Horizontal and vertical tracing: a cognitive forcing strategy to improve diagnostic accuracy

2020 ◽  
Vol 96 (1140) ◽  
pp. 581-583 ◽  
Author(s):  
Taro Shimizu
Keyword(s):  
Diagnostic Accuracy ◽  
Medical Care ◽  
Cognitive Processes ◽  
Substantial Reduction ◽  
Diagnostic Error ◽  
Cognitive Error ◽  
Underlying Condition ◽  
Diagnostic Strategies ◽  
New Strategies

Reducing diagnostic error is a major issue in medical care. Various strategies have been proposed to prevent diagnostic error. The most prevalent factor for the diagnostic error is a cognitive error by physicians; reducing the cognitive error should lead to a substantial reduction in diagnostic error. That said, few studies have described new strategies to increase diagnostic accuracy that focuses on the cognitive processes of physicians. The current study describes new diagnostic strategies using cognitive forcing. Horizontal tracing is a strategy to identify comorbidities reliably, and vertical tracing identifies an underlying condition.

Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Maria R. Dahm ◽  
Carmel Crock
Keyword(s):  
Diagnostic Accuracy ◽  
Correct Diagnosis ◽  
Linguistic Analysis ◽  
Diagnostic Error ◽  
The Other ◽  
Personal Knowledge ◽  
History Taking ◽  
High Stakes ◽  
Diagnosis And Management

Abstract Objectives To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy. Methods To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature. Results Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9). Conclusions Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy.

Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism

2017 ◽  
Vol 117 (10) ◽  
pp. 1937-1943 ◽  
Author(s):  
Jim Julian ◽  
Lori-Ann Linkins ◽  
Shannon Bates ◽  
Clive Kearon ◽  
Sarah Takach Lapner
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Diagnostic Accuracy ◽  
Blood Samples ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein ◽  
New Strategies ◽  
D Dimer

SummaryTwo new strategies for interpreting D-dimer results have been proposed: i) using a progressively higher D-dimer threshold with increasing age (age-adjusted strategy) and ii) using a D-dimer threshold in patients with low clinical probability that is twice the threshold used in patients with moderate clinical probability (clinical probability-adjusted strategy). Our objective was to compare the diagnostic accuracy of age-adjusted and clinical probability-adjusted D-dimer interpretation in patients with a low or moderate clinical probability of venous thromboembolism (VTE). We performed a retrospective analysis of clinical data and blood samples from two prospective studies. We compared the negative predictive value (NPV) for VTE, and the proportion of patients with a negative D-dimer result, using two D-dimer interpretation strategies: the age-adjusted strategy, which uses a progressively higher D-dimer threshold with increasing age over 50 years (age in years × 10 µg/L FEU); and the clinical probability-adjusted strategy which uses a D-dimer threshold of 1000 µg/L FEU in patients with low clinical probability and 500 µg/L FEU in patients with moderate clinical probability. A total of 1649 outpatients with low or moderate clinical probability for a first suspected deep vein thrombosis or pulmonary embolism were included. The NPV of both the clinical probability-adjusted strategy (99.7%) and the age-adjusted strategy (99.6%) were similar. However, the proportion of patients with a negative result was greater with the clinical probability-adjusted strategy (56.1% vs, 50.9%; difference 5.2%; 95% CI 3.5% to 6.8%). These findings suggest that clinical probability-adjusted D-dimer interpretation is a better way of interpreting D-dimer results compared to age-adjusted interpretation.

scholarly journals Isolating red flags to enhance diagnosis (I-RED): An experimental vignette study

2019 ◽  
Author(s):  
Corey Chartan ◽  
Hardeep Singh ◽  
Parthasarathy Krishnamurthy ◽  
Moushumi Sur ◽  
Ashley Meyer ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Correct Diagnosis ◽  
Diagnostic Error ◽  
Cognitive Intervention ◽  
Potential Effect ◽  
Case Vignette ◽  
Control Group ◽  
Red Flags ◽  
Within Subjects ◽  
Complex Cases

Abstract Objective To investigate effects of a cognitive intervention based on isolation of red flags (I-RED) on diagnostic accuracy of ‘do-not-miss diagnoses.’ Design A 2 × 2 randomized case vignette-based experiment with manipulation of I-RED strategy between subjects and case complexity within subjects. Setting Two university-based residency programs. Participants One-hundred and nine pediatric residents from all levels of training. Interventions Participants were randomly assigned to the I-RED vs. control group, and within each group, they were further randomized to the order in which they saw simple and complex cases. The I-RED strategy involved an instruction to look for a constellation of symptoms, signs, clinical data or circumstances that should heighten suspicion for a serious condition. Main Outcome Measures Primary outcome was diagnostic accuracy, scored as 1 if any of the three differentials given by participants included the correct diagnosis, and 0 if not. We analyzed effects of I-RED strategy on diagnostic accuracy using logistic regression. Results I-RED strategy did not yield statistically higher diagnostic accuracy compared to controls (62 vs. 48%, respectively; odd ratio = 2.07 [95% confidence interval, 0.78–5.5], P = 0.14) although participants reported higher decision confidence compared to controls (7.00 vs. 5.77 on a scale of 1 to 10, P < 0.02) in simple but not complex cases. I-RED strategy significantly shortened time to decision (460 vs. 657 s, P < 0.001) and increased the number of red flags generated (3.04 vs. 2.09, P < 0.001). Conclusions A cognitive strategy of prompting red flag isolation prior to differential diagnosis did not improve diagnostic accuracy of ‘do-not-miss diagnoses.’ Given the paucity of evidence-based solutions to reduce diagnostic error and the intervention’s potential effect on confidence, findings warrant additional exploration.

