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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
26 to 50 of 545 Research Studies DisplayedGarber A, Garabedian P, Wu L
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
This study’s objective was to describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. The interventions to be developed were a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. After initial refinement from an analysis, final requirements were created for 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses including the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. An analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers identified included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).
AHRQ-funded; HS026613.
Citation: Garber A, Garabedian P, Wu L .
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
JAMIA Open 2023 Jul; 6(2):ooad031. doi: 10.1093/jamiaopen/ooad031..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety
Bradford A, Goeschel C, Shofer M
AHRQ Author: Shofer M
Five new ways to advance diagnostic safety in your clinical practice.
This AHRQ-authored article describes new resources that clinicians can use to advance diagnostic safety and prevent errors. The new AHRQ-funded resources include Calibrate Dx, Measure Dx, Safer Dx Checklist, TeamSTEPPS for Diagnostic Improvements, and the Toolkit for Engaging Patients to Improve Diagnostic Safety. A table is provided which describes the resource, gives an example or strategy or practice change, and describes the audience for the resource. Recommendations are also given to help clinicians reduce barriers to diagnostic safety including: 1) Start small and focused; 2) Align with other high-priority initiatives; 3) Start with the resources you have; and 4) Consider how diagnostic safety work can enhance missions other than clinical care.
AHRQ-authored.
Citation: Bradford A, Goeschel C, Shofer M .
Five new ways to advance diagnostic safety in your clinical practice.
Am Fam Physician 2023 Jul; 108(1):14-16..
Keywords: Diagnostic Safety and Quality, Patient Safety
Congdon M, Rauch B, Carroll B
Opportunities for diagnostic improvement among pediatric hospital readmissions.
The purpose of this retrospective cohort study was to: 1) identify and describe diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs) in general pediatric patients who experienced hospital readmission, 2) outline improvement opportunities, and 3) explore factors associated with increased risk of MOID. The researchers included unplanned readmissions within 15 days of discharge from a freestanding children's hospital between October 2018 and September 2020. Health records were reviewed and discussed by practicing inpatient physicians to identify MOIDs using SaferDx, an established instrument. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. The study found that MOIDs were identified in 6.3% of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (50%) and failure to order needed test (45%). Patients with MOIDs were older than patients without MOIDs but similar in gender, primary language, race, ethnicity, and insurance type. The researchers did not identify conditions related with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID.
AHRQ-funded; HS028682.
Citation: Congdon M, Rauch B, Carroll B .
Opportunities for diagnostic improvement among pediatric hospital readmissions.
Hosp Pediatr 2023 Jul; 13(7):563-71. doi: 10.1542/hpeds.2023-007157..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Hospitals, Hospital Readmissions
Michelson KA, Bachur RG, Grubenhoff JA
Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals.
This study’s objective was to determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), or sepsis. The authors evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients included had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. The authors compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. They analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with a missed appendicitis or DKA diagnosis had more hospital days and readmissions, but there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage or perforated appendicitis. Those with missed DKA were more likely to have cerebral edema, mechanical ventilation, or death. Those with missed sepsis were less likely to have mechanical ventilation.
AHRQ-funded; HS026503.
Citation: Michelson KA, Bachur RG, Grubenhoff JA .
Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals.
J Emerg Med 2023 Jul; 65(1):e9-e18. doi: 10.1016/j.jemermed.2023.04.006..
Keywords: Children/Adolescents, Sepsis, Diabetes, Diagnostic Safety and Quality
Wretman CJ, Boynton MH, Preisser JS
Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: a discrete choice experiment.
The purpose of this study was to address the overdiagnosis of UTIs in nursing home residents as a significant public health threat by exploring which patient-level information was related with the overdiagnosis. The study found that the results of urinalyses and lower urinary tract status were most related with the overdiagnosis of UTIs.
AHRQ-funded; HS024519.
Citation: Wretman CJ, Boynton MH, Preisser JS .
Patient-level information underlying overdiagnosis of urinary tract infections in nursing homes: a discrete choice experiment.
Infect Control Hosp Epidemiol 2023 Jul; 44(7):1151-54. doi: 10.1017/ice.2022.171..
Keywords: Urinary Tract Infection (UTI), Nursing Homes, Long-Term Care, Diagnostic Safety and Quality, Elderly
Mehta SD, Congdo M, Phillips CA
Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.
