2 articles of interest - Are more heads better than one?

Bruno, Michael mbruno at PENNSTATEHEALTH.PSU.EDU
Mon Mar 4 17:01:25 UTC 2019


Hi Ted,



We are trying to basically accomplish exactly what you are suggesting by means of electronic clinical decision support (CDS) at the point-of-care, which presents ordering providers with on-the-spot, relevant evidence to guide their imaging choices.  Since about half of radiology studies are ordered inappropriately (rough estimate) that should have a huge beneficial effect on this problem.  Congress agreed, and they mandated the use of CDS for all medicare & medicaid patients starting in 2020, in a bill known as the "PAM Act."



But clinicians have not accepted CDS.  Wherever it's been tried, physicians choose to circumvent it, they game it, and they flat-out reject it.



I've recently received a grant from ACR to explore the reasons for this "clinician resistance" problem.



As more and more places move to alternative payment models, the financial incentives will flip away from rewarding doing more testing (regardless of its clinical value) toward doing less imaging and lab tests; but I agree, right now, "more is more."



Mike





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From: Edward Winslow <edbjwinslow at GMAIL.COM>
Sent: Monday, March 4, 2019 11:19 AM
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Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?

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Fascinating thread. We seem to be concentrating on radiology and path errors.

One thing that struck me on the original paper was that the attending physicians were not "better" than many of the juniors. That was a bit of a surprise.

One thing that MIGHT help reduce some of the radiology load would be to look at the indications for a study and perhaps suggest another, potentially less controversial study to the physician who is asking for it.

This will likely NOT be welcomed by hospital administration, who get $$ from a study whether done and/or interpreted correctly. Sometimes there are conflicts among stakeholders, and hopefully physicians and nurses could be referees. If patients insist on a study, there might be ways to dis-incentivize them.

Sometimes, discussing a diagnosis in a forum like "grand rounds" or a "CPC" shows us all how others of us think and this MAY be helpful to us all. Unfortunately, participation in conferences is, now a days, not encouraged. It seems to take away from "productive" (RVU generating) time.  Sometimes these activities are rewarded with CME credits, which may be needed for organizational membership (Hosp Staff, Professional Societies, MOC), but not always.

Might we recommend:
   1. Preview some test requests, and potentially suggest another study.
   2. Discuss in groups the diagnostic process - in those situations that went right as well as those that didn't
   3. Try to reduce the institutional incentives to order the most expensive/newest test or procedure, unless it has a proven track record (

Best to all.
Ted


On Mon, Mar 4, 2019 at 7:42 AM Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:
Thought this may be of interest to this group:)

Facts Don’t Change People’s Minds. Here’s What Does
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Robert (Bob) J. Latino
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From: Applegate, Kimberly E [mailto:keapple at UKY.EDU<mailto:keapple at UKY.EDU>]
Sent: Monday, March 04, 2019 6:47 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?


Good afternoon,

I enjoy this discussion as it brings up all the potential implementation science pitfalls. Yet, it is not an 'all or none' proposal to double read imaging in these medical professions (radiology, and also cardiology, dermatology, pathology). I am quite confident that we have the (be it artificial) intelligence to design appropriate processes that select the most important and problematic in our interpretative areas that will benefit our patients. So, why not do it?



I will add that in some countries, to deal with the insufficient number of radiologists, they simply do not interpret (or bill for) any plain radiographs (Japan). That decreases the work load a great deal and they have one of the best WHO health and longevity ranks in the world...I would urge us to think out of the box.

Kimberly



________________________________
From: Mark Gusack <gusackm at COMCAST.NET<mailto:gusackm at COMCAST.NET>>
Sent: Sunday, March 3, 2019 5:29 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?


Good Afternoon Everyone:



I agree that double reading is very valuable.  We do it all the time in Surgical and Cytopathology.  However, the devil is in the details.  The double read has to occur under circumstances that assures both do an independent read to avoid bias.  In addition, it has to be structured so the ‘ball’ isn’t dropped because each figures the other will get it if they don’t.  Finally, there has to be a way of resolving differences of ‘opinion’ that avoids confrontation and provides as means of a ‘third party’ expert being available to confirm one, or the other, or neither diagnosis.



Mark Gusack, M.D.

President

MANX Enterprises, Ltd.

304 521-1980

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From: Bruno, Michael <mbruno at PENNSTATEHEALTH.PSU.EDU<mailto:mbruno at PENNSTATEHEALTH.PSU.EDU>>
Sent: Sunday, March 3, 2019 2:55 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?



Yes, that was a fantastic paper!!  I think your data suggest that the potential value of double reading could be as much as 12X for error reduction.  I cited it on p3 of the attached paper from the December, 2018 issue of the journal Radiology.