scholarly journals Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error

2018 ◽  
Vol 37 (11) ◽  
pp. 1828-1835 ◽  
Author(s):  
Robert Berenson ◽  
Hardeep Singh
Keyword(s):  
Diagnostic Accuracy ◽  
Diagnostic Error

Cognitive error in an academic emergency department

Diagnosis ◽  
2018 ◽  
Vol 5 (3) ◽  
pp. 135-142 ◽  
Author(s):  
Benjamin H. Schnapp ◽  
Jean E. Sun ◽  
Jeremy L. Kim ◽  
Reuben J. Strayer ◽  
Kaushal H. Shah
Keyword(s):  
Emergency Department ◽  
Information Processing ◽  
Diagnostic Error ◽  
Cognitive Factors ◽  
Complex Nature ◽  
Cognitive Errors ◽  
Clinical Environment ◽  
Cognitive Error ◽  
Medicine Service ◽  
The Individual

Abstract Background Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment. Methods Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians. Results Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%). Conclusions Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.

scholarly journals A health economic evaluation of needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cysts

2017 ◽  
Vol 05 (10) ◽  
pp. E987-E995 ◽  
Author(s):  
Claude Le Pen ◽  
Laurent Palazzo ◽  
Bertrand Napoléon
Keyword(s):  
Public Sector ◽  
Diagnostic Accuracy ◽  
Health Economic Evaluation ◽  
Needle Aspiration ◽  
Economic Benefits ◽  
Confocal Laser Endomicroscopy ◽  
Confocal Laser ◽  
Pancreatic Cysts ◽  
Diagnostic Strategies ◽  
Diagnostic Uncertainty

Abstract Background and study aims The low sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), especially for the diagnosis of serous cystadenomas (SCAs), can be associated with diagnostic uncertainty that can regularly lead to unnecessary surgical procedures. Needle-based confocal laser endomicroscopy (nCLE) used with EUS-FNA improves diagnostic accuracy, helping to reduce unnecessary surgery and patient follow-up. This study was conducted to evaluate the economic benefit of EUS-FNA + nCLE. Patients and methods Probabilities used were derived from two studies representative of the two diagnostic strategies: a retrospective analysis of patients diagnosed by EUS-FNA alone and a prospective study of patients diagnosed by EUS-FNA + nCLE. Costs were based on French healthcare system rates; both private and public sector rates were included. A decision tree structure model used these probabilities and costs for two hypothetical cohorts of 1000 patients. Results EUS-FNA + nCLE resulted in a reduction of 23 % in the total rate of surgical intervention, which translated to a reduction in clinical costs of 13 % (public sector) and 14 % (private sector). Additionally, the reduced rate of surgery would save the lives of 4 in 1000 patients. A stochastic sensitivity analysis using 100 simulations showed that in all cases the number of interventions was less for EUS-FNA + nCLE than for EUS-FNA. There was also a reduction in the incidence of false negatives using EUS-FNA + nCLE. Conclusions EUS-FNA + nCLE results in significant economic benefits by reducing the incidence of misdiagnosis through improved diagnostic accuracy.

Education for the Next Frontier in Patient Safety: A Longitudinal Resident Curriculum on Diagnostic Error

2016 ◽  
Vol 32 (6) ◽  
pp. 625-631 ◽  
Author(s):  
Emily Ruedinger ◽  
Maren Olson ◽  
Justin Yee ◽  
Emily Borman-Shoap ◽  
Andrew P. J. Olson
Keyword(s):  
Decision Making ◽  
Medical Education ◽  
Medical Decision Making ◽  
Diagnostic Error ◽  
Medical Decision ◽  
Decision Making Process ◽  
Education Programs ◽  
Cognitive Error ◽  
Error Mitigation ◽  
Second Victim

Diagnostic error is a common, serious problem that has received increased attention recently for its impact on both patients and providers. Presently, most graduate medical education programs do not formally address this topic. The authors developed and evaluated a longitudinal, multimodule resident curriculum about diagnostic error and medical decision making. Key components of the curriculum include demystifying the medical decision-making process, building skills in critical thinking, and providing strategies for diagnostic error mitigation. Special attention was paid to avoiding the second victim effect and to fostering a culture that supports constructive, productive feedback when an error does occur. The curriculum was rated by residents as helpful (96%), and residents were more likely to be aware of strategies to reduce cognitive error (27% pre vs 75% post, P < .0001) following its implementation. This article describes the development, implementation, and effectiveness of this curriculum and explores generalizability of the curriculum to other programs.