This study’s objective was to apply diagnostic process improvement frameworks to identify missed opportunities for improvement in diagnosis (MOID) in pediatric emergency transfers (ETs) and evaluate their association with outcomes. ET is defined as hospitalized patients who require ICU interventions within 1 hour of ICU transfer, which is a proximal measure of late recognition associated with increased mortality and length of stay (LOS). This single-center retrospective cohort study was conducted from January 2015 to June 2019. Primary outcome was the presence of missed opportunities for improvement in diagnosis (MOID), determined using SaferDx. MOID was identified in 37 of 129 ETs (29%). Cases with MOID differed in originating service, but not demographically, with failure to recognize urgency of an identified condition the most common diagnostic process opportunity. ET cases with MOID had higher odds of mortality and longer post-transfer LOS.
AHRQ-funded; HS028682.
Citation: Mehta SD, Congdo M, Phillips CA .
Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.
J Hosp Med 2023 Jun; 18(6):509-18. doi: 10.1002/jhm.13103..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Intensive Care Unit (ICU)
Auerbach AD, Astik GJ, O'Leary KJ
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.
During the COVID-19 pandemic, clinicians were required to address a disease with continuously changing traits while simultaneously complying with changes in care (e.g., physical distancing) that could contribute to diagnostic errors (DEs). The purpose of this study was to examine the frequency of DEs and their causes in patients hospitalized under investigation (PUI) for COVID-19. The researchers randomly selected up to 8 cases per site per month for evaluation, with each case evaluated by two clinicians to determine whether a DE occurred, and whether any diagnostic process faults took place. The study found that wo hundred and fifty-seven patient charts were evaluated, of which 14% contained a DE. Patients with and without DE were statistically similar in socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. The most common diagnostic process issues contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination. Diagnostic process issues related with COVID-19 policies and procedures were not related with DE risk. 35.9% of patients with errors and 5.4% of patients overall suffered harm or death due to diagnostic error.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Astik GJ, O'Leary KJ .
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.
J Gen Intern Med 2023 Jun; 38(8):1902-10. doi: 10.1007/s11606-023-08176-6..
Keywords: COVID-19, Diagnostic Safety and Quality, Hospitals, Inpatient Care, Quality of Care
Michelson KA, McGarghan FLE, Patterson EE
Clinician factors associated with delayed diagnosis of appendicitis.
The purpose of this study was to assess the relationship of clinician demographics and practice patterns with delayed appendicitis diagnosis. The researchers included children presenting with appendicitis at 13 regional emergency departments (EDs), screening patients for delayed diagnosis through a chart review for a previous ED visit within 7 days. The study found that among 7,452 children with appendicitis, 1.4% (105) had delayed diagnosis. Clinicians who used more blood tests in their general practice had a lower risk of delayed diagnosis of appendicitis. Clinicians' specialty, gender, rates of imaging, and experience were not related with delayed diagnosis.
AHRQ-funded; HS026503.
Citation: Michelson KA, McGarghan FLE, Patterson EE .
Clinician factors associated with delayed diagnosis of appendicitis.
Diagnosis 2023 May; 10(2):183-86. doi: 10.1515/dx-2022-0119..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Emergency Department
Petragallo R, Bertram P, Halvorsen P
Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images.
In image-guided radiotherapy (IGRT), lack of correct alignment to the vertebral body continues to be a rare but serious risk to patient safety. The researchers propose that an automated image-review algorithm be included in the IGRT process as an interlock to detect off-by-one vertebral body errors. The purpose of this study was to describe the development and validation of a convolutional neural network (CNN)-based approach for an automated image-review algorithm using patient image data from a planar stereoscopic x-ray IGRT system. The researchers collected X-rays and digitally reconstructed radiographs (DRRs) from 429 spine radiotherapy patients treated using a stereoscopic x-ray image guidance system. True-negative, "no-error" cases were established using clinically-applied, physician approved alignments. "Off-by-one vertebral body" errors were simulated by translating DRRs along the spinal column using a semi-automated method. A leave-one-institution-out method was utilized to estimate the accuracy of the model on data from unseen institutions as follows: every image from five of the institutions was used to train a CNN model from scratch. The size of the resulting training set ranged from 5700 to 9372 images, and was dependent on which five institutions had contributed data. The training set was randomized and split using a 75/25 split into the final training/ validation sets. X-ray/ DRR image pairs and the related labels of "no-error" or "shift" were used as the model input. Accuracy of the model was assessed utilizing images from the sixth institution, which was omitted from the training phase. This test set ranged from 180 to 3852 images, again depending on which institution had been left out of the training phase. The trained model was utilized to categorize the images from the test set as either "no-error" or "shifted", and the model predictions were compared to the ground truth labels to evaluate model accuracy. This process was repeated until the images of each institution had been utilized as the testing dataset. The study found that when the six models were utilized to categorize unseen image pairs from the institution omitted during training, the resulting receiver operating characteristic area under the curve values ranged from 0.976 to 0.998.
