quick ?

Xavier De La Cruz Montserrat xavier.delacruz at VHIR.ORG
Mon Apr 28 15:52:23 UTC 2014


Hi, I am very much interested in incidentalomes, particularly in those 
related to the use of sequencing technologies (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3821385/). I work in the development 
of bioinformatics tools for classifying mutations from patient sequence data. I am not 
an MD but can see from our collaboration with my colleagues at the hospital that there is 
a huge problem coming. Nobody seems to know very well how to handle the it, in spite of 
which sequencing seems to be increasingly used in the clinical. Anybody having 
any experience/info he/she would like to share? Sorry if this is a too specialized issue; 
I'll be glad to restrict future emails only to those interested people. 


Xavier de la Cruz, PhD 
Vall d'Hebron Institute of Research 
Barcelona, Spain 
http://www.vhir.org/larecerca/grupsrecerca/ca_grups_objectius.asp?area=4&grup=13&mh1=2&mh2=1&mh3=1&mv1=2&mv2=1&menu=1&Idioma=en 


----- Mensaje original -----
De: "Leonard Berlin" <lberlin at LIVE.COM> 
Para: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 
Enviados: Sábado, 26 de Abril 2014 2:23:47 
Asunto: Re: [IMPROVEDX] quick ? 



Incidental findings ("incidentalomas") are today a major problem -- indeed a conundrum -- particularly in radiologic imaging, but also involving many medicial specialties. For anyone who will be in the Washington DC area on June 14, 2014, there will be a National Conference, titled "Come Together: The Future of Veterans' Health Care," sponsored by the Foundation for Veteran's Health and National Association of Veterans Affairs Physicians and Dentists (NAVADP). The Conference will be held in the National Press Club. 

A panel has been scheduled for 2:15 - 3:30pm. It will deal with the rampant growth in diagnostic findings as the mother of unnecessary treatment - concerns of the Presidential Commission.The exact title is "Incidental Findings: Blessing or Curse?" 

The panelists are: 

Dr. Brenda Sirovich, M.D., M.S,. an Associate Professor of Medicine, Community & Family Medicine, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine; Interests include the incidentalomas dilemma as well as utilization, outcomes, and downstream consequences of screening and diagnostic testing; variation in, and causes and consequences of clinical practice intensity (the tendency for physicians to intervene);physician survey research. 

Dr.Nelson L. Michael, M.D., Ph.D., Colonel in the US Army Medical Corps; Director, U.S. Military HIV Research Program (MHRP), Walter Reed Army Institute of Research; Member of the Presidential Commission on Bioethics, the most recent report of which, dated Dec 2013, was entitled, "Incidentalomas: Anticipate and Communicate". 

Dr. Leonard Berlin, M.D.,is a diagnostic radiologist with broad practice, administrative and policy experience. He is the author of sagatious presentations of positions for and against reporting incidental findings, addressing moral obligations with practical concerns and explaining the medico-legal implications and more than 400 scientific publications. 

As Moderator, Jill Wruble, D.O., diagnostic radiologist and US Army veteran, serving at the VA Medical Center, West Haven, CT; a member of the faculty of both Yale and UCONN Medical Schools as a Clinical Assistant Professor, has developed a large body of work on and lectures on the subject of incidentalomas and their consequences: member of the board of directors of NAVADP. 

It is expected that a number of Congressmen and their staffs will attend. It's open to the public -- no admission charge. 




Date: Fri, 25 Apr 2014 13:46:43 -0700 
From: rmsbell at ESEDONA.NET 
Subject: Re: [IMPROVEDX] quick ? 
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG 

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 



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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. 





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