Band 5, Heft 3

Over a third of adults go online to diagnose their health condition. Direct-to-consumer (DTC), interactive, diagnostic apps with information personalization capabilities beyond those of static search engines are rapidly proliferating. While these apps promise faster, more convenient and more accurate information to improve diagnosis, little is known about the state of the evidence on their performance or the methods used to evaluate them. We conducted a scoping review of the peer-reviewed and gray literature for the period January 1, 2014–June 30, 2017. We found that the largest category of evaluations involved symptom checkers that applied algorithms to user-answered questions, followed by sensor-driven apps that applied algorithms to smartphone photos, with a handful of evaluations examining crowdsourcing. The most common clinical areas evaluated were dermatology and general diagnostic and triage advice for a range of conditions. Evaluations were highly variable in methodology and conclusions, with about half describing app characteristics and half examining actual performance. Apps were found to vary widely in functionality, accuracy, safety and effectiveness, although the usefulness of this evidence was limited by a frequent failure to provide results by named individual app. Overall, the current evidence base on DTC, interactive diagnostic apps is sparse in scope, uneven in the information provided and inconclusive with respect to safety and effectiveness, with no studies of clinical risks and benefits involving real-world consumer use. Given that DTC diagnostic apps are rapidly evolving, rigorous and standardized evaluations are essential to inform decisions by clinicians, patients, policymakers and other stakeholders.

Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report Improving Diagnosis in Health Care. The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.

Diagnostic stewardship is an increasingly recognized means to reduce unnecessary tests and diagnostic errors. As a leading cause of healthcare-associated infection for which accurate laboratory diagnosis remains a challenge, Clostridium difficile offers an ideal opportunity to apply the principles of diagnostic stewardship. The recently updated 2017 Infectious Diseases Society of America (IDSA)-Society for Healthcare Epidemiology of America (SHEA) Clinical Practice Guidelines for C. difficile infection now recommend separate diagnostic strategies depending on whether an institution has adopted diagnostic stewardship in test decision making. IDSA-SHEA endorsement of diagnostic stewardship for C. difficile highlights the increasing role of diagnostic stewardship in hospitals. In this opinion piece, we introduce the concept of diagnostic stewardship by discussing the new IDSA-SHEA diagnostic recommendations for laboratory diagnosis of C. difficile . We outline recent examples of diagnostic stewardship, challenges to implementation, potential downsides and propose future areas of study.

Diagnostic dilemmas refer to situations in which physicians face a challenging clinical scenario. The goal of our paper is to outline strategies which we have found to be most helpful in the approach to a diagnostic dilemma. We review each strategy and provide illustrative clinical examples. Among the most helpful strategies are performing a thorough history and physical examination (H&P) (including pertinent epidemiological factors and careful medication review), avoidance of non-specific testing and empiric treatment, judicious use of consultants, maintaining an open-mind and humility and ongoing, open communication with your patient.

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.

Background Cognitive errors are a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conferences. We aimed to describe the frequency of cognitive errors in relation to the occurrence of diagnostic and other error types, in cases presented at an emergency medicine (EM) resident M&M conference. Methods We conducted a retrospective study of all cases presented at a suburban US EM residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record (EMR) and notes from the M&M case by two EM physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for contributing cognitive and non-cognitive factors. Finally, when a cognitive error occurred, the case was classified into faulty knowledge, faulty data gathering or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third EM physician. Results A total of 87 M&M cases were reviewed; the two reviewers agreed on 73 cases, and 14 cases required mediation by a third reviewer. Forty-eight cases involved diagnostic errors, 47 of which were cognitive errors. Of these 47 cases, 38 involved faulty synthesis, 22 involved faulty data gathering and only 11 involved faulty knowledge. Twenty cases contained more than one type of cognitive error. Twenty-nine cases involved both a resident and an attending physician, while 17 cases involved only an attending physician. Twenty-one percent of the resident cases involved all three cognitive errors, while none of the attending cases involved all three. Forty-one percent of the resident cases and only 6% of the attending cases involved faulty knowledge. One hundred percent of the resident cases and 94% of the attending cases involved faulty synthesis. Conclusions Our review of 87 EM M&M cases revealed that cognitive errors are commonly involved in cases presented, and that these errors are less likely due to deficient knowledge and more likely due to faulty synthesis. M&M conferences may therefore provide an excellent forum to discuss cognitive errors and how to reduce their occurrence.

Background Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains. Methods We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains. Results Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains. Conclusions Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.

Background Pediatric hypertension is a serious problem associated with target organ damage in children and an increased risk for adult hypertension. African-American and Latino children are disproportionately affected. Unfortunately, due to a variety of factors, including the complexity of blood pressure (BP) standards, pediatric hypertension is undiagnosed in the majority of cases. We sought to identify factors associated with correct diagnosis and to better understand diagnosis of hypertension by studying the diagnostic paths of a small number of children. Methods Data were extracted from electronic health records (EHRs) of children who met criteria for hypertension. Logistic regression was used to identify factors associated with correct diagnosis. Diagnostic paths for 20 diagnosed children were extracted through chart review and analyzed. Results Among 1478 hypertensive children, only 85 were diagnosed (6.1%). Age ≥12 compared to age ≤6 was associated with correct diagnosis [odds ratio (OR) of 1.96, 95% confidence interval (CI) (1.16, 3.32)]. Diagnostic paths revealed that primary care providers (PCPs) make the diagnosis based on multiple readings over time and order laboratory tests appropriately. Conclusions Hypertension is missed in a large proportion of all children. Effective, systematic approaches to diagnosis are necessary.

Background Reporting on the presence of antimicrobial resistance is of considerable concern both for individual patient care and for understanding the underlying health status within the community at large. Antimicrobial resistance is solely dependent upon clinical laboratory detection and thus can be impacted upon by the quality and competence of medical laboratories. Proficiency testing or external quality assessment (PT/EQA) is the international standard for the direct measurement of medical laboratory performance on critical testing. Methods An international, intercontinental collaborative retrospective study of medical laboratory performance in antibiotic resistance was performed by the Microbiology Working Group (MWG) of the European Organisation for External Quality Assurance for Laboratory Medicine (EQALM) with particular examination of laboratory performance on the testing and reporting of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and carbapenem-resistant Enterobacteriaceae (CRE). Results The results of 1880 medical laboratories were compiled. Strictly accurate reporting of isolates as resistant occurred with MRSA 96.9%, with VRE 91.3% and with CRE 93.1% of the time. On the other hand, very major errors (reporting of false susceptibility) were observed with 2.2% of MRSA and 2.4% of VRE and 0.8% of CRE. Major errors (false resistance) were reported for vancomycin susceptibility testing for MRSA at a rate of 0.6%. Conclusions Depending on how clinical physicians read and understand microbiology susceptibility reports, proficient acceptable results were reported either between 91% and 94% of the time, or between 97% and 100%. While very major errors are infrequently reported, they were found in all regions and could potentially cause poor treatment decisions by clinicians. A collective analysis of multi-program PT/EQA information can provide valuable insights into the testing and reporting practices of medical laboratories.