AHRQ-funded; HS026486.
Citation: Petragallo R, Bertram P, Halvorsen P .
Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images.
Med Phys 2023 May; 50(5):2662-71. doi: 10.1002/mp.16359..
Keywords: Imaging, Patient Safety, Diagnostic Safety and Quality
Dhudasia MB, Benitz WE, Flannery DD
Diagnostic performance and patient outcomes with c-reactive protein use in early-onset sepsis evaluations.
This study’s objective was to determine performance of C-reactive protein (CRP) in the diagnosis of early-onset sepsis, and to assess patient outcomes with and without routine use of CRP in infants in the neonatal intensive care unit (NICU). This retrospective cohort study looked at infants admitted to 2 NICUs from 2009 to 2014. During the time period, 10,134 infants were admitted, 89.9% had CRP, and 74.5% had blood culture obtained within 3 days of birth. CRP obtained plus/minus 4 hours had a sensitivity of 41.7%, specificity 89.9%, and positive likelihood ratio 4.12 in diagnosis of early-onset sepsis. When obtained 24-72 hours after blood culture, sensitivity of CRP increased significantly (89.5%), but specificity (55.7%) and positive likelihood ratio (2.02) decreased. Comparing the periods with (n = 4977) and without (n = 5135) routine use of CRP, the authors observed lower rates of early-onset sepsis evaluation (74.5% vs 50.5%), antibiotic initiation (65.0% vs 50.8%), and antibiotic prolongation in the absence of early-onset sepsis (17.3% vs 7.2%) in the later period.
AHRQ-funded; HS027468.
Citation: Dhudasia MB, Benitz WE, Flannery DD .
Diagnostic performance and patient outcomes with c-reactive protein use in early-onset sepsis evaluations.
J Pediatr 2023 May; 256:98-104.e6. doi: 10.1016/j.jpeds.2022.12.007..
Keywords: Newborns/Infants, Sepsis, Diagnostic Safety and Quality
Le P, Payne JY, Zhang L
Disease state transition probabilities across the spectrum of NAFLD: a systematic review and meta-analysis of paired biopsy or imaging studies.
This paper is a meta-analysis that summarized the rates of progression to and regression of nonalcoholic fatty liver (NAFL), nonalcoholic steatohepatitis (NASH), and fibrosis in adults with nonalcoholic fatty liver disease (NAFLD). PubMed/MEDLINE and 4 other databases were searched from 1985 to 2020. The authors included observational studies and randomized controlled trials in any language that used liver biopsy or imaging to diagnose NAFLD in adults with a follow-up period of ≥48 weeks. They screened 9744 articles and included 54 studies involving 26,738 patients. Among observational studies, 20% of healthy adults developed NAFL while 21% of people with fatty liver had resolution of NAFL after a median of approximately 4.5 years. In addition, 31% of patients developed NASH after 4.7 years, whereas in 29% of those with NASH, resolution occurred after a median of 3.5 years. Fibrosis stages range from F0 to F3, and time to progression by 1 fibrosis stage was 9.9, 10.3, 13.3, and 22.2 years for F0, F1, F2, and F3, respectively. In reverse, time to regress by 1 stage was 21.3, 12.5, 20.4, and 40.0 years for F4, F3, F2, and F1, respectively.
AHRQ-funded; HS026937.
Citation: Le P, Payne JY, Zhang L .
Disease state transition probabilities across the spectrum of NAFLD: a systematic review and meta-analysis of paired biopsy or imaging studies.
Clin Gastroenterol Hepatol 2023 May; 21(5):1154-68. doi: 10.1016/j.cgh.2022.07.033..
Keywords: Imaging, Diagnostic Safety and Quality
Sloane JF, Donkin C, Newell BR
Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.
