[EXTERNAL] [IMPROVEDX] Bayesian diagnosis

Harold Lehmann lehmann at JHMI.EDU
Sun Jul 20 02:57:46 UTC 2014


I apologize to reiterate, but our prior schemes were also simple minded.
We don¹t only diagnose disease, we diagnose *severity* of disease, and the
approach to that concern has never really been articulated.

Before we embark on a new round of testing of Bayesian systems, we need to
bring appropriate sophistication (severity, thresholds, and conjoint
diagnoses) to bear. And it can¹t be toy problems (³pneumonia²Š²strep
throat²), but conditions that challenge diagnostic reasoning.

Harold

On 7/19/14, 1:01 PM, "Graber, Mark" <Mark.Graber at VA.GOV> wrote:

>I'd love to see the kind of comparative study Bimal is advocating.  One
>of the suggestions on how to improve diagnosis that seems like it should
>work is exactly what Bimal is advocating: expanding the differential
>diagnosis and weighing the options appropriately.  Hardeep's work found
>that in cases of dx error there was no differential diagnosis listed 80%
>of the time.  Would this be an antidote to dx error, as Jason Maude has
>suggested (Differential diagnosis: The key to reducing diagnostic error?
> DIAGNOSIS 2014; 1:107-109).
>
>Just to make a point though:  The Ledley\Lusted approach was to use the
>full range of conditional probability analysis in diagnosis, which
>includes first deriving all the possible candidate diagnoses, then
>weighing the evidence pro and con, and using tests to adjust
>probabilities to narrow the list down..  It seems that when people refer
>to Bayesian analysis these days they are referring to the narrower usage
>of Bayes theorem to calculate the probability of a SINGLE disease
>probability.  This focus on just one entity is exactly the opposite of
>what Ledley\Lusted were advocating, and to the extent that it discourages
>thinking about all the other diagnostic options, could work against
>diagnostic accuracy.
>
>
>________________________________
>From: Lorri Zipperer <Lorri at zpm1.com>
>Reply-To: Society to Improve Diagnosis in Medicine
><IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Lorri Zipperer <Lorri at zpm1.com>
>Date: Thu, 17 Jul 2014 17:05:08 -0400
>To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>Subject: [EXTERNAL] [IMPROVEDX] Bayesian diagnosis
>
>**** moderator forwarded ****
>
>-----Original Message-----
>From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG]
>Sent: Wednesday, July 16, 2014 5:35 AM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; 'Graber, Mark'
>Subject: RE: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Patient-Provider
>Communication and Diagnostic Error
>
>Great references. Here are some thoughts on a somewhat unrelated topic--
>Bayesian diagnosis.
>
>1. Since Ledley and Lusted introduced a probabilistic (Bayesian) approach
>to
>clinical diagnosis in 1959 (SCIENCE 1959), innumerable books and papers
>have
>been written advocating its use in actual practice.
>
>2. However, this does not seem to have happened to any great extent in
>last
>55 years. For example, CPCs in NEJM continue to be discussed in a manner
>that is not Bayesian. Also discussions about diagnosis in clinical problem
>solving exercises on actual patients published in journals do not employ a
>Bayesian approach. In the occasional patient in whom it is employed, it
>does
>not come out looking too good as it seems to suggest an erroneous
>diagnosis
>(Pauker, NEJM 1992).
>
>3. There is no published evidence it is superior to the usual method of
>diagnosis in actual practice which is about 85 percent accurate (Graber
>BMJ
>2013). There are no head to head trials which demonstrate superiority of
>Bayesian over usual method of diagnosis.
>
>4. It is ironic, in this day and age of evidence based medicine, Bayesian
>diagnosis continues to be advocated without any evidence for its
>superiority.
>If it were a treatment, this issue would have been settled a long time
>back
>by a controlled trial.
>
>5. In all studies on diagnostic errors (Gordon Schiff, Hardeep Singh, Mark
>Graber), the method of diagnosis has not been identified as a source of
>diagnostic error. How would switching to a Bayesian approach reduce error?
>
>6. One of the major causes of errors found in these studies is a failure
