[EXTERNAL] Re: [IMPROVEDX] quick ?

Pauker, Stephen SPauker at TUFTSMEDICALCENTER.ORG
Sun Apr 27 17:02:13 UTC 2014


Let me push a bit further

We use the 'term make a diagnosis' but again have not defined it. Do we me that the probability of A disease is above some (therapeutic) threshold and we take some action on that basis (usually a therapeutic action)

Steve



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-----Original Message-----
From: Xavier Prida [dr.xavier.prida at GMAIL.COM]
Sent: Sunday, April 27, 2014 12:55 PM Eastern Standard Time
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?


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 <tel:%28585%29%20427-2790%20x230>  . 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.
	
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--

Xavier E. Prida MD FACC FSCAI 
813 813 0721(H)
813 245 3143(C)

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