Blog posting on ICD-10 and Diagnosis

Mark H Ebell ebell at UGA.EDU
Thu Nov 12 12:53:56 UTC 2015


Another example is Alastair Hay’s TARGET study in Britain, that recruited 8300 children with acute lower RTI.  They are possible.

Mark

From: "Mahajan, Prashant" <PMahajan at dmc.org<mailto:PMahajan at dmc.org>>
Date: Thursday, November 12, 2015 at 6:51 AM
To: 'Society to Improve Diagnosis in Medicine' <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Mark Ebell <ebell at uga.edu<mailto:ebell at uga.edu>>
Subject: RE: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis

Great point - this will require a priority list of conditions that would need to be addressed in a systematic manner.
For instance - the reference standard for infection is a culture - however, performance of cultures are sub-optimal - too many false positives and unknown number of false negatives.
Thus, we would need to create definitions for infections - it could be a syndrome of infection - a composite score that includes pertinent historical elements, physical examination findings and supporting labs in addition to results of blood culture - currently we are using results of blood culture for categorizing presence or absence of infection.

A very robust example that addressed #1 and #2 points raised by Mark is the landmark study by Kuppermann et al  Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.

We would need more studies like that - however, that required unprecedented effort and in many instances will require multi-center networks (in some instances they may need a global network).
Hence a prioritization of conditions would be a great start - that will inform policy makers and payors while setting the research agenda.
Maybe the Coalition could take this as one of its first steps.
Regards
Prashant


Prashant Mahajan MD MPH MBA
Division Chief and Research Director
Pediatric Emergency Medicine
Professor of Pediatrics & Emergency Medicine
Director Center for Quality and Innovation
Carman & Ann Adams Department of Pediatrics
Children's Hospital of Michigan
Detroit, MI - 48201
Phone: 313-745-5260
Fax: 313-993-7166
Email: pmahajan at dmc.org<mailto:pmahajan at dmc.org> and mahajan at comcast.net<mailto:mahajan at comcast.net>
The materials in this message are private and may contain Protected Healthcare Information. If you are not the intended recipient, be advised that any unauthorized use, disclosure, copying or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this email in error, please immediately notify the sender via telephone or return mail.



________________________________
From: Mark H Ebell [mailto:ebell at UGA.EDU]
Sent: Wednesday, November 11, 2015 3:24 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis


  1.  Studies that link symptoms at presentation to the final diagnosis by a valid reference standard in the ambulatory setting.
  2.  Development of prospectively validated clinical decision support tools (rules, algorithms, etc) built using those data.

From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Wednesday, November 11, 2015 at 1:12 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis

Mark, what would be two things that you would like to see accomplished to help prevent diagnostic errors nation wide in say the next five years?

Rob Bell

Sent from my iPad

On Nov 11, 2015, at 8:24 AM, "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>> wrote:

Thanks for sending these Mark.  As you’ve noted, we know surprisingly little about the prevalence of the diseases that cause common symptoms in primary care.  Most differential diagnoses in textbooks and online resources are organized according to anatomy or body system, and we often teach medical students to use these organizational methods (or a mnemonic like VITAMIN D) when trying to generate a differential diagnosis from memory.  But these methods are not very helpful to clinicians.  I think more helpful would be to order the differential diagnosis according to disease prevalence, with the most prevalent diseases at the top.  (If we only knew what these prevalences were . . .)  There are other possibilities for ordering the diagnoses.  We could list serious “don’t miss” diagnoses first, followed by less serious diagnoses, and that would often lead to the reverse order of the prevalence method since rare diseases tend to be serious and common diseases tend to be benign.  Or we could list them in order of which ones are easiest to rule out with a simple test or physical exam maneuver or additional question in the history.  You could even limit the list to don’t miss diagnoses to make it shorter, but I think a comprehensive differential diagnosis would be most useful because, when it comes to diagnosis, the clinician has two jobs:  (1) Don’t miss bad diseases and (2) Make the right diagnosis.  You can’t do the second job with just the don’t-miss list.
John
From: Mark H Ebell [mailto:ebell at UGA.EDU]
Sent: Tuesday, November 10, 2015 8:53 AM
To: <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis
The Europeans, and in particular the Dutch, used this system. I know the Lee Green (Alberta) and Don Nease (Colorado) were working with it and created software around it while at Michigan. And, Henk Lamberts published a series of great articles. I’ve attached a couple, I published the grainy one while I was editor of JFP because I thought it was so important. Unfortunately, Henk died a few years ago.
Best,
Mark
From: Mark Graber <<mailto:mark.graber at improvediagnosis.org>mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>>
Date: Tuesday, November 10, 2015 at 9:49 AM
To: Listserv ImproveDx <<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Mark Ebell <<mailto:ebell at uga.edu>ebell at uga.edu<mailto:ebell at uga.edu>>
Subject: Re: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis
Thanks to Mark Ebell for calling attention to the WHO's classification system, the International Classification for Primary Care (ICPC-2).  One NICE feature in ICPC-2 is that it captures the reason for the encounter, which would be a huge help to future research on diagnostic error.  We need that !
Our exclusive use of ICD-10 in the US is a complicating factor in regard to research, because so often a presumptive diagnosis is chosen instead of just the chief complaint.
Mark L Graber MD FACP
President, SIDM  <http://www.improvediagnosis.org> www.improvediagnosis.org<http://www.improvediagnosis.org>
On Nov 9, 2015, at 8:47 PM, Mark H Ebell <<mailto:ebell at uga.edu>ebell at UGA.EDU<mailto:ebell at UGA.EDU>> wrote:
How about:
<http://www.who.int/classifications/icd/adaptations/icpc2/en/>http://www.who.int/classifications/icd/adaptations/icpc2/en/
Mark Ebell
From: "<mailto:graber.mark at GMAIL.COM>graber.mark at GMAIL.COM<mailto:graber.mark at GMAIL.COM>" <<mailto:graber.mark at GMAIL.COM>graber.mark at GMAIL.COM<mailto:graber.mark at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "<mailto:graber.mark at GMAIL.COM>graber.mark at GMAIL.COM<mailto:graber.mark at GMAIL.COM>" <<mailto:graber.mark at GMAIL.COM>graber.mark at GMAIL.COM<mailto:graber.mark at GMAIL.COM>>
Date: Monday, November 9, 2015 at 11:08 PM
To: "<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Blog posting on ICD-10 and Diagnosis
Dr Yul Ejnes (an internist and  past chair of ACP's Board of Regents) has an interesting  blog post<http://www.kevinmd.com/blog/2015/10/icd-10-isnt-just-the-problem-its-also-the-symptom.html> on the new ICD-10 coding system.  Echoing the same point made in the IOM report Improving Diagnosis in Health Care, he labels ICD-10 an "absurdly complicated payment 'non-system'" and calls for "alternatives that make getting the diagnosis right more important than selecting the correct code."

Mark L Graber MD FACP
President, Society to Improve Diagnosis in Medicine
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