This article presented a modified model of interruptions to visualize the interruption process and to illustrate where potential interventions could be implemented. The authors considered empirically tested strategies from health care and cognitive psychology to lay the groundwork for additional research to mitigate effects of interruptions during diagnostic decision-making. Strategies to minimize the negative impacts of interruptions as well as strategies to prevent interruptions were highlighted, and the authors built upon these strategies to propose research priorities within the field of diagnostic safety.
AHRQ-funded; 233201500022I.
Citation: Sloane JF, Donkin C, Newell BR .
Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.
J Gen Intern Med 2023 May; 38(6):1526-31. doi: 10.1007/s11606-022-08019-w..
Keywords: Diagnostic Safety and Quality, Decision Making
Prasad PA, Correia J, Fang MC
Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19.
The purpose of this study was to determine whether sepsis risk stratification scores can predict poor outcomes among hospitalized COVID-19 patients. The researchers retrospectively evaluated a cohort of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare emergency departments (Eds) from March 2, 2020, to February 11, 2021. The study administered the Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at patient presentation. The primary outcome was in-hospital mortality, and secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. The study identified 90,376 patients with community-acquired COVID-19. 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality, followed by ICU admission, mechanical ventilation, and vasopressor receipt. The researchers concluded that sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use.
AHRQ-funded; HS027369.
Citation: Prasad PA, Correia J, Fang MC .
Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19.
J Hosp Med 2023 May; 18(5):413-23. doi: 10.1002/jhm.13106..
Keywords: COVID-19, Emergency Department, Diagnostic Safety and Quality
Krevat SA, Samuel S, Boxley C
Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis.
The purpose of this study was to evaluate legal claims data to assess whether there is a relationship between problems with electronic health records and diagnostic errors. The researchers also explored specific types of errors that took place and at which point in the diagnostic process the errors occurred.
AHRQ-funded; HS027119.
Citation: Krevat SA, Samuel S, Boxley C .
Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis.
JAMA Netw Open 2023 Apr 3; 6(4):e238399. doi: 10.1001/jamanetworkopen.2023.8399..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality
Bell SK, Dong ZJ, Desroches CM
Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.
Involving patients and their families in the diagnostic process is crucial, but there is a lack of methods for consistent engagement. The implementation of policies providing patients with access to electronic health records offers new possibilities. The researchers evaluated a novel online tool ("OurDX"), co-created with patients and families, to examine the nature and frequency of potential safety issues identified by patients and their families with chronic health conditions and whether these insights were incorporated into visit notes. At two US healthcare facilities, patients and their families were encouraged to participate via an online pre-visit questionnaire, which covered: (1) visit priorities, (2) recent medical history and symptoms, and (3) potential diagnostic concerns. Two physicians assessed patient-reported diagnostic issues to validate and classify diagnostic safety opportunities (DSOs). The researchers performed a chart review to determine if patient inputs were integrated into the visit note. Descriptive statistics were employed to report implementation outcomes, DSO verification, and chart review findings. The study found that OurDX reports were completed in 7075 of 18,129 (39%) eligible pediatric subspecialty visits (site 1) and 460 of 706 (65%) eligible adult primary care visits (site 2). Of the patients expressing diagnostic concerns, 63% were confirmed as probable DSOs. Overall, 7.5% of pediatric and adult patients and their families with chronic health conditions identified probable DSOs. The most frequent DSO types included patients and families feeling unheard; issues or delays in tests or referrals; and complications or delays in clarification or subsequent steps. The chart review revealed that most clinician notes incorporated all or some of the patient or family priorities and patient-reported histories.
AHRQ-funded; HS027367
Citation: Bell SK, Dong ZJ, Desroches CM .
Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.
J Am Med Inform Assoc 2023 Mar 16;30(4):692-702. doi: 10.1093/jamia/ocad003.
Keywords: Chronic Conditions, Diagnostic Safety and Quality, Health Information Technology (HIT), Patient and Family Engagement, Healthcare Delivery
Tabatneck ME, He W, Lamb GS
Interferon gamma release asssay results and testing trends among patients younger than 2 years old at two US health centers.