>to
>suspect a disease in patients with atypical presentations. This error has
>potential to increase with a Bayesian approach in which a low pretest
>probability may be interpreted as low plausibility or low pretest evidence
>leading to ruling out a disease without testing.
>
>7. A Bayesian approach appears attractive, it seems, due to consistency
>and
>elegance of underlying Bayes theorem which it employs.But reliance solely
>on
>mathematical criteria without observation can be misleading as seen from
>the
>well known example of planetary orbits. For over two thousand years,
>planetary orbits were believed to be circular due to mathematical beauty
>and
>elegance of a circle as a geometrical figure. This belief was found to be
>erroneous when Kepler observed positions of Mars and calculated its orbit
>to
>be elliptical.
>
>8. I believe we need to have observational evidence of some sort, probably
>from a controlled trial, to decide if Bayesian diagnosis is superior to
>usual diagnosis or not. Only if it is found to be superior can it be
>recommended for widespread use.
>
>Bimal
>
>Bimal Jain MD
>NorthShore Medical Center
>Lynn MA 01904
>
>-----Original Message-----
>From: Graber, Mark [mailto:Mark.Graber at VA.GOV]
>Sent: Tuesday, July 15, 2014 5:54 PM
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Patient-Provider
>Communication and Diagnostic Error
>
>Barbara - Thanks for asking a GREAT question.  I think we all know the
>answer.   The bad news is that I don't think you'll find a paper that
>clearly links effective communication with improved diagnostic accuracy.
>The reason is that so far we don't have a good way to actually measure
>diagnostic accuracy.  We really need that tool to start making progress in
>studying diagnostic accuracy and error.  David Sofen (Palo Alto Foundation
>Medical Group) and I have discussed this exact issue a couple of times,
>and
>the possibility of looking to see if there is correlation between
>communication style and diagnostic accuracy just amongst all the
>physicians
>in a large practice.  Hopefully he will weigh in on his own as well.
>
>
>The good news is that there is PLENTY of INDIRECT evidence to support the
>relationship between effective communication and diagnostic quality:
>
>1)   Communication breakdowns are a common cause of diagnostic error.
>(Graber et al.  Diagnostic Error in Internal Medicine.  Arch Int Med
>(2005).
>165:1493-99).  Hardeep Singh also has a series of publications on
>diagnostic
>errors arising from breakdowns in lab communications, which is a related
>issue.
>
>2)  As Charlene Weir points out, there is evidence that the diagnosis
>emerges from the history alone in the majority of cases.    (Peterson MC,
>Holbrook JH, Von Hales D, et al. Contributions of the history, physical
>examination, and laboratory investigation in making medical diagnoses. The
>Western Journal of Medicine. BMJ 1992;156:163-5.  Wahner-Roedler DL,
>Chaliki
>SS, Bauer BA, et al. Who makes the diagnosis? The role of clinical skills
>and diagnostic test results. J Eval Clin Pract 2007;13:321-5.)  There is
>also a famous Osler quote on this:  "Listen to your patient, he is telling
>you the diagnosis".
>
>3  There is substantial evidence that high levels of patient satisfaction
>(typically reflecting communication) correlate with improved health
>outcomes
>in general. Articles that David sent me address this point:
>
>§  Doyle, C., Lennox, L., & Bell, D. (2013). "A systematic review of
>evidence on the links between patient experience and clinical safety and
>effectiveness." BMJ Open, 3. Available at
>http://bmjopen.bmj.com/content/3/1/e001570.full. This study finds
>consistent
>positive associations among patient experience, patient safety, and
>clinical
>effectiveness for a wide range of disease areas, settings, outcome
>measures,
>and study designs. It finds that patient experience is positively
>associated
>with clinical effectiveness and patient safety, and the results support
>the
>case for the inclusion of patient experience as one of the central pillars
>of quality in health care.
>
>§  Boulding, W., Glickman, S. W., Manary, M. P., Schulman, K. A., &
>Staelin,
>R. (2011). "Relationship between patient satisfaction with inpatient care
