Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims

ObjectiveDiagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.DesignUsing retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.ResultsRates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits.ConclusionHigher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

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Palliative home care and emergency department visits in the last 30 and 90 days of life: a retrospective cohort study of patients with cancer

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2021-002889 ◽

2021 ◽

pp. bmjspcare-2021-002889

Author(s):

Jennifer Mracek ◽

Madalene Earp ◽

Aynharan Sinnarajah

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Home Care ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Emergency Department Visits ◽

Palliative Home Care ◽

Patients With Cancer ◽

Diagnosis Of Cancer ◽

Ed Visits

ObjectivesEvaluate the association of specialist palliative home care (HC) on emergency department (ED) visits in the 30 and 90 days prior to death.MethodsThis retrospective cohort study using administrative data identified 6976 adults deceased from cancer between 2008 and 2015, living ≥180 days after diagnosis of cancer, and residing in the urban Calgary Zone of Alberta Health Services. All palliative HC and generalist HC services were examined. Regression analyses examined the relationships of HC type to ED visits in the last 30 or 90 days of life.ResultsIn the last 30 days of life, compared with patients receiving palliative HC, patients receiving only generalist HC, or no HC, were more likely to visit the ED (OR)generalist-HC 1.19; 95% CI 1.06 to 1.34; ORno-HC 1.54; 95% CI 1.31 to 1.82). In the last 90 days of life, compared with patients receiving palliative HC, those receiving generalist HC (OR 1.48; 95% CI 1.32 to 1.67) and no HC (OR 1.66; 95% CI 1.39 to 1.99) had increased odds of visiting the ED.ConclusionsReceiving generalist HC and no HC was associated with increased odds of visiting the ED in the last 30 and 90 days of life, when compared with patients receiving palliative HC. Improving access to palliative HC for patients at high risk of visiting the ED may reduce ED visits and acute care costs and improve quality of life in the last 90 days of life.

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Using a chatbot to reduce emergency department visits and unscheduled hospitalizations among patients with gynecologic malignancies during chemotherapy: a retrospective cohort study (Preprint)

10.2196/preprints.33824 ◽

2021 ◽

Author(s):

Ming-Yuan Huang ◽

Chia-Sui Weng ◽

Hsiao-Li Kuo ◽

Yung-Cheng Su

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Usual Care ◽

Cancer Patients ◽

Retrospective Cohort Study ◽

Text Messaging ◽

Retrospective Cohort ◽

Emergency Department Visits ◽

Gynecologic Malignancies ◽

Ed Visits

BACKGROUND A chatbot is an automatic text-messaging tool that creates a dynamic interaction and simulates a human conversation through text or voice via smartphones or computers. A chatbot could be an effective solution for cancer patients’ follow-up during treatment, and could save time for healthcare providers. OBJECTIVE We conducted a retrospective cohort study to evaluate whether a chatbot-based collection of patient-reported symptoms during chemotherapy, with automated alerts to clinicians, could decrease emergency department (ED) visits and hospitalizations. A control group received usual care. METHODS Self-reporting symptoms were communicated via the chatbot, a Facebook Messenger-based interface for patients with gynecologic malignancies. The chatbot included questions about common symptoms experienced during chemotherapy. Patients could also use the text-messaging feature to speak directly to the chatbot, and all reported outcomes were monitored by a cancer manager. The primary and secondary outcomes of the study were emergency department visits and unscheduled hospitalizations after initiation of chemotherapy after diagnosis of gynecologic malignancies. Multivariate Poisson regression models were applied to assess the adjusted incidence rate ratios (aIRRs) for chatbot use for ED visits and unscheduled hospitalizations after controlling for age, cancer stage, type of malignancy, diabetes, hypertension, chronic renal insufficiency, and coronary heart disease. RESULTS Twenty patients were included in the chatbot group, and 43 in the usual-care group. Significantly lower aIRRs for chatbot use for ED visits (0.27; 95% CI 0.11–0.65; p=0.003) and unscheduled hospitalizations (0.31; 95% CI 0.11–0.88; p=0.028) were noted. Patients using the chatbot approach had lower aIRRs of ED visits and unscheduled hospitalizations compared to usual-care patients. CONCLUSIONS The chatbot was helpful for reducing ED visits and unscheduled hospitalizations in patients with gynecologic malignancies who were receiving chemotherapy. These findings are valuable for inspiring the future design of digital health interventions for cancer patients.

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Evaluation of a novel prognostic score based on thrombosis and inflammation in patients with sepsis: a retrospective cohort study

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2017-0863 ◽

2018 ◽

Vol 56 (7) ◽

pp. 1182-1192 ◽

Cited By ~ 5

Author(s):

Dongze Li ◽

Yaxiong Zhou ◽

Jing Yu ◽

Haifang Yu ◽

Yiqin Xia ◽

...

