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Murphy J, Malik R, Lau B, Conway SJ, Johnson PT. Refocusing the Lens: Adding Downstream Value to the Radiology Quality Equation. J Am Coll Radiol 2024; 21:88-92. [PMID: 37690537 DOI: 10.1016/j.jacr.2023.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Jacob Murphy
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rubab Malik
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn Lau
- Department of Radiology & Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah J Conway
- Chief Medical Officer, Johns Hopkins Clinical Alliance, Baltimore, Maryland; Assistant Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela T Johnson
- Vice President of Care Transformation, Johns Hopkins Health System, Baltimore, Maryland; Vice Chair of Quality, Safety and Value, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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2
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Liberman AL, Wang Z, Zhu Y, Hassoon A, Choi J, Austin JM, Johansen MC, Newman-Toker DE. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Diagnosis (Berl) 2023; 10:225-234. [PMID: 37018487 PMCID: PMC10659025 DOI: 10.1515/dx-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023]
Abstract
Diagnostic errors in medicine represent a significant public health problem but continue to be challenging to measure accurately, reliably, and efficiently. The recently developed Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach measures misdiagnosis related harms using electronic health records or administrative claims data. The approach is clinically valid, methodologically sound, statistically robust, and operationally viable without the requirement for manual chart review. This paper clarifies aspects of the SPADE analysis to assure that researchers apply this method to yield valid results with a particular emphasis on defining appropriate comparator groups and analytical strategies for balancing differences between these groups. We discuss four distinct types of comparators (intra-group and inter-group for both look-back and look-forward analyses), detailing the rationale for choosing one over the other and inferences that can be drawn from these comparative analyses. Our aim is that these additional analytical practices will improve the validity of SPADE and related approaches to quantify diagnostic error in medicine.
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Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Justin Choi
- Department of Internal Medicine, Weill Cornell Medicine
| | - J. Matthew Austin
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine and the Armstrong Institute Center for Diagnostic Excellence
| | - Michelle C. Johansen
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - David E. Newman-Toker
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
- The Johns Hopkins Bloomberg School of Public Health, Departments of Epidemiology and Health Policy & Management
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Ardila CM, Gonzalez-Arroyave D, Angel S, Zuluaga-Gomez M. Primary Headache Approach in the Emergency Departments: A Systematic Scoping Review of Prospective Studies. Cureus 2023; 15:e36131. [PMID: 37065368 PMCID: PMC10100244 DOI: 10.7759/cureus.36131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/16/2023] Open
Abstract
This systematic scoping review aims to answer questions related to the main characteristics of primary headache, the need for neuroimaging, and the presence of red flags in these patients. A review of prospective studies including the MEDLINE/PubMed, Scopus, LILACS, and SCIELO databases, as well as the grey literature, was conducted. The methodological quality of the selected investigations was also assessed. Six investigations met the selection criteria. The mean age of people with primary headache was less than 43 years, with ages ranging from 39 to 46 years. Most of the studies reported the presence of nausea/vomiting, between 12% and 60% of the patients studied. To a lesser extent, there was also the presence of intense and moderate pain, loss of consciousness, stiff neck, presence of aura, and photophobia. The most frequent diagnoses were unspecified headache, migraine, and tension headache. The studies did not recommend neuroimaging and no red flags were reported. Primary headache occurred more frequently in women, in those under 46 years of age with a history of migraine and similar episodes. Moreover, the presence of red flags and the need for neuroimaging in patients with primary headaches were not evidenced.
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Liberman AL, Zhang C, Lipton RB, Kamel H, Parikh NS, Navi BB, Segal AZ, Razzak J, Newman-Toker DE, Merkler AE. Short-term stroke risk after emergency department treat-and-release headache visit. Headache 2022; 62:1198-1206. [PMID: 36073865 PMCID: PMC10041409 DOI: 10.1111/head.14387] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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Liberman AL, Hassoon A, Fanai M, Badihian S, Rupani H, Peterson SM, Sebestyen K, Wang Z, Zhu Y, Lipton RB, Newman-Toker DE. Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study. Acad Emerg Med 2022; 29:41-50. [PMID: 34309135 PMCID: PMC8766867 DOI: 10.1111/acem.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. METHODS We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05. RESULTS Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03). CONCLUSION We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.
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Affiliation(s)
- Ava L. Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Mehdi Fanai
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Shervin Badihian
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Hetal Rupani
- The Johns Hopkins University School of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Susan M. Peterson
- The Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland, USA
| | - Krisztian Sebestyen
- The Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, Maryland, USA
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Richard B. Lipton
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - David E. Newman-Toker
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology,The Johns Hopkins University School of Medicine, Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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Liberman AL, Cheng NT, Friedman BW, Gerstein MT, Moncrieffe K, Labovitz DL, Lipton RB. Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study. Diagnosis (Berl) 2021; 9:225-235. [PMID: 34855312 DOI: 10.1515/dx-2021-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022]
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.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Khadean Moncrieffe
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L Labovitz
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Wallace EJC, Liberman AL. Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes. Neuropsychiatr Dis Treat 2021; 17:1469-1480. [PMID: 34017173 PMCID: PMC8129915 DOI: 10.2147/ndt.s275750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/08/2021] [Indexed: 12/14/2022] Open
Abstract
Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic time-outs into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.
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Affiliation(s)
- Emma J C Wallace
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
| | - Ava L Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Department of Neurology, Bronx, NY, USA
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