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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
1 to 25 of 553 Research Studies DisplayedBartsch SM, Weatherwax C, Martinez MF
Cost-effectiveness of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing and isolation strategies in nursing homes.
This study examined the question when and how often nursing homes should test staff for COVID-19 and how this may change as severe acute respiratory coronavirus virus 2 (SARS-CoV-2) evolves. In winter 2023-2024, when the SARS-CoV-2 omicron variant was prevalent, symptom-based antigen testing averted 4.5 COVID-19 cases compared to no testing, saving $191 in direct medical costs. Testing implementation costs far outweighed these savings, resulting in net costs of $990 from the CMS perspective, $1,545 from the third-party payer perspective, and $57,155 from the societal perspective. Testing did not return sufficient positive health effects to make it cost-effective, but it exceeded this threshold in ≥59% of simulation trials. However, if conditions changed to make a severe outcome risk ≥3 times higher than that of current omicron variants, all antigen testing strategies became cost-effective (≤$31,906 per QALY) or cost saving (saving ≤$18,372).
AHRQ-funded; HS028165.
Citation: Bartsch SM, Weatherwax C, Martinez MF .
Cost-effectiveness of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing and isolation strategies in nursing homes.
Infect Control Hosp Epidemiol 2024 Jun; 45(6):754-61. doi: 10.1017/ice.2024.9..
Keywords: COVID-19, Healthcare Costs, Nursing Homes, Diagnostic Safety and Quality
Campbell KA, Sternberg SB, Benneyan J
Completion rates and timeliness of diagnostic colonoscopies for rectal bleeding in primary care.
This study looked at the completion rates and timeliness of diagnostic colonoscopies for rectal bleeding in primary care, as rectal bleeding is usually the most common presenting symptom of colorectal cancer. This retrospective cohort study was a medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices-an urban academic practice and affiliated community health center-between January 1, 2018, and December 31, 2020. Primary outcomes were percentages of patient cases classified as having completed recommended follow-up workup ("closed loop") vs. not ("open loop"). A total of 837 patients had been coded with rectal bleeding, with 67 excluded leaving 770 patients included. A total of 172 patients (22.3%) failed to undergo timely recommended workup. Reasons for a failed timely workup included the majority not having a procedure ordered, or the procedure was ordered but never scheduled or cancelled and not kept.
AHRQ-funded; HS027282.
Citation: Campbell KA, Sternberg SB, Benneyan J .
Completion rates and timeliness of diagnostic colonoscopies for rectal bleeding in primary care.
J Gen Intern Med 2024 May; 39(6):985-91. doi: 10.1007/s11606-023-08513-9..
Keywords: Diagnostic Safety and Quality, Screening, Cancer: Colorectal Cancer, Primary Care, Prevention, Cancer
Tokede B, Brandon R, Lee CT
Development and validation of a rule-based algorithm to identify periodontal diagnosis using structured electronic health record data.
This article describes the development and validation of an automated electronic health record (EHR) based algorithm to suggest a periodontal diagnosis. It was based on materials from the 2017 World Workshop on the Classification of Periodontal Diseases and Conditions. Findings suggested that a rule-based algorithm using EHR data can be implemented with moderate accuracy in support of chairside clinical diagnostic decision making, and may be particularly useful for inexperienced clinicians. The authors noted that grey-zone cases where clinical judgement will be required still exist and that future applications of similar algorithms will depend upon the quality of EHR data.
AHRQ-funded; HS027938.
Citation: Tokede B, Brandon R, Lee CT .
Development and validation of a rule-based algorithm to identify periodontal diagnosis using structured electronic health record data.
J Clin Periodontol 2024 May; 51(5):547-57. doi: 10.1111/jcpe.13938..
Keywords: Dental and Oral Health, Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality
Manojlovich M, Bettencourt AP, Mangus CW
Refining a framework to enhance communication in the emergency department during the diagnostic process: an edelphi approach.
This study’s goal was to examine the entire diagnostic process in the emergency department (ED) using eDelphi methodology to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. The authors developed a final framework that positioned communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. The process identified two specific types of communication-information exchange and shared understanding̲-as high priority for optimal outcomes. There were three categories identified for ideas for communication-focused interviews to prevent diagnosis error in the ED: patient-facing, clinician-facing, and system-facing interventions.