Researchers performed a retrospective cohort study of interferon-gamma release assay (IGRA) use for the diagnosis of tuberculosis infection in patients under 2 years old in two large Boston healthcare systems. A total of 321 IGRA results were analyzed; over 90 percent were valid. The proportion of invalid/indeterminate results was found to be significantly higher among immunocompromised patients. The researchers concluded that the high proportion of valid IGRA test results in patients less than 2 years of age in a low TB prevalence setting supported the adoption of IGRAs for this age group in certain clinical scenarios. They note that the interpretation of IGRAs, particularly in immunocompromised patients, should consider the broader clinical context.
AHRQ-funded; HS000063.
Citation: Tabatneck ME, He W, Lamb GS .
Interferon gamma release asssay results and testing trends among patients younger than 2 years old at two US health centers.
Pediatr Infect Dis J 2023 Mar; 42(3):189-94. doi: 10.1097/inf.0000000000003794..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Infectious Diseases
Ho TH, Bissell MCS, Lee CI
Prioritizing screening mammograms for immediate interpretation and diagnostic evaluation on the basis of risk for recall.
The purpose of this study was to establish a prioritization method for immediate interpretation of screening mammograms and potential diagnostic assessment. A cohort based on the population, comprising screening mammograms conducted from 2012 to 2020 at 126 radiology centers from 7 Breast Cancer Surveillance Consortium registries, was examined. Classification trees were used to identify combinations of clinical history (age, BI-RADS density, time elapsed since the previous mammogram, history of false-positive recall or biopsy outcome), screening technique (digital mammography, digital breast tomosynthesis), and facility features (profit status, location, screening volume, practice type, academic affiliation) that grouped screening mammograms by recall rate, with ≥12/100 classified as high and ≥16/100 as very high. The efficiency ratio was calculated as the percentage of recalls divided by the percentage of mammograms. The research cohort consisted of 2,674,051 screening mammograms in 925,777 women, with 235,569 recalls. The study found that the primary predictor of recall was the time interval since the last mammogram, followed by age, history of false-positive recall, breast density, history of benign biopsy, and screening method. Recall rates were extremely high for baseline mammograms and high for women with ≥5 years since their previous mammogram. The 9.2% of mammograms in subgroups with very high and high recall rates represented 19.2% of recalls, yielding an efficiency ratio of 2.1 compared to a random strategy. Including women under 50 with dense breasts accounted for 20.3% of mammograms and 33.9% of recalls (efficiency ratio = 1.7). Findings incorporating facility-level characteristics were analogous.
AHRQ-funded; HS018366
Citation: Ho TH, Bissell MCS, Lee CI .
Prioritizing screening mammograms for immediate interpretation and diagnostic evaluation on the basis of risk for recall.
J Am Coll Radiol 2023 Mar;20(3):299-310. doi: 10.1016/j.jacr.2022.09.030.
Keywords: Cancer: Breast Cancer, Cancer, Screening, Imaging, Women, Prevention, Diagnostic Safety and Quality
Liberman AL, Holl JL, Romo E
Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.
The authors conducted a failure modes, effects, and criticality analysis (FMECA) of the emergency department (ED)-based acute stroke diagnostic process at three health systems in Chicago. The FMECA was designed to identify and rank order failures in the processes of care. The authors found that failure to use existing screening scales to identify patients with large-vessel occlusions early in the ED course ranked highest; other highly ranked failures were obtaining an accurate history of the index event, suspecting acute stroke in triage, and using established stroke screening tools at ED arrival to identify potential stroke patients. They concluded that these results highlight the crucial importance of the first steps in the diagnostic process.
AHRQ-funded; HS025359; HS027264.
Citation: Liberman AL, Holl JL, Romo E .
Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.
Acad Emerg Med 2023 Mar; 30(3):187-95. doi: 10.1111/acem.14648..
Keywords: Stroke, Cardiovascular Conditions, Diagnostic Safety and Quality
Michelson KA, Bachur RG, Dart AH
Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study.
This study’s objective was to derive and validate a tool that retrospectively identifies delayed diagnosis of pediatric appendicitis in administrative data with high accuracy. A cross-sectional study of five pediatric emergency departments (EDs) was conducted using a cohort of 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis. Delayed diagnosis occurred in 70.4% of patients. The tool had an area under the curve (AUC) of 0.892 in the derivation group and 0.859 in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% and identified 46.8% of delayed cases.
AHRQ-funded; HS026503.
Citation: Michelson KA, Bachur RG, Dart AH .
Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study.
BMJ Open 2023 Feb 28;13(2):e064852. doi: 10.1136/bmjopen-2022-064852.
