Toward a model of shared meaningful diagnosis

Development and Psychometric Analysis of a Patient-Reported Measure of Diagnostic Excellence for Emergency and Urgent Care Settings

BACKGROUND

Emergency and urgent care settings face challenges with routinely obtaining performance feedback related to diagnostic care. Patients and their care partners provide an important perspective on the diagnostic process and outcome of care in these settings. We sought to develop and test psychometric properties of Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED), a measure of patient-reported diagnostic excellence in these care settings.

METHODS

We developed PRIME-ED based on literature review, expert feedback, and cognitive testing. To assess psychometric properties, we surveyed AmeriSpeak, a probability-based panel that provides sample coverage of approximately 97% of the U.S. household population, in February 2022 to adult patients, or their care partners, who had presented to an emergency department or urgent care facility within the last 30 days. Respondents rated their agreement on a 5-point Likert scale with each of 17 statements across multiple domains of patient-reported diagnostic excellence. Demographics, visit characteristics, and a subset of the Emergency Department Consumer Assessment of Healthcare Providers & Systems were also collected. We conducted psychometric testing for reliability and validity.

RESULTS

Over a thousand (n = 1116) national panelists completed the PRIME-ED survey, of which 58.7% were patients and 40.9% were care partners; 49.6% received care at an emergency department and 49.9% at an urgent care facility. Responses had high internal consistency within 3 patient-reported diagnostic excellence domain groupings: diagnostic process (Cronbach's alpha 0.94), accuracy of diagnosis (0.93), and communication of diagnosis (0.94). Domain groupings were significantly correlated with concurrent Emergency Department Consumer Assessment of Healthcare Providers & Systems items. Factor analyses substantiated 3 domain groupings.

CONCLUSIONS

PRIME-ED has potential as a tool for capturing patient-reported diagnostic excellence in emergency and urgent care.

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey

BACKGROUND

Language barrier, reduced self-advocacy, lower health literacy or biased care may hinder the diagnostic process. Data on how patients/families with limited English-language health literacy (LEHL) or disadvantaged socioeconomic position (dSEP) experience diagnostic errors are sparse.

METHOD

We compared patient-reported diagnostic errors, contributing factors and impacts between respondents with LEHL or dSEP and their counterparts in the 2017 Institute for Healthcare Improvement US population-based survey, using contingency analysis and multivariable logistic regression models for the analyses.

RESULTS

596 respondents reported a diagnostic error; among these, 381 reported LEHL or dSEP. After adjusting for sex, race/ethnicity and physical health, individuals with LEHL/dSEP were more likely than their counterparts to report unique contributing factors: "(No) qualified translator or healthcare provider that spoke (the patient's) language" (OR and 95% CI 4.4 (1.3 to 14.9)); "not understanding the follow-up plan" (1.9 (1.1 to 3.1)); "too many providers… but no clear leader" (1.8 (1.2 to 2.7)); "not able to keep follow-up appointments" (1.9 (1.1 to 3.2)); "not being able to pay for necessary medical care" (2.5 (1.4 to 4.4)) and "out-of-date or incorrect medical records" (2.6 (1.4 to 4.8)). Participants with LEHL/dSEP were more likely to report long-term emotional, financial and relational impacts, compared with their counterparts. Subgroup analysis (LEHL-only and dSEP-only participants) showed similar results.

CONCLUSIONS

Individuals with LEHL or dSEP identified unique and actionable contributing factors to diagnostic errors. Interpreter access should be viewed as a diagnostic safety imperative, social determinants affecting care access/affordability should be routinely addressed as part of the diagnostic process and patients/families should be encouraged to access and update their medical records. The frequent and disproportionate long-term impacts from self-reported diagnostic error among LEHL/dSEP patients/families raises urgency for greater prevention and supportive efforts.

Patient outcomes of a clinician curriculum on how to deliver a diabetes diagnosis

AIMS

To investigate the effects of a curriculum that teaches medical decision making and interpersonal communication in the context of prediabetes (preDM) and type 2 diabetes (T2DM).