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Cohort Study ◽

Sequential Organ Failure Assessment ◽

Organ Failure ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Prognostic Score ◽

Adverse Outcomes ◽

Failure Assessment

Abstract Background: Inflammation and thrombosis are involved in the development and progression of sepsis. A novel thrombo-inflammatory prognostic score (TIPS), based on both an inflammatory and a thrombus biomarker, was assessed for its ability to predict adverse outcomes of sepsis patients in the emergency department (ED). Methods: This was a retrospective cohort study of sepsis patients. TIPS (range: 0–2) was predictive of adverse outcomes. Multivariable logistic regression analyses were performed to investigate the associations between TIPS and 28-day adverse outcomes. The study end points were mortality, mechanical ventilation (MV), consciousness disorder (CD) and admission to the intensive care unit (AICU). Results: In total, 821 sepsis patients were enrolled; 173 patients died within the 28-day follow-up period. Procalcitonin and D-dimer values were used to calculate TIPS because they had the best performance in the prediction of 28-day mortality by receiver operating characteristic curves. The 28-day mortality and the incidence of MV, CD and AICU were significantly higher in patients with higher TIPS. Multivariable logistic regression analysis indicated TIPS was an independent predictor of 28-day mortality, MV and AICU. TIPS performed better than other prognostic scores, including quick sequential organ failure assessment, Modified Early Warning Score and Mortality in Emergency Department Sepsis Score for predicting 28-day mortality, and similar to the Acute Physiology and Chronic Health Evaluation II, but inferior to sequential organ failure assessment. Conclusions: TIPS is useful for stratifying the risk of adverse clinical outcomes in sepsis patients shortly after admission to the ED.

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Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-010896 ◽

2020 ◽

Vol 29 (12) ◽

pp. 971-979 ◽

Cited By ~ 1

Author(s):

Katie E Raffel ◽

Molly A Kantor ◽

Peter Barish ◽

Armond Esmaili ◽

Hana Lim ◽

...

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Correct Diagnosis ◽

Diagnostic Errors ◽

Hospital Medicine ◽

Diagnostic Error ◽

Diagnostic Reasoning ◽

Diagnostic Process ◽

Patient Morbidity

BackgroundThe prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge.MethodsRetrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error.ResultsThere were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission.ConclusionThe prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies.

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Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study

Canadian Medical Association Journal ◽

10.1503/cmaj.200277 ◽

2021 ◽

Vol 193 (3) ◽

pp. E85-E93

Author(s):

Michael Hong ◽

Amardeep Thind ◽

Gregory S. Zaric ◽

Sisira Sarma

Keyword(s):

Primary Care ◽

Emergency Department ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Emergency Department Use ◽

After Hours

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Adverse outcomes of colonisation with vancomycin-resistant enterococci: a retrospective cohort study, Norway, 2010–2015

10.26226/morressier.57fe118cd462b8028d89072a ◽

2016 ◽

Author(s):

Hinta Meijerink

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Adverse Outcomes ◽

Vancomycin Resistant Enterococci ◽

Vancomycin Resistant

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A Retrospective Cohort Study of SARS-CoV-2 Infection in Hypertenses Patients in a Primary Care Center

SSRN Electronic Journal ◽

10.2139/ssrn.3605259 ◽

2020 ◽

Author(s):

Esther Hernandez Castilla ◽

Lucia Vallejo Serrano ◽

Monica Saenz Ausejo ◽

Beatriz Pax Sanchez ◽

Katharina Ramrath ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Care Center ◽

Primary Care Center

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Treatment of chronic noncancer pain in patients on opioid therapy in primary care: A retrospective cohort study

Canadian Pharmacists Journal / Revue des Pharmaciens du Canada ◽

10.1177/1715163519887766 ◽

2019 ◽

Vol 153 (1) ◽

pp. 52-58

Author(s):

Arden R. Barry ◽

Chantal E. Chris

Keyword(s):

Primary Care ◽

Cohort Study ◽

Back Pain ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Opioid Therapy ◽

Opioid Agonist ◽

Chronic Noncancer Pain ◽

Opioid Dose ◽

Noncancer Pain

Background: This study sought to characterize the real-world treatment of chronic noncancer pain (CNCP) in patients on opioid therapy in primary care. Methods: A retrospective cohort study from 2014-18 was conducted at a multidisciplinary primary care clinic in Chilliwack, British Columbia. Included were adults on daily opioid therapy for CNCP. Patients receiving palliative care or ≤1 visit were excluded. Outcomes of interest included use of opioid/nonopioid pharmacotherapy, number/frequency of visits and proportion of patients able to reduce/discontinue opioid therapy. Results: Seventy patients (mean age 53 years, 53% male, 51% back pain) were included. Median follow-up was 6 visits over 12 months. Sixty-two patients (89%) reduced their opioid dose, 6 patients had no change and 2 patients required a dose increase. Mean opioid dose was reduced from 183 to 70 mg morphine equivalents daily. Twenty-four patients (34%) discontinued opioid therapy, 6 patients (9%) transitioned to opioid agonist therapy and 6 patients (9%) breached their opioid treatment agreement. Nonopioid pharmacotherapy included nonsteroidal anti-inflammatory drugs (64%), gabapentinoids (63%), tricyclic antidepressants (56%) and nabilone (51%). Discussion: Over half of patients were no longer on opioid therapy by the end of the study. Most patients had a disorder (e.g., back pain) for which opioids are generally not recommended. Overall mean opioid dose was reduced from baseline by approximately 60% over 1 year. Lack of access to specialized pain treatments may have accounted for high nonopioid pharmacotherapy usage. Conclusions: This study demonstrates that treatment of CNCP and opioid tapering can successfully be achieved in a primary care setting. Can Pharm J (Ott) 2020;153:xx-xx.

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