Keywords: Children/Adolescents, Diagnostic Safety and Quality
Miller AC, Arakkal AT, Koeneman SH
A clinically-guided unsupervised clustering approach to recommend symptoms of disease associated with diagnostic opportunities.
The authors proposed a methodological approach to finding diagnostic codes that exhibit known patterns of diagnostic delays. IBM MarketScan Research Databases were used to analyze diagnosis codes during healthcare visits before the index diagnosis for two conditions: tuberculosis and appendicitis. The authors concluded that their approach could mine administrative datasets to detect patterns of diagnostic delay, help avoid under-identifying potential missed diagnostic opportunities, and be used to discover less-common presentations of frequently misdiagnosed conditions.
AHRQ-funded; HS027375.
Citation: Miller AC, Arakkal AT, Koeneman SH .
A clinically-guided unsupervised clustering approach to recommend symptoms of disease associated with diagnostic opportunities.
Diagnosis 2023 Feb; 10(1):43-53. doi: 10.1515/dx-2022-0044..
Keywords: Diagnostic Safety and Quality
Coley RY, Smith JJ, Karliner L RY, Smith JJ, Karliner L
External validation of the eRADAR risk score for detecting undiagnosed dementia in two real-world healthcare systems.
Drupal date: Feb, 2023
It is estimated that half of the individuals with dementia remain undiagnosed. The electronic health record (EHR) Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) was designed to detect older adults at risk of undiagnosed dementia using routinely gathered clinical information. The purpose of this retrospective cohort study was to externally validate eRADAR in two real-world healthcare systems, examining its performance over time and across race/ethnicity. The study found a total of 7631 dementia diagnoses were observed at KPWA and 216 at UCSF. The area under the curve was 0.84 (95% confidence interval: 0.84-0.85) at KPWA and 0.79 (0.76-0.82) at UCSF. Using the 90th percentile as the cut point for identifying high-risk patients, sensitivity was 54% (53-56%) at KPWA and 44% (38-51%) at UCSF. Performance was consistent over time, including across the transition from International Classification of Diseases, version 9 (ICD-9) to ICD-10 codes, and across racial/ethnic groups (although small samples limited precision in some groups). The study concluded that eRADAR demonstrated strong external validity for identifying undiagnosed dementia in two healthcare systems with diverse patient populations and varying availability of external healthcare data for risk calculations. This study showed that eRADAR is generalizable from a research sample to real-world clinical populations, transportable across health systems, resilient to temporal changes in healthcare, and exhibits similar performance across major racial/ethnic groups.
It is estimated that half of the individuals with dementia remain undiagnosed. The electronic health record (EHR) Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) was designed to detect older adults at risk of undiagnosed dementia using routinely gathered clinical information. The purpose of this retrospective cohort study was to externally validate eRADAR in two real-world healthcare systems, examining its performance over time and across race/ethnicity. The study found a total of 7631 dementia diagnoses were observed at KPWA and 216 at UCSF. The area under the curve was 0.84 (95% confidence interval: 0.84-0.85) at KPWA and 0.79 (0.76-0.82) at UCSF. Using the 90th percentile as the cut point for identifying high-risk patients, sensitivity was 54% (53-56%) at KPWA and 44% (38-51%) at UCSF. Performance was consistent over time, including across the transition from International Classification of Diseases, version 9 (ICD-9) to ICD-10 codes, and across racial/ethnic groups (although small samples limited precision in some groups). The study concluded that eRADAR demonstrated strong external validity for identifying undiagnosed dementia in two healthcare systems with diverse patient populations and varying availability of external healthcare data for risk calculations. This study showed that eRADAR is generalizable from a research sample to real-world clinical populations, transportable across health systems, resilient to temporal changes in healthcare, and exhibits similar performance across major racial/ethnic groups.
AHRQ-funded; HS026369.
Citation: Coley RY, Smith JJ, Karliner L RY, Smith JJ, Karliner L .
External validation of the eRADAR risk score for detecting undiagnosed dementia in two real-world healthcare systems.
J Gen Intern Med 2023 Feb; 38(2):351-60. doi: 10.1007/s11606-022-07736-6..
Keywords: Dementia, Neurological Disorders, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT)
Chiotos K, Marshall D, Kellom K
Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.