Mike





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From: Applegate, Kimberly E <keapple at UKY.EDU<mailto:keapple at UKY.EDU>>
Sent: Sunday, March 3, 2019 7:15 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] 2 articles of interest - Are more heads better than one?



Thank you--in some countries double radiology interpretations are required (e.g., Sweden) and we might find addition evidence for value of collective intelligence.



As one proxy measure for error,  we looked at the addenda rate in radiology reports and noted fewer addenda when a radiology resident had co-interpreted with us. Many hypothesized just the opposite. This suggests that 2 pair of eyes serves our patients better than one pair. AI may do the same to augment our abilities. Parenthetically, women radiologists were more likely to perform addenda than men. This leads to further social science questions.

Kimberly Applegate, MD, MS



https://www.ajronline.org/doi/pdf/10.2214/AJR.17.18339<https://urldefense.proofpoint.com/v2/url?u=https-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Furldefense.proofpoint.com-252Fv2-252Furl-253Fu-253Dhttps-2D3A-5F-5Fwww.ajronline.org-5Fdoi-5Fpdf-5F10.2214-5FAJR.17.18339-2526d-253DDwMFAw-2526c-253D-5FFmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0-2526r-253DXZJky8Jx0OuETXcWpBMhx9j-5FwSYpSZPDVXdInJ5O9gQ-2526m-253DEAMFtePHzo6ZQgbZ2v0FJz3flNDZXves7yjGtviYQoE-2526s-253Dyu-2DWCLXEYbV95mPkkhipwS-2D7GWgPwOQRgaQsNXUoitM-2526e-253D-26data-3D02-257C01-257Ckeapple-2540UKY.EDU-257C6c4cf3d100db4812bc3d08d6a05244a5-257C2b30530b69b64457b818481cb53d42ae-257C0-257C1-257C636872672544462378-26sdata-3D-252FT6TAllQx87xkRivgScnyGI1DxAwC-252F2HzLEGGcnuOjM-253D-26reserved-3D0&d=DwMFaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=A0imS5Fcd1giUfqkaTLt_sjradipizw5uUG1lULUAJw&s=Gnah0nD5rLFFENdhS3cFkHlGWgGBbSE7OjC_LnPIqQI&e=>



Trainees May Add Value to Patient FOCUS ON: Care by Decreasing Addendum Utilization in Radiology Reports - ajronline.org<https://urldefense.proofpoint.com/v2/url?u=https-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Furldefense.proofpoint.com-252Fv2-252Furl-253Fu-253Dhttps-2D3A-5F-5Fwww.ajronline.org-5Fdoi-5Fpdf-5F10.2214-5FAJR.17.18339-2526d-253DDwMFAw-2526c-253D-5FFmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0-2526r-253DXZJky8Jx0OuETXcWpBMhx9j-5FwSYpSZPDVXdInJ5O9gQ-2526m-253DEAMFtePHzo6ZQgbZ2v0FJz3flNDZXves7yjGtviYQoE-2526s-253Dyu-2DWCLXEYbV95mPkkhipwS-2D7GWgPwOQRgaQsNXUoitM-2526e-253D-26data-3D02-257C01-257Ckeapple-2540UKY.EDU-257C6c4cf3d100db4812bc3d08d6a05244a5-257C2b30530b69b64457b818481cb53d42ae-257C0-257C1-257C636872672544462378-26sdata-3D-252FT6TAllQx87xkRivgScnyGI1DxAwC-252F2HzLEGGcnuOjM-253D-26reserved-3D0&d=DwMFaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=A0imS5Fcd1giUfqkaTLt_sjradipizw5uUG1lULUAJw&s=Gnah0nD5rLFFENdhS3cFkHlGWgGBbSE7OjC_LnPIqQI&e=>

www.ajronline.org<https://urldefense.proofpoint.com/v2/url?u=https-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Furldefense.proofpoint.com-252Fv2-252Furl-253Fu-253Dhttp-2D3A-5F-5Fwww.ajronline.org-2526d-253DDwQFAw-2526c-253D-5FFmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0-2526r-253DXZJky8Jx0OuETXcWpBMhx9j-5FwSYpSZPDVXdInJ5O9gQ-2526m-253DEAMFtePHzo6ZQgbZ2v0FJz3flNDZXves7yjGtviYQoE-2526s-253DcnHDh3VuicDuDQBbBCK8W-5FyaCJmJ1ijgZuBJoSiVB6A-2526e-253D-26data-3D02-257C01-257Ckeapple-2540UKY.EDU-257C6c4cf3d100db4812bc3d08d6a05244a5-257C2b30530b69b64457b818481cb53d42ae-257C0-257C1-257C636872672544472379-26sdata-3DKdlscRoF8SwSAfJM-252B3lISVdoELgHsLW4XUwu7VZSh1Y-253D-26reserved-3D0&d=DwMFaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=A0imS5Fcd1giUfqkaTLt_sjradipizw5uUG1lULUAJw&s=hFlKSj-gPpdY0QowHcxdcrP-uZkDYPeI5o2UrkeAmaM&e=>

976 AJR:209, November 2017 patient care decisions [6]. To correct or ex-pand on a previously finalized report, radi-ologists must generate an addendum to the




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From: David L Meyers <dm0015 at COMCAST.NET<mailto:dm0015 at COMCAST.NET>>
Sent: Saturday, March 2, 2019 1:08 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] 2 articles of interest - Are more heads better than one?



