment could have averted death.4 Other autopsy studies have shown similar rates of missed diagnoses; one study reported the rate to be between 10% to 12%5, while another placed it at 14%.6 Autopsies are considered the gold standard for definitive evidence of diagnostic error, but they are being performed less frequently and provide only retrospective information.
>  
> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7%283%29/Pages/76.aspx
>  
> Knowing the CDC are well aware death certificates are often falsified... even the Joint Commission are against autopsies .. so the prevailing logic is, keep the facts blurry and the conversation of how bad is the problem will keep the public in the dark. and make correcting the diagnosis problem nearly impossible to do anything about.  = keep the excuses alive.
>  
>  
> :-( garbage in garbage out to keep the data corrupt.
>  
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> The information in this e-mail is intended only for the person to whom it is
> addressed. If you believe this e-mail was sent to you in error and the e-mail
> contains patient information, please contact the Partners Compliance HelpLine at
> http://www.partners.org/complianceline . If the e-mail was sent to you in error
> but does not contain patient information, please contact the sender and properly
> dispose of the e-mail.
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/









HTML Version:
URL: <../attachments/20140425/c9cdd65e/attachment.html>


More information about the Test mailing list