The purpose of this study was to perform an evaluation of a diagnostic stewardship initiative for respiratory culture in the healthcare setting within a pediatric intensive care unit (PICU) in a tertiary-care center. The study found that the frequency of culture collection per day of service differed among attending physicians, ranging from 2.2 to 27 cultures per 100 days. A total of 14 interviews were conducted, and 87 clinicians (response rate: 47%) along with 77 nurses or respiratory therapists (response rate: 17%) participated in the survey. There was a variation in clinicians' stated practices concerning culture ordering, which was influenced by both their specialty and their perception of the respiratory culture's usefulness. Additionally, group "default" practices, fear, and hierarchy affected the decision to order cultures. Obstacles to standardization encompassed concerns about missing a diagnosis and the conflict between standardized practices and individual judgment.
AHRQ-funded; HS026393.
Citation: Chiotos K, Marshall D, Kellom K .
Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention.
Infect Control Hosp Epidemiol 2023 Feb; 44(2):191-99. doi: 10.1017/ice.2022.299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Antibiotics, Medication, Antimicrobial Stewardship, Intensive Care Unit (ICU)
Acharya C, Shaw J, Duong N
QuickStroop, a shortened version of EncephalApp, detects covert hepatic Encephalopathy with similar accuracy within one minute.
This study sought to determine whether QuickStroop, a shortened version of EncephalApp, can detect covert hepatic encephalopathy (CHE) as accurately and quickly as psychometric hepatic encephalopathy score (PHES), the gold standard for CHE testing. Data was analyzed for a total of 398 individual runs versus total EncephalApp time versus PHES-CHE split into training (n = 299) and test (n = 99) sets. The validation cohort showed an accuracy of 84% to diagnose PHES-CHE. Time for CHE diagnosis decreased from 203.7 to 36.8 seconds in the derivation and from 178.2 to 32.9 seconds in the validation cohort.
AHRQ-funded; HS025412.
Citation: Acharya C, Shaw J, Duong N .
QuickStroop, a shortened version of EncephalApp, detects covert hepatic Encephalopathy with similar accuracy within one minute.
Clin Gastroenterol Hepatol 2023 Jan;21(1):136-42. doi: 10.1016/j.cgh.2021.12.047..
Keywords: Diagnostic Safety and Quality
Peng L, Luo G, Walker A
Evaluation of federated learning variations for COVID-19 diagnosis using chest radiographs from 42 US and European hospitals.
The goals of this study were to compare a single-site, COVID-19 computer diagnosis system that used the Federated Averaging (FedAvg) algorithm with 3-client Federated learning (FL) models, and to evaluate the performance of the four FL variations. Researchers leveraged a FL healthcare collaborative that included data from five US and European healthcare systems encompassing 42 hospitals. They concluded that FedAvg could significantly improve generalization of the model in comparison with other personalization FL algorithms--FedProx, FedBN, and FedAMP--but at the cost of poor internal validity.
AHRQ-funded; HS026379.
Citation: Peng L, Luo G, Walker A .
Evaluation of federated learning variations for COVID-19 diagnosis using chest radiographs from 42 US and European hospitals.
J Am Med Inform Assoc 2022 Dec 13;30(1):54-63. doi: 10.1093/jamia/ocac188..
Keywords: COVID-19, Diagnostic Safety and Quality, Imaging, Hospitals
Giardina TD, Hunte H, Hill MA
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
This study looked at peer-reviewed published literature to explore how researchers operationalize the National Academies of Science, Engineering, and Medicine’s (NASEM) definition of diagnostic error that was defined in their 2015 publication “Improving Diagnosis in Health Care”. Published literature was identified from October 2015 to February 2021. The authors also conducted subject matter expert interviews. Of the 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by four themes: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies identified used the NASM definition. Five of those studies also operationalized with existing definitions proposed before the NASEM report, four operationalized the components of the NASEM definition, and three studies operationalized error using existing definitions only. Subject matter experts concluded that the NASEM definition functions as a foundation for researchers to conceptualize diagnostic error.
AHRQ-funded; 233201500022I; HS027280; HS025474; HS027363.
Citation: Giardina TD, Hunte H, Hill MA .
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
J Patient Saf 2022 Dec 1;18(8):770-78. doi: 10.1097/pts.0000000000000999..
Keywords: Diagnostic Safety and Quality, Quality of Care, Medical Errors, Adverse Events, Healthcare Delivery