AHRQ-funded; HS028375.
Citation: Manojlovich M, Bettencourt AP, Mangus CW .
Refining a framework to enhance communication in the emergency department during the diagnostic process: an edelphi approach.
Jt Comm J Qual Patient Saf 2024 May; 50(5):348-56. doi: 10.1016/j.jcjq.2024.01.013..
Keywords: Emergency Department, Clinician-Patient Communication, Communication, Diagnostic Safety and Quality
Michelson KA, Rees CA, Florin TA
Emergency department volume and delayed diagnosis of serious pediatric conditions.
The objective of this retrospective cohort study was to evaluate the association between annual pediatric volume in emergency departments (EDs) with delayed diagnosis. Subjects were children under 18 treated at 954 EDs in eight states with a first-time diagnosis of any of 23 acute, serious conditions, identified using HCUP State ED and Inpatient databases. The findings indicated that EDs with fewer pediatric encounters had more possible delayed diagnoses across all 23 conditions; there were decreased rates of possible delayed diagnosis with increasing ED volume for 21 of 23 conditions. The authors concluded that tools to support timely diagnosis in low-volume EDs are needed.
AHRQ-funded; HS026503.
Citation: Michelson KA, Rees CA, Florin TA .
Emergency department volume and delayed diagnosis of serious pediatric conditions.
JAMA Pediatr 2024 Apr; 178(4):362-68. doi: 10.1001/jamapediatrics.2023.6672..
Keywords: Children/Adolescents, Emergency Department, Diagnostic Safety and Quality
Auerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Ali KJ, Goeschel CA, Eckroade MM
The TeamSTEPPS for improving diagnosis team assessment tool: scale development and psychometric evaluation.
The authors developed and evaluated the TeamSTEPPS Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical domains. The TAT was administered as a cross-sectional survey to health professionals in nine diverse US health systems. A psychometric evaluation demonstrated that the TAT was a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The authors concluded that TAT added a novel, evidence-based measurement tool.
AHRQ-funded; 233201500022I.
Citation: Ali KJ, Goeschel CA, Eckroade MM .
The TeamSTEPPS for improving diagnosis team assessment tool: scale development and psychometric evaluation.
Jt Comm J Qual Patient Saf 2024 Feb; 50(2):95-103. doi: 10.1016/j.jcjq.2023.08.009..
Keywords: Diagnostic Safety and Quality, Teams, TeamSTEPPS
Gyftopoulos S, Simon E, Swartz JL
Efficacy and impact of a multimodal intervention on CT pulmonary angiography ordering behavior in the emergency department.
The objective of this study was to evaluate the efficacy of a multimodal intervention to reduce overutilization of computed tomography pulmonary angiography (CTPA) for suspected pulmonary embolism in the emergency department. Results indicated that guideline concordance increased significantly after intervention. The authors concluded that their success in increasing guideline concordance demonstrated the efficacy of a mixed-methods, human-centered approach to behavior change; however, given that neither of the secondary outcomes improved, the results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies.
AHRQ-funded; HS024376.
Citation: Gyftopoulos S, Simon E, Swartz JL .
Efficacy and impact of a multimodal intervention on CT pulmonary angiography ordering behavior in the emergency department.
J Am Coll Radiol 2024 Feb; 21(2):309-18. doi: 10.1016/j.jacr.2023.02.033.
Keywords: Emergency Department, Respiratory Conditions, Imaging, Diagnostic Safety and Quality, Blood Clots
Ali KJ, Goeschel CA, DeLia DM
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
The authors conducted a literature review and interviewed subject matter experts to develop a multi-component Payer Relationships for Improving Diagnoses (PRIDx) framework. The PRIDx framework can be used to encourage public and private payers to take specific actions to improve diagnostic safety. The authors noted that implementation of the PRIDx framework will require new types of partnerships, including external support from public and private payer organizations, and also require the creation of strong provider incentives.
AHRQ-funded; 2332015000221.
Citation: Ali KJ, Goeschel CA, DeLia DM .
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
https://www.pubmed.ncbi.nlm.nih.gov/37795579.
Keywords: Diagnostic Safety and Quality, Quality of Care, Patient Safety
Liu SK, Bourgeois F, Dong J
What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process.
