AHRQ Grants for Diagnostic Error

Xavier Prida dr.xavier.prida at GMAIL.COM
Fri Apr 17 20:20:58 UTC 2015


Guidelines contain inherent COI(well demonstrated by precedent publicized
events) by virtue of authorship and their durability(rate of change- fast
and slow ) has been called into question . And..... guidelines should be
 "guidance" documents not instruction manuals.

The essence,as David well elucidates, is  how do we attain SMART MEDICINE
for the singular benefit for the patient(N=1), as collaboratively designed
with the patient(shared decision making), and  with the patient decision
based on their understanding of utility or dysutility of a diagnostic test
or treatment. And, this requires proper conveyance of information to the
N=1 with decision tools(grids, visual displays, etc.). It is from guidance
documents, meta-analysis, trial data that clinical TEAMS, again with the
patient,  translate to available resources ( human cognitive, technical
skills, and technology) - the latter in the aggregate is clinical
experience and expected performance - as to the best practice for the best
fit for N=1 .

So, how do commercial insurance carriers have primacy here?

Best. Xavier

On Fri, Apr 17, 2015 at 10:58 AM, Robert Bell <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:

> I thought wrongly that Dr. Prida was talking about legal insurance
> companies, hence my comment, but I now see he was talking about heathcare
> insurance companies, as is Dr. Lawrence.
>
> It does not alter the fact that legal/litigation insurance companies are
> basically on our side in the desire to reduce error?
>
> Rob
>
> Sent from my iPad
>
> On Apr 17, 2015, at 6:59 AM, David Lawrance <david.lawrance at gmail.com>
> wrote:
>
> > Is it not an ethical principle,at least for health insurance
> > cooperatives and mutuals, to return to its purchasers the maximum good
> > for a given dollar?
> >
> > Many of our guidelines direct us along pathways that ultimate will not
> > help the majority of patients that use them (any pathway where the NNT
> >> 1.)  Many guidelines are based upon studies that exclude confounding
> > variables in order to provide focus. It is easy to believe that a
> > particular individual does not meet the criteria that were used in
> > establishing the guideline.
> >
> > Which is not an argument against following clinical pathways. It is
> > simply a statement that following a guideline is not necessarily
> > ultimately in a patient's best interest, and therein lies a problem.
> >
> > At the time of a preauthorization request, a denial always seems to
> > patient and provider as ridiculous arbitrariness. The criteria for
> > whether a guideline applies or not are generally fairly simple, half a
> > dozen measurable factors or less.  It doesn't take a medical
> > professional to make the determination. Sticking to the guideline
> > hopefully provides more good on the average than not following it.
> >
> > Neither patient nor provider, insurer or anyone else can know the
> > ultimate outcome in the moment. The insurer is  nudging toward or away
> > from a particular guideline that seems to apply, nudged away by
> > patient/provider by individual circumstance for an exception. The
> > patient is nudged toward following the guideline for financial
> > reasons, nudged away by knowledge that of alternate pathways. How
> > should such determinations be arbitrated?
> >
> > Usually, there is an appeals process that involves a medical
> > professional. The intent of appeal is to show that a particular
> > guideline does not apply for this particular circumstance, that there
> > is evidence for this particular case for an alternate pathway. But
> > generally, the appeal decision-making process seems to me to me to
> > rely mostly upon expert opinion not guided by evidence-based factors.
> > Should the reviewer give the patient/provider the benefit of a doubt?
> >
> > At this point, the process becomes completely opaque. We have no
> > knowledge of how an appeals reviewer is selected or how they are
> > rewarded. There is no body of evidence that we can use to weigh the
> > decision-making ability. There is no independent peer review, itself a
> > most problematic quality measure.
> >
> > David
> >
> >
> >
> > On Thu, Apr 16, 2015 at 9:01 PM, robert bell
> > <0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
> >> Xavier,
> >>
> >> I am not sure that I totally agree.
> >>
> >> All peoples in the Healthcare industry, as you mention including
> physicians,
> >> have biases.
> >>
> >> Would it not be considered a good thing for patients If insurance
> industry
> >> biases lead to less errors in medicine and reduced litigation costs?
> >>
> >> The Insurance Industry has a fairly good record in sponsoring
> educational
> >> events in an attempt to reduce errors.
> >>
> >> Rob Bell
> >>
> >>
> >>
> >>
> >> On Apr 14, 2015, at 11:31 AM, Xavier Prida <dr.xavier.prida at GMAIL.COM>
> >> wrote:
> >>
> >> Insurance companies should not have even a subordinate role, in that
> they
> >> possess the identical conscious or unconscious, intentional or
> unintentional
> >> bias conflict of interest(COI) of a fiduciary responsibility to the
> >> shareholders of the corporation(identical biases that physicians have
> in a
> >> fee for service environment-but opposite incentive).
> >>
> >> On Tue, Apr 14, 2015 at 11:30 AM, Jackson, Brian <
> brian.jackson at aruplab.com>