>and hospital readmission within 30 days", American Journal of Managed
>Care,
>17(1), 41-48. Focusing on three common ailments-heart attack, heart
>failure
>and pneumonia-the authors measured 30-day readmission rates at roughly
>2,500
>hospitals and found that patient satisfaction scores were more closely
>linked with high-quality hospital care than clinical performance measures.
>Hospitals that scored highly on patient satisfaction with discharge
>planning
>also tended to have the lowest number of patients return within a month
>for
>all three specified ailments. Overall, high patient satisfaction scores
>were
>more closely linked to a hospital's low readmission rates than a solid
>showing on clinical performance measures.
>
>§  Glickman, S. W., Boulding, W., Manary, M., Staelin, R., Roe, M. T.,
>Wolosin, R. J., et al. (2010). "Patient satisfaction and its relationship
>with clinical quality and inpatient mortality in acute myocardial
>infarction", Cardiovascular Quality and Outcomes, 3(2), 188-195. Hospitals
>use patient satisfaction surveys to assess their quality of care. The
>objective of this study was to determine whether patient satisfaction is
>associated with adherence to practice guidelines and outcomes for acute
>myocardial infarction and to identify the key drivers of patient
>satisfaction. The authors found that higher patient satisfaction is
>associated with improved guideline adherence and lower inpatient mortality
>rates, suggesting that patients are good discriminators of the type of
>care
>they receive. Thus, patients' satisfaction with their care provides
>important incremental information on the quality of acute myocardial
>infarction care.
>
>§  Isaac, T., Zaslavsky, A. M., Cleary, P. D., & Landon, B. E. (2010).
>"The
>relationship between patients' perception of care and measures of hospital
>quality and safety", Health Services Research, 45(4), 1024-1040. The
>overall
>rating of the hospital and willingness to recommend the hospital had
>strong
>relationships with technical performance in all medical conditions and
>surgical care. The authors found that better patient experiences for each
>measure domain were associated with lower decubitus ulcer rates, and for
>at
>least some domains with each of the other assessed complications, such as
>infections due to medical care.
>
>§  Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). "Patients'
>perception of hospital care in the United States", New England Journal of
>Medicine, 359, 1921-1931. This study assessed the performance of hospitals
>across multiple domains of patients' experiences and found a positive
>relationship between patients' experiences and the quality of clinical
>care.
>The authors found that patients who received care in hospitals with a high
>ratio of nurses to patient-days reported somewhat better experiences than
>those who received care in hospitals with a lower ratio, and hospitals
>that
>performed well on the HCAHPS survey provided a higher quality of care
>across
>all measures of clinical quality than did those that did not perform well
>on
>the survey.
>
>
>Mark L Graber MD FACP
>President, SIDM
>Sr Fellow, RTI International
>
>
>
>________________________________
>From: Barbara Balik <Barbara at THECOMMONFIRE.COM>
>Reply-To: Society to Improve Diagnosis in Medicine
><IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Barbara Balik
><Barbara at THECOMMONFIRE.COM>
>Date: Tue, 15 Jul 2014 10:30:03 -0400
>To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>Subject: [EXTERNAL] [IMPROVEDX] Patient-Provider Communication and
>Diagnostic Error
>
>I am looking for citations that link effective patient-provider
>communication and improvement in diagnosis accuracy.
>
>Effective communication from the patient's view is often described as an
>effective listener, understanding the patient's story, and respecting
>values
>and choices
>
>I appreciate any help
>
>
>
>Barbara Balik, RN, EdD
>
>Balik.Barbara at gmail.com
>www.thecommonfire.com <http://www.thecommonfire.com>
>
>Cell: 651.249.9237
>Office: 505.797.8933
>
>Common Fire Healthcare Consulting:
>Partnering with healthcare leaders to forge quality and safety outcomes
>
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