AHRQ Grants for Diagnostic Error

Moulton, Carol-Anne Carol-Anne.Moulton at UHN.CA
Tue Apr 14 01:01:57 UTC 2015


I study this among surgeons. In surgery, the problem often is not in diagnosis but in what u refer to here Phil. It is complicated by two facts: 1) You are assuming motive which will rarely be admitted. Instead stories of justification get constructed by the surgeon to frame the decision in what I refer to as "avowed" reasons..in the best interests of the patient (borrowed from a framework used in professionalism). The "unavowed" (teaching or administrative pressures for example) and the "disavowed" (the surgeons pocketbook, or ego) would not be admitted. We construct the story for the patient, the family and often to our colleagues in "avowed" principles. As outsiders we can only wonder how much these other disavowed and unavowed principles weigh in. I try and teach this as a reflective tool for surgeons to consider decisions they make "in the moment" of practice, in a timely manner for them to make a better decision recognizing these other influences.
And 2) decision making is not like a diagnosis. There are often several plausible and justifiable decisions and experts often do not agree on the one approach. I found this hard to believe myself when I studied decision making in surgeons but my research results have continuously pointed towards variability in judgment and decision making. When there is not one gold standard (sometimes there is) or when there are several reasonable options it is difficult to criticize some decisions as "wrong". The best people to judge are those in the same area of practice. As a surgeon myself (liver and pancreas) I cannot really judge or really understand the nuances in the case u provide for example. This is why it has to be a self regulating profession.
It is tough to make judgments about surgeons motives or decision making. I am by no means saying this stuff u refer to doesn't happen. Of course it does but is tough to "prove".
We need a systems approach to this to safeguard against some of this.
I have been suggesting perhaps a more central triage where a group of surgeons make decisions about a reasonable approach to complex cases.
The problem with independent second opinions in management plans is that they will often come up with a different answer. Doesn't mean either are wrong...
Carol-Anne Moulton
Toronto, Canada


Sent from my iPhone

On Apr 13, 2015, at 8:16 PM, Phillip Benton <0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

Rob & Mark,

Yes, theoretically the insurance carrier should be the primary filter, but most of the reviewer's who pre-certify (approve/turn down) surgery requested have little or no formal medical education, and operate strictly from a computer screen that lists what they will or will not approve for a certain diagnosis. Whether it is unnecessary or excessive at that point in time (with so little symptomatic disease, confirmed by appropriate studies) is outside their discretion.

'Second Opinion' also falls short of controlling inappropriate or unnecessary surgery (see L. Leape, attached). In small communities, friends may approve each other's cases without the insurors' knowledge. Some specialty societies, such as North American Spine Society, are working actively to establish 'surgical appropriateness criteria' to help apply the clinical practice guidelines its' dedicated guideline committees have worked so hard to formulate.

Many have written about this (Leape, Epstein, others) but no one yet has tried to take real action. Deyo & Mirza in 2010 described a 15-fold increase in complex surgery for spinal stenosis (as occured in my Power Point example) between 2002 and 2007.

The JC's Mission Statement extols 'Quality Care and Patient Safety' in hospitals it accredits, but it has not yet acknowledged or confronted the problem of  unnecessary or excessive surgery. When asked JC says they depend upon the hospitals QA committees to control this -- but there are no guidelines, no monitoring and no sanctions for cases such as that described in my Spinal Stenosis PowerPoint. I am preparing a presentation to The Joint Commission on this point and I may ask SIDM to weigh in.

Phil Benton
Atlanta, GA


-----Original Message-----
From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Mon, Apr 13, 2015 2:32 pm
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Excellent point.

Where are the loyalties of the Joint Commission - are the mainly patient or hospital?  Who pays the JCs fees? I ask this as there seem to be 100s many areas where the JC could help reduce errors to a far greater extent. Accurate data collection could be a start.

Insurance carriers often are asking for approval for expensive procedures, operations, or drugs. Do they ever challenge a surgeons decision to perform an operation?  Are second opinions ever sought in those situations?  Could the Insurance Carriers be the filter that you ask for?

But let’s not forget ambulatory care diagnostic errors, which must be massive, when so many do not have the training to diagnose many of the conditions.