An interesting article and editorial comment, just published, relevant to improving diagnosis:



https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2726708?guestAccessKey=1856b32c-88c6-4eda-912e-9717b95a5807&utm_source=silverchair&utm_campaign=jama_network&utm_content=weekly_highlights&cmp=1&utm_medium=email<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.proofpoint.com%2Fv2%2Furl%3Fu%3Dhttps-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Fjamanetwork.com-252Fjournals-252Fjamanetworkopen-252Ffullarticle-252F2726708-253FguestAccessKey-253D1856b32c-2D88c6-2D4eda-2D912e-2D9717b95a5807-2526utm-5Fsource-253Dsilverchair-2526utm-5Fcampaign-253Djama-5Fnetwork-2526utm-5Fcontent-253Dweekly-5Fhighlights-2526cmp-253D1-2526utm-5Fmedium-253Demail-26data-3D02-257C01-257Ckeapple-2540UKY.EDU-257Cbab531af97f5430f1c1208d69f3a26ef-257C2b30530b69b64457b818481cb53d42ae-257C0-257C1-257C636871469444760085-26sdata-3DoAzpxiki519EpecFrku1fTD9Qi2ayKDa-252B-252FO0ERf6lsU-253D-26reserved-3D0%26d%3DDwMFAw%26c%3D_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0%26r%3DXZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ%26m%3DEAMFtePHzo6ZQgbZ2v0FJz3flNDZXves7yjGtviYQoE%26s%3DerI_D95U1zanI2cyIcizWb9rWaavDu72ezoj3uttdDg%26e%3D&data=02%7C01%7Ckeapple%40UKY.EDU%7C6c4cf3d100db4812bc3d08d6a05244a5%7C2b30530b69b64457b818481cb53d42ae%7C0%7C1%7C636872672544482388&sdata=XIDsjGunpEzl33DoGbrWcsElIcL4%2Bf8XQmeUAnZ66ag%3D&reserved=0>



https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2726709?guestAccessKey=464bc45c-77b0-442b-993e-c1e91e784773&utm_source=silverchair&utm_campaign=jama_network&utm_content=weekly_highlights&cmp=1&utm_medium=email<https://na01.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.proofpoint.com%2Fv2%2Furl%3Fu%3Dhttps-3A__na01.safelinks.protection.outlook.com_-3Furl-3Dhttps-253A-252F-252Fjamanetwork.com-252Fjournals-252Fjamanetworkopen-252Ffullarticle-252F2726709-253FguestAccessKey-253D464bc45c-2D77b0-2D442b-2D993e-2Dc1e91e784773-2526utm-5Fsource-253Dsilverchair-2526utm-5Fcampaign-253Djama-5Fnetwork-2526utm-5Fcontent-253Dweekly-5Fhighlights-2526cmp-253D1-2526utm-5Fmedium-253Demail-26data-3D02-257C01-257Ckeapple-2540UKY.EDU-257Cbab531af97f5430f1c1208d69f3a26ef-257C2b30530b69b64457b818481cb53d42ae-257C0-257C1-257C636871469444770094-26sdata-3D69SDOVELd8-252FeKKnm-252F1YC-252FViGj1Hcf2fMkdXn3xYBBFs-253D-26reserved-3D0%26d%3DDwMFAw%26c%3D_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0%26r%3DXZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ%26m%3DEAMFtePHzo6ZQgbZ2v0FJz3flNDZXves7yjGtviYQoE%26s%3DlQkKez--1HANf6ODFFrUQ77U4kq3DKZNXc9yIBhSkek%26e%3D&data=02%7C01%7Ckeapple%40UKY.EDU%7C6c4cf3d100db4812bc3d08d6a05244a5%7C2b30530b69b64457b818481cb53d42ae%7C0%7C1%7C636872672544482388&sdata=fE14R%2FHz1X3wDG%2F4aMMLHrfTJUIKGfgf9syjHM5dTjg%3D&reserved=0>





David

David L Meyers, MD FACEP

Society to Improve Diagnosis in Medicine

Listserv Moderator/Board member

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Edward B, J. Winslow, MD, MBA
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“...the more you know about the past, the better you are prepared for the future.”

Theodore Roosevelt, 26th President of United States of America


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Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

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


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