This paper evaluated positive patient/family feedback to generate broader perspectives on what constitutes a "good" diagnostic process (DxP). Eligible participants included patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) who were then invited to complete a survey between December 2020 and March 2020. The authors adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words. A total of 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Positive feedback was provided by 1,578 participants, ranging from 1-79 words. Categories of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). In the Relationships category patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). For Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %).
AHRQ-funded; HS027367.
Citation: Liu SK, Bourgeois F, Dong J .
What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process.
Diagnosis 2024 Feb 1; 11(1):63-72. doi: 10.1515/dx-2023-0075.
Keywords: Diagnostic Safety and Quality, Clinician-Patient Communication, Communication, Patient and Family Engagement
Newman-Toker DE, Nassery N, Schaffer AC
Burden of serious harms from diagnostic error in the USA.
Americans who experience serious harm from misdiagnosis annually. Serious harm is defined as permanent morbidity or morality. This cross-sectional analysis used nationally representative observational data. The authors estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). US-based cancer registries were used to find annual new cancers. They derived diagnostic errors and serious harms by multiplying by literature-based rates for disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories). Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), they estimated total serious harms annually in the USA to be 795,000 (plausible range 598,000-1,023,000). Using more conservative assumptions they estimated 549,000 serious harms. These results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. Fifteen dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.
AHRQ-funded; HS027614; HS029350.
Citation: Newman-Toker DE, Nassery N, Schaffer AC .
Burden of serious harms from diagnostic error in the USA.
BMJ Qual Saf 2024 Jan 19; 33(2):109-20. doi: 10.1136/bmjqs-2021-014130..
Keywords: Healthcare Cost and Utilization Project (HCUP), Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality of Care, Adverse Events
Schnipper JL, Raffel KE, Keniston A
Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: a multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.
This paper describes the protocol for a study that will build surveillance for hospital diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates. The authors will test achieving diagnostic excellence through prevention and teamwork (ADEPT), a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. They will use a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. There will be surveillance for diagnostic errors on 10 events per month per site using a previously established two-person adjudication process. With guidance from national experts in quality and safety, study sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. The primary outcome sought after will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program.
AHRQ-funded; HS029366.
Citation: Schnipper JL, Raffel KE, Keniston A .
Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: a multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.
J Hosp Med 2023 Dec; 18(12):1072-81. doi: 10.1002/jhm.13230..
Keywords: Diagnostic Safety and Quality, Patient Safety, Quality of Care, Hospitals, Inpatient Care
Meiselbach MK, Bai G, Anderson GF
Charges of COVID-19 diagnostic testing and antibody testing across facility types and states.
The authors discuss the practice of high charges for COVID-19 testing by some healthcare providers, with the charges for COVID-19 testing having important implications for uninsured patients, out-of-network services, and other payers without negotiating power. The purpose of this study was to examine the charges for the most commonly performed COVID-19 diagnostic test and antibody test across facility types and states. The study found that for COVID-19 diagnostic testing, the mean, median, and standard deviations of charges were $144.06, $100.00, and $162.18. The most common facility type was independent laboratories (performing 49.7% of all tests), with an average charge of $140.41, followed by hospital outpatient settings (performing 34.5% of all tests), with an average charge of $168.87. For antibody testing, the mean, median, and standard deviations of charges were $63.93, $55.00, and $48.92. Independent laboratories performed 97.2% of all tests, with an average charge of $62.30. In sum, 8.0% of diagnostic testing services and 14.0% of antibody testing claims were charged one standard deviation above the mean ($306.24 for diagnostic testing and $112.85 for antibody testing). The state average testing charges ranged between $64.98 (UT) and $505.65 (DC) for diagnostic testing, and $45.85 (NY) and $195.41 (NM) for antibody testing. AR, LA, MO, and NM had high average charges for both tests. GA, KS, MA, MD, NC, NV, and OK had low charges for both tests. No statistically significant association was found between testing charges and state-level testing rates, infection rates, or mortality rates.
AHRQ-funded; HS000029.
Citation: Meiselbach MK, Bai G, Anderson GF .
Charges of COVID-19 diagnostic testing and antibody testing across facility types and states.