METHODS

This evaluation was an active-controlled trial of 56 patients, including patients who received their diagnosis from intervention-trained clinicians or a control group. Patients attended a research appointment for informed consent and collection of baseline measures. Over the following six months, both groups were mailed surveys and informational handouts monthly. Upon conclusion, we recorded the most recent A1c from the patient's record.

RESULTS

An analysis of covariance test revealed patients who received a T2DM diagnosis from an intervention-trained clinician reported higher reassurance from the diagnosing clinician and had a higher perception of threat. Although not statistically significant, patients with T2DM in the intervention group had a lower A1c at follow up and patients in the intervention group reported less poor eating and a higher degree of diet decision making.

CONCLUSIONS

The curriculum itself does not influence glycemic control, but our results demonstrate the positive impact on patients of the curriculum to teach critical skills to clinicians delivering a diabetes diagnosis.

Monitoramento avançado de enfermagem: pacientes de risco na atenção primária

Resumo Objetivo avaliar o efeito do monitoramento de enfermagem avançado em relação ao usual para identificação do risco cardiovascular e renal, adesão medicamentosa e prática de exercícios na atenção primária à saúde. Método estudo quantitativo, quase-experimental desenvolvido na Atenção primária. Em relação a intervenção, foram consultas de enfermagem trimestrais de monitoramento avançado e laboratorial trimestral. Para coleta de dados, aplicou-se questionário sociodemográfico, escala Morisky e Questionário Internacional de Atividade Física. Resultados sexo feminino predominou nos dois grupos intervenção e controle (62,79% vs. 76,74%). O percentual de pacientes sem risco cardiovascular do grupo intervenção superou o grupo controle da consulta 1 para consulta 3, (0,00% - 25,58% vs. 6,98 - 2,33). Adesão medicamentosa máxima, ao longo do tempo, foi superior no grupo intervenção comparado ao grupo controle (48,8% vs. 23,3%). O risco cardiovascular dos usuários interferiu na atividade física de forma significativa no grupo intervenção e controle (p=0,0261 vs. 0,0438). Conclusões e implicações para a prática a monitorização avançada possibilitou uma melhor identificação de pacientes de risco e orientações aos pacientes hipertensos e diabéticos com risco cardiovascular e renal, o que favoreceu o monitoramento avançado e contribuiu ao autogerenciamento da prática de exercícios e adesão medicamentosa, a partir de consultas de enfermagem.

Dissonance in the discourse of the duration of diabetes: A mixed methods study of patient perceptions and clinical practice

Background

Remission of diabetes can be rewarding for patients and physicians, but there is limited study of how patients perceive the timeline of a disease along the continuum of glycaemic control.

Objective

To explore how patients perceive the timeline of diabetes along the continuum of glycaemic control and their goals of care and to identify whether family physicians communicate the principles of regression and remission of diabetes.

Design

Mixed methods approach of qualitative semi‐structured interviews with purposive sampling followed by cross‐sectional survey of physicians.

Participants

Thirty‐three patients living with prediabetes (preDM) or type 2 diabetes mellitus (T2DM) at medical centres in Georgia and Nevada; and 387 family physicians providing primary care within the same health system.

Results

Patients described two timelines of diabetes: as a lifelong condition or as a condition that can be cured. Patients who perceived a lifelong condition described five treatment goals: reducing glucose‐related laboratory values, losing weight, reducing medication, preventing treatment intensification and avoiding complications. For patients who perceived diabetes as a disease with an end, the goal of care was to achieve normoglycaemia. In response to patient vignettes that described potential cases of remission and regression, 38.2% of physician respondents would still communicate that a patient has preDM and 94.6% would tell the patient that he still had diabetes.

Conclusions

Most physicians here exhibited reluctance to communicate remission or regression in patient care. Yet, patients describe two different potential timelines, including a subset who expect their diabetes can be ‘cured’. Physicians should incorporate shared decision making to create a shared mental model of diabetes and its potential outcomes with patients.

Patient or Public Contribution

In this mixed methods study, as patients participated in the qualitative phase of this study, we asked patients to tell us what additional questions we should ask in subsequent interviews. Data from this qualitative phase informed the design and interpretation of the quantitative phase with physician participants.