[EXTERNAL] Re: [IMPROVEDX] quick ?

Xavier Prida dr.xavier.prida at GMAIL.COM
Sun Apr 27 15:22:05 UTC 2014


Art,
     As to your stated example(cellulitis vs. stasis dermatitis), in our
paradigm this would be a Type 1 error- cognitive("I didn't know that").
 The remedy would be a decision matrix that excluded diagnosis of
cellulitis if bilateral in description and defer to a diagnostic pathway
including lymphedema/stasis dermatitis, e. nodosum, etc.

Xavier


On Sat, Apr 26, 2014 at 5:21 PM, Art Papier MD <apapier at logicalimages.com>wrote:

> One of the common misperceptions is that diagnostic error always involves
> rare diagnoses and therefore is really hard to study, another is that
> prospective studies are not being performed.   Often very COMMON diagnoses
> are missed due to premature closure, over confidence and other cognitive
> reasons.  We looked at consecutive admissions for cellulitis at 2 major
> teaching centers and showed that on average 28% of patients admitted for
> cellulitis, did not have cellulitis
> http://www.ncbi.nlm.nih.gov/pubmed/21426867  (also presented a poster on
> this at DEM) a similar study in the UK showed the error rate to be 33%
> http://www.ncbi.nlm.nih.gov/pubmed/21564054   Incredibly there are many
> admissions for BILATERAL cellulitis in every city and town every day.  (for
> the non-physicians on the list, cellulitis is a soft tissue infection, that
> is 99.9% of the time only on one side of the body, usually the leg, but
> hands, arms and other body parts occur..but not bilateral!) Dermatologists
> have been grimacing, frowning, wringing their hands about this problem for
> decades.  Ask pretty much any general medical dermatologist and you will
> get
> the same puzzled response.  The academic dermatologists who cover the
> inpatient consultation services all look like they are going to have a
> seizure when you talk about this problem because it has been going on for
> decades.  We are unsure why so many clinicians cannot diagnosis
> lymphedema/stasis dermatitis in particular, but also common diseases like
> gout, zoster, erythema nodosum, lyme disease and many other diseases that
> are commonly called cellulitis.    Stasis dermatitis is the moist frequent
> condition mis-diagnosed as cellulitis.   This single diagnostic error area
> we estimate costs over 1.3 billion dollars in hospital admissions.  These
> are potentially fixable mistakes.  The human cost includes giving health
> people c. difficile or a life-threatening drug reaction such as Stevens
> Johnson Or TEN to a person that did not need antibiotics, nor
> hospitalization.   My hunch is there are many other problem areas where
> diagnosis is led by the good old fashioned physical exam where misdiagnosis
> thrives and is tolerated.  PS  Manoj-  admittedly this particular
> diagnostic
> problem area is centered in adult medicine.
>
> Art Papier MD
> Chief Executive Officer
> 3445 Winton Place . Suite 240 . Rochester NY 14623
> (585) 427-2790 x230 . apapier at logicalimages.com
>  www.visualdx.com
> www.skinsight.com
>
>
>
> -----Original Message-----
> From: Mittal, Manoj K [mailto:MITTAL at EMAIL.CHOP.EDU]
> Sent: Saturday, April 26, 2014 3:40 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
> Hi,
>
> Thanks for your input.
>
> I like Hardeep's framing of diagnostic errors as missed opportunities. It
> is
> important what labels we use.
>
> Retrospective studies to identify diagnostic errors are a good start. The
> problem of hindsight bias in these studies, however, may make front line
> clinicians resistant to accept their conclusions.
>
> I am a practicing PEM physician. Our practice has evolved to such an extent
> that new onset serious diseases (where improving diagnosis is most
> important
> as it can have a difference between life and death) have become very rare,
> be they serious sepsis/septic shock, bacterial meningitis (much less than 1
> in 1000 children presenting with febrile illness), brain tumor, renal
> failure, etc. that any test (historical information and physical exam
> findings) has a very low positive predictive value.
>
> We have to find a way to study diagnostic errors by prospective analysis of
> records. it is going to be difficult as all the records will have to be
> analyzed, but with the increasing use of EMRs and machine learning, it may
> become possible. The system could pick up suspect records that would be
> reviewed by the clinician's peers, who will decide if something was missed.
> The follow-up will show the truth.
>
> Thanks,
> Manoj Mittal, MD
> The Children's Hospital of Philadelphia
> ________________________________________
> From: Graber, Mark [Mark.Graber at VA.GOV]
> Sent: Saturday, April 26, 2014 2:00 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
> I'd like to underline the comment from David Gordon that .... "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
> couldn't agree more.
>
> David was concerned that if we see an 'explosion' of research that focuses
> excessively on delayed and missed diagnoses, we will under-emphasize the
> harm from over-diagnosis.  I certainly acknowledge the costs and harm from
> over-diagnosis, but would argue that an explosion of studies on diagnostic
> error (under-diagnosis) is exactly what's needed right now to understand
> how
> to improve the efficiency and quality of diagnosis.
>
> If there is going to be any explosion (doubtful, given that the funding for
> dx error research is almost nil at the moment) my bet will be that this
> will
> come from the over-diagnosis community.  The evidence for this is number of
> abstracts submitted to the Overdiagnosis Conference (in the hundreds) vs
> the
> Diagnostic Error in Medicine conference (a few dozen).  And the reason is
> that it is so much easier to study over-diagnosis - all the data has
> already
> been collected, and the extra CT's and incidentaloma's have all been
> tallied.  Finding and studying under-diagnosis is much harder, for all the
> reasons everyone has described.  It may take months or years to know that a
> diagnosis was missed and in many cases we may never know at all.
>
>
>
>
>
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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-- 
Xavier E. Prida MD FACC FSCAI
813 813 0721(H)
813 245 3143(C)







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