J Gen Intern Med 2023 Dec; 38(16):3640-43. doi: 10.1007/s11606-020-06198-y..
Keywords: COVID-19, Diagnostic Safety and Quality, Healthcare Costs
Michelson KA, Bachur RG, Rangel SJ
Emergency department volume and delayed diagnosis of pediatric appendicitis: a retrospective cohort study.
The objective of this study was to assess the association of emergency department (ED) volume of children and delayed appendicitis diagnoses and to compare complication rates by delayed diagnosis occurrence. HCUP data from eight states were studied on children under the age of 18 with appendicitis in all EDs. The results indicated that higher ED volumes were associated with lower risk of delayed diagnosis of pediatric appendicitis; delay was associated with complications.
AHRQ-funded; HS026503.
Citation: Michelson KA, Bachur RG, Rangel SJ .
Emergency department volume and delayed diagnosis of pediatric appendicitis: a retrospective cohort study.
Ann Surg 2023 Dec 1; 278(6):833-38. doi: 10.1097/sla.0000000000005972..
Keywords: Children/Adolescents, Emergency Department, Diagnostic Safety and Quality
Hasegawa S, Livorsi DJ, Perencevich EN S, Livorsi DJ, Perencevich EN
Diagnostic accuracy of hospital antibiograms in predicting the risk of antimicrobial resistance in enterobacteriaceae isolates: a nationwide multicenter evaluation at the Veterans Health Administration.
This study examined the effectiveness of an antibiogram to predict antimicrobial resistance (AMR) at the patient-level for Escherichia coli and Klebsiella spp. The authors retrospectively generated hospital antibiograms for the nationwide Veterans Health Administration (VHA) facilities from 2000 to 2019 using all clinical culture specimens positive for E. coli and Klebsiella spp., then assessed the diagnostic accuracy of an antibiogram to predict resistance for isolates in the following calendar year using logistic regression models and predefined 5-step interpretation thresholds. At 127 VHA facilities, the discrimination abilities of hospital-level antibiograms in predicting individual patient AMR were mostly poor, with the areas under the receiver operating curve at 0.686 and 0.715 for ceftriaxone, 0.637 and 0.675 for fluoroquinolones, and 0.576 and 0.624 for trimethoprim-sulfamethoxazole, respectively.
AHRQ-funded; HS027472.
Citation: Hasegawa S, Livorsi DJ, Perencevich EN S, Livorsi DJ, Perencevich EN .
Diagnostic accuracy of hospital antibiograms in predicting the risk of antimicrobial resistance in enterobacteriaceae isolates: a nationwide multicenter evaluation at the Veterans Health Administration.
Clin Infect Dis 2023 Nov 30; 77(11):1492-500. doi: 10.1093/cid/ciad467..
Keywords: Diagnostic Safety and Quality, Hospitals
Cifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Baghdadi JD, O'Hara LM, Johnson JK
Diagnostic stewardship to support optimal use of multiplex molecular respiratory panels: a survey from the Society for Healthcare Epidemiology of America Research Network.
This study’s objective was to explore current and future approaches to diagnostic stewardship of multiplex polymerase chain reaction (PCR) respiratory panels. The authors conducted a survey of the Society for Healthcare Epidemiology of America Research Network, with 41 sites completing the survey (response rate, 50%). Results of the survey were that multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Additionally, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1-4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites), with 3 sites reporting that education was “helpful” but with limitations.
AHRQ-funded; HS028854.
Citation: Baghdadi JD, O'Hara LM, Johnson JK .
Diagnostic stewardship to support optimal use of multiplex molecular respiratory panels: a survey from the Society for Healthcare Epidemiology of America Research Network.
Infect Control Hosp Epidemiol 2023 Nov; 44(11):1823-28. doi: 10.1017/ice.2023.72..
Keywords: Diagnostic Safety and Quality, Respiratory Conditions
Michelson KA, Bachur RG, Cruz AT
Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data.