Emergency medicine physicians’ perspectives on diagnostic accuracy in neurology: a qualitative study

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Ava L. Liberman ◽  
Natalie T. Cheng ◽  
Benjamin W. Friedman ◽  
Maya T. Gerstein ◽  
Khadean Moncrieffe ◽  
...  
Keyword(s):  
Emergency Medicine ◽  
Content Analysis ◽  
Diagnostic Accuracy ◽  
Cognitive Biases ◽  
Neurological Diseases ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Structured Interviews ◽  
Diagnostic Uncertainty ◽  
Diagnostic Decision Making

Abstract Objectives We sought to understand the knowledge, attitudes, and beliefs of emergency medicine (EM) physicians towards non-specific neurological conditions and the use of clinical decision support (CDS) to improve diagnostic accuracy. Methods We conducted semi-structured interviews of EM physicians at four emergency departments (EDs) affiliated with a single US healthcare system. Interviews were conducted until thematic saturation was achieved. Conventional content analysis was used to identify themes related to EM physicians’ perspectives on acute diagnostic neurology; directed content analysis was used to explore views regarding CDS. Each interview transcript was independently coded by two researchers using an iteratively refined codebook with consensus-based resolution of coding differences. Results We identified two domains regarding diagnostic safety: (1) challenges unique to neurological complaints and (2) challenges in EM more broadly. Themes relevant to neurology included: (1) knowledge gaps and uncertainty, (2) skepticism about neurology, (3) comfort with basic as opposed to detailed neurological examination, and (4) comfort with non-neurological diseases. Themes relevant to diagnostic decision making in the ED included: (1) cognitive biases, (2) ED system/environmental issues, (3) patient barriers, (4) comfort with diagnostic uncertainty, and (5) concerns regarding diagnostic error identification and measurement. Most participating EM physicians were enthusiastic about the potential for well-designed CDS to improve diagnostic accuracy for non-specific neurological complaints. Conclusions Physicians identified diagnostic challenges unique to neurological diseases as well as issues related more generally to diagnostic accuracy in EM. These physician-reported issues should be accounted for when designing interventions to improve ED diagnostic accuracy.

256 Shades of gray: uncertainty and diagnostic error in radiology

Diagnosis ◽  
2017 ◽  
Vol 4 (3) ◽  
pp. 149-157 ◽  
Author(s):  
Michael A. Bruno
Keyword(s):  
Cognitive Processes ◽  
Image Interpretation ◽  
Diagnostic Error ◽  
High Variability ◽  
Radiological Imaging ◽  
Reduction Strategies ◽  
Diagnostic Power ◽  
High Level ◽  
High Uncertainty ◽  
Degree Of Overlap

Abstract Radiologists practice in an environment of extraordinarily high uncertainty, which results partly from the high variability of the physical and technical aspects of imaging, partly from the inherent limitations in the diagnostic power of the various imaging modalities, and partly from the complex visual-perceptual and cognitive processes involved in image interpretation. This paper reviews the high level of uncertainty inherent to the process of radiological imaging and image interpretation vis-à-vis the issue of radiological interpretive error, in order to highlight the considerable degree of overlap that exists between these. The scope of radiological error, its many potential causes and various error-reduction strategies in radiology are also reviewed.

scholarly journals Cobalamin Deficiency in General Practice. Assessment of the Diagnostic Utility and Cost-Benefit Analysis of Methylmalonic Acid Determination in Relation to Current Diagnostic Strategies

1999 ◽  
Vol 45 (2) ◽  
pp. 189-198 ◽  
Author(s):  
Geir Hølleland ◽  
Jørn Schneede ◽  
Per Magne Ueland ◽  
Per Kristian Lund ◽  
Helga Refsum ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Methylmalonic Acid ◽  
Cost Benefit Analysis ◽  
Cost Benefit ◽  
Cobalamin Deficiency ◽  
Reference Standard ◽  
Benefit Analysis ◽  
Diagnostic Strategies ◽  
Practice Assessment ◽  
Higher Sensitivity

Abstract Diagnosing cobalamin deficiency is often difficult. We investigated the diagnostic strategies that 224 general practitioners used to assess cobalamin status and the criteria on which they based their decisions to supplement patients. From all serum cobalamin analyses carried out at a single laboratory during 1993, individuals with serum cobalamin concentrations &lt;300 pmol/L were identified, and one patient per general practitioner was included. When serum methylmalonic acid (s-MMA) values &gt;0.376 μmol/L were used as the “reference standard” for cobalamin deficiency, the serum cobalamin assay had a diagnostic sensitivity of 0.40 and a specificity of 0.98. With the same reference standard, the diagnostic accuracy of the physicians’ decision to supplement patients had the same specificity but a higher sensitivity (0.51). Cost-benefit analysis indicated that measurement of s-MMA can be recommended in patients with serum cobalamin &gt;60–90 pmol/L and &lt;200–220 pmol/L, depending on its diagnostic accuracy.

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