Rob Bell

On Apr 13, 2015, at 10:32 AM, pgbentonmd at aol.com<mailto:pgbentonmd at aol.com> wrote:

Rob, Mark and SIDM,

I would like to add another very important area in which "diagnostic" errors may cause massive and irreparable patient harm. I'm talking about not an error of diagnosis, but about the misapplication of surgical treatment indications for some diagnoses.. Currently there are no barriers to posting surgery that is inappropriate (viz unnecessary or excessive) for the underlying diagnosis.

 Patients usually have given their "informed" consent to the procedure because they trusted their physician. Most physicians are trustworthy, but some surgeons looking to enhance the surgical fee treat surgically all pathology seen on the diagnostic imaging, or do the surgery prematurely. Attached, anonymized, is one example.

What we really need is a diagnosis related "appropriateness criteria" screening system at the surgery scheduling desk that the OR nurses can understand and apply, that can trigger review of questionable case postings by senior surgeons with departmental administrative responsibility for quality of care. The Department Chair will also need timely backup consultation available from specialty society Practice Guidelines Committees when needed.

Hopefully Joint Commission will face the problem and  join this effort to ensure patient safety and quality care in America's accredited hospitals.

Phillip G. Benton, MD, JD
Atlanta, Georgia


-----Original Message-----
From: robert bell < rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
To: IMPROVEDX < IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Mon, Apr 13, 2015 11:33 am
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

That was the point I was trying to make previously, and asking where most diagnostic errors are to be found.  In hospitals or in private specialty practice and primary care practice?

If it is thought that most diagnostic errors come from the latter, then funding should be be available there.

Rob Bell
On Apr 12, 2015, at 4:24 PM, Julianne Nemes Walsh < nemeswalsh at GMAIL.COM<mailto:nemeswalsh at GMAIL.COM>> wrote:

After reviewing the grant criteria, primary care practice groups that are not attached to a higher ed institution are not eligible.   Would love to see grant opportunities available to smaller settings to stimulate more diversified opportunities for all levels of providers interested in diagnostic error.

On Thu, Apr 9, 2015 at 9:52 PM, <graber.mark at gmail.com<mailto:graber.mark at gmail.com>> wrote:
This is a big day for our diagnostic safety community:  AHRQ has just issued the first-ever grant announcement that specifically targets “ Diagnostic Safety in Ambulatory Care”.  Both R01 (large grants) and R18 (small grants) will be funded under this initiative, which will be open annually until 2018.  With so many proposed, but untested interventions that have been raised, there’s many opportunities.  Go get ‘em !

Mark

Mark L Graber MD FACP
President, SIDM

Title:     Understanding and Improving Diagnostic Safety in Ambulatory Care: Strategies and Interventions

Deadline Date:  Standard due dates apply: January 25, May 25, and September 25.

For details, click on the link below:
http://www.egrants.net/Public/index.cfm?ID=17660&UserID=graber%2Emark%40gmail%2Ecom<http://www.egrants.net/Public/index.cfm?ID=17660&UserID=graber.mark@gmail.com>

or copy the above link into your web browser and hit the enter key.




________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.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<mailto: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:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.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<mailto: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:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


Robert M. Bell, M.D., Ph.C.
P.O. Box 3668
West Sedona, AZ  86340-3668
USA
Tel: Fax: 928 203-4517

I am changing my e-mail address to  rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>

Kindly change the e-sedona e-mail above in your address book so  we stay in touch.







________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.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<mailto: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:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/
<Spinal_Stenosis.ppt_BASIC +.pptx>

Robert M. Bell, M.D., Ph.C.
P.O. Box 3668
West Sedona, AZ  86340-3668
USA
Tel: Fax: 928 203-4517

I am changing my e-mail address to  rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>

Kindly change the e-sedona e-mail above in your address book so  we stay in touch.







________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.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<mailto: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:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.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<mailto: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:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

<Deyo_&_Mirza_2010_JAMA.pdf>
<Lucian Leape (1989) Unnecessary surgery..pdf>
<Epstein Unnecessary Surgery.pdf>

This e-mail may contain confidential and/or privileged information for the sole use of the intended recipient. 
Any review or distribution by anyone other than the person for whom it was originally intended is strictly prohibited. 
If you have received this e-mail in error, please contact the sender and delete all copies. 
Opinions, conclusions or other information contained in this e-mail may not be that of the organization.






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine




More information about the Test mailing list