The objectives of this study were to derive a method of automated identification of delayed diagnosis of two serious pediatric conditions in the emergency department (ED). Subjects were patients under the age of 21 who had two EDs encounters within 7 days, the second resulting in a diagnosis of new-onset diabetic ketoacidosis (DKA) or sepsis. The results showed that delayed diagnosis was present in 89 % of DKA patients seen twice within 7 days. 17 % of sepsis patients were deemed to have delayed diagnosis; the authors noted that many children with sepsis delayed diagnosis may be identified using the proposed approach with low specificity, indicating a need for manual case review. The fewer days between ED encounters was the most important characteristic associated with delayed diagnosis.
AHRQ-funded; HS026503.
Citation: Michelson KA, Bachur RG, Cruz AT .
Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data.
Diagnosis 2023 Nov; 10(4):383-89. doi: 10.1515/dx-2023-0019..
Keywords: Diabetes, Diagnostic Safety and Quality, Sepsis
Woods-Hill CZ, Koontz DW, Colantuoni EA
Sustainability of the Bright STAR diagnostic stewardship program to reduce blood culture rates among critically ill children.
From 2017 to2020, 14 pediatric intensive care units (PICUs) participated in the Bright STAR (Testing Stewardship for Antibiotic Reduction) QI collaborative to reduce unnecessary blood cultures for PICU patients. The collaborative project found that 4 sites demonstrated a 33% decrease in blood culture rates and a 13% decrease in broad spectrum antibiotic use. The purpose of this current study was to assess whether sites sustained reduced blood culture rates after completion of the formal project. The study found that all sites had lower blood culture rates during the sustainability period when compared with the pre-implementation period. The blood culture rate increased 8% during the sustainability period compared with the postimplementation period but was 27% lower than during the pre-implementation period.
AHRQ-funded; HS025642.
Citation: Woods-Hill CZ, Koontz DW, Colantuoni EA .
Sustainability of the Bright STAR diagnostic stewardship program to reduce blood culture rates among critically ill children.
JAMA Pediatr 2023 Nov; 177(11):1234-37. doi: 10.1001/jamapediatrics.2023.3229..
Keywords: Children/Adolescents, Critical Care, Quality Improvement, Diagnostic Safety and Quality, Quality of Care
Georgette N, Michelson K, Monuteaux M
A temperature- and age-adjusted shock index for emergency department identification of pediatric sepsis.
The objective of this retrospective cohort study was to derive a temperature- and age-adjusted mean shock index (TAMSI) for early identification of sepsis and septic shock in children with suspected infection. Researchers analyzed data on children who presented with suspected infection to a single emergency department over a 10-year period. Test characteristics for the TAMSI cutoffs were compared with those for the Pediatric Advanced Life Support (PALS) tachycardia or systolic hypotension cutoffs. The results showed that TAMSI achieved a similar negative likelihood ratio and improved positive likelihood ratio compared with PALS vital sign cutoffs for the prediction of septic shock, but did not improve on PALS for sepsis prediction among children with suspected infection.
AHRQ-funded; HS026503.
Citation: Georgette N, Michelson K, Monuteaux M .
A temperature- and age-adjusted shock index for emergency department identification of pediatric sepsis.
Ann Emerg Med 2023 Oct; 82(4):494-502. doi: 10.1016/j.annemergmed.2023.03.026..
Keywords: Children/Adolescents, Emergency Department, Sepsis, Diagnostic Safety and Quality
Gupta AB, Greene MT, Fowler KE
Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.
Hospitalists are frequently attending to multiple tasks when overseeing patient care, and patients are at risk for diagnostic errors. The purpose of this single-center, prospective, pilot observational study was to measure hospitalist workload and examine its influences on diagnostic performance in a real-world clinical setting. The researchers had hospitalists admitting new patients to the hospital complete an abbreviated Mindful Attention Awareness Tool and a survey on diagnostic confidence upon shift completion. Complete data were available for 37 unique hospitalists who admitted 160 unique patients. The study found that increases in admissions and pages were related with higher odds of hospitalists reporting it was "difficult to focus on what is happening in the present." Increased pages was associated with a decrease in the number of differential diagnoses listed.
AHRQ-funded; HS024385; HS025891.
Citation: Gupta AB, Greene MT, Fowler KE .
Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.
J Patient Saf 2023 Oct 1; 19(7):447-52. doi: 10.1097/pts.0000000000001157..
Keywords: Hospitals, Diagnostic Safety and Quality, Patient Safety
Bonner SN, Lagisetty K, Reddy RM
Clinical implications of removing race-corrected pulmonary function tests for African American patients requiring surgery for lung cancer.