> >> wrote:
> >>>
> >>> There’s an important point in this thread that I want to call out.
> Health
> >>> insurance companies are NOT the right entity to play the main role in
> >>> ensuring high quality care.  They’ve only stepped into that role
> because
> >>> clinical care delivery entities (medical groups, hospitals, etc.)
> haven’t
> >>> fully owned it.  And I suspect this is largely because of a
> misunderstanding
> >>> of the role of professionalism.
> >>>
> >>>
> >>>
> >>> Utilization reviewers working for insurers will never be in a good
> >>> position to assess clinical quality because they’re organizationally
> too
> >>> distant from the point of care.  What we need instead are more
> front-line
> >>> leadership roles filled by experienced doctors who supervise their
> peers,
> >>> reporting up to clinically-trained top-level leaders.  In an ideal
> world,
> >>> insurance companies would play a subordinate role.  Or to paraphrase a
> VP at
> >>> Intermountain Health Care (I forget his name), health insurers should
> own
> >>> actuarial risk (who gets what diseases) and healthcare delivery systems
> >>> should own medical risk (how much value is delivered to those
> patients).
> >>>
> >>>
> >>>
> >>> --Brian Jackson
> >>>
> >>>
> >>>
> >>>
> >>>
> >>> From: Phillip Benton
> >>> [mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
> >>> Sent: Monday, April 13, 2015 3:23 PM
> >>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> >>>
> >>>
> >>> Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error
> >>>
> >>>
> >>>
> >>> 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>
> >>> To: IMPROVEDX <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 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>
> >>> To: IMPROVEDX < 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>
> >>> 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> 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
> >>>
> >>>
> >>>
> >>> or copy the above link into your web browser and hit the enter key.
> >>>
> >>>
> >>>
> >>>
> >>>
> >>> ________________________________
> >>>
> >>>
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> >>>
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> >>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
> in
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> >>>
> >>> To learn more about SIDM visit:
> >>> http://www.improvediagnosis.org/
> >>>
> >>>
> >>>
> >>>
> >>>
> >>> ________________________________
> >>>
> >>>
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> >>>
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> >>>
> >>>
> >>>
> >>> 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
> >>>
> >>>
> >>>
> >>> 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
> >>>
> >>> To unsubscribe from IMPROVEDX: click the following link:
> >>>
> >>>
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> >>>
> >>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> >>>
> >>> Visit the searchable archives or adjust your subscription at:
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> >>>
> >>>
> >>> 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
> >>>
> >>>
> >>>
> >>> 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
> >>>
> >>> To unsubscribe from IMPROVEDX: click the following link:
> >>>
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> >>> Visit the searchable archives or adjust your subscription at:
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> >>>
> >>>
> >>> 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
> >>>
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> >>>
> >>>
> >>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis
> in
> >>> Medicine
> >>>
> >>> To learn more about SIDM visit:
> >>> http://www.improvediagnosis.org/
> >>>
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> >>
> >>
> >>
> >>
> >> --
> >> Xavier E. Prida MD FACC FSCAI
> >> Assistant Professor of Medicine
> >> USF Morsani College of Medicine
> >> Department of Cardiovascular Sciences
> >> Tampa, Fl
> >>
> >>
> >> ________________________________
> >>
> >> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> >>
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> >> Visit the searchable archives or adjust your subscription at:
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> >>
> >>
> >> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> >> Medicine
> >>
> >> To learn more about SIDM visit:
> >> http://www.improvediagnosis.org/
> >>
> >>
> >> As of 1.1.2015 my new email address is: rmsbell200 at yahoo.com
> >>
> >> Please update your address books accordingly
> >>
> >>
> >> ________________________________
> >>
> >> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> >>
> >> To unsubscribe from IMPROVEDX: click the following link:
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> >>
> >> 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/
>
>
>
>
>
>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
>
> To unsubscribe from the IMPROVEDX list, click the following link:<br>
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> </p>
>



-- 
Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
USF Morsani College of Medicine
Department of Cardiovascular Sciences
2 Tampa General Circle
STC 5 th Floor
Tampa, Fl 33606






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


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