This study’s objective was to identify how many hospitals providing lung cancer surgery use race correction in pulmonary function tests (PFTs), examine the association of race correction with predicted lung function, and test the effect of decorrection on surgeons' treatment recommendations. Percent predicted preoperative and postoperative forced expiratory volume in 1 second (FEV1) was calculated for African American patients who underwent lung cancer resection between January 1, 2015, and September 31, 2022, using race-corrected and race-neutral equations for hospitals performing race correction. Randomization of US cardiothoracic surgeons was conducted to receive 1 clinical vignette that differed by the use of Global Lung Function Initiative equations for (1) African American patients (percent predicted postoperative FEV1, 49%), (2) other race or multiracial patients (percent predicted postoperative FEV1, 45%), and (3) race-neutral patients (percent predicted postoperative FEV1, 42%). A total of 515 African American patients (308 [59.8%] female; mean age, 66.2 years) were included in the study. Among these patients, the percent predicted preoperative FEV1 and postoperative FEV1 would have decreased by 9.2% and 7.6%, respectively, if race-neutral equations had been used. A total of 225 surgeons (194 male [87.8%]; mean time in practice, 19.4 years) were successfully randomized and completed the vignette items regarding risk perception and treatment outcomes (76% completion rate). Surgeons randomized to the vignette with African American race-corrected PFTs were more likely to recommend lobectomy (79.2%) compared with surgeons randomized to the other race or multiracial-corrected (61.7%) or race-neutral PFTs (52.8%).
AHRQ-funded; HS028038.
Citation: Bonner SN, Lagisetty K, Reddy RM .
Clinical implications of removing race-corrected pulmonary function tests for African American patients requiring surgery for lung cancer.
JAMA Surg 2023 Oct; 158(10):1061-68. doi: 10.1001/jamasurg.2023.3239..
Keywords: Racial and Ethnic Minorities, Cancer: Lung Cancer, Cancer, Surgery, Diagnostic Safety and Quality
Bourgeois FC, Hart NJ, Dong Z
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
This study’s objective was to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage pediatric patients and their families in the diagnostic process (DxP). This cross-sectional study included 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, which was codeveloped and tested with patients and families. Patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns prior to each visit. The authors conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70) or "other" race (OR: 1.48) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53). No significant differences were found in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference.
AHRQ-funded; HS027367.
Citation: Bourgeois FC, Hart NJ, Dong Z .
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
Appl Clin Inform 2023 Oct; 14(5):903-12. doi: 10.1055/s-0043-1776055..
Keywords: Diagnostic Safety and Quality, Patient Safety, Racial and Ethnic Minorities
Evans NJ, Arakkal AT, Cavanaugh JE
The incidence, duration, risk factors, and age-based variation of missed opportunities to diagnose pertussis: a population-based cohort study.
This study’s objective was to estimate the incidence, duration and risk factors for diagnostic delays associated with pertussis. The authors used longitudinal retrospective insurance claims from the Marketscan Commercial Claims and Encounters, Medicare Supplemental (2001-2020), and Multi-State Medicaid (2014-2018) databases. They estimated the number of visits with pertussis-related symptoms before diagnosis beyond that expected in the absence of diagnostic delays, including the number of visits representing a delay, the number of missed diagnostic opportunities per patient, and the duration of delays. They identified 20,828 patients meeting inclusion criteria. On average, delay duration was 12 days, and patients had almost 2 missed opportunities prior to diagnosis. The duration of delays increased considerably with age from an average of 5.6 days for patients aged less than 2 years to 13.8 days for patients aged ≥18 years. Factors associated with increased risk of delays included recent prescriptions for antibiotics not effective against pertussis, emergency department visits, and telehealth visits.
AHRQ-funded; HS027375.
Citation: Evans NJ, Arakkal AT, Cavanaugh JE .
The incidence, duration, risk factors, and age-based variation of missed opportunities to diagnose pertussis: a population-based cohort study.
Infect Control Hosp Epidemiol 2023 Oct; 44(10):1629-36. doi: 10.1017/ice.2023.31..
Keywords: Respiratory Conditions, Risk, Diagnostic Safety and Quality