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Raffel KE, Gershanik EF, Ranji SR. Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. J Hosp Med 2024. [PMID: 38654433 DOI: 10.1002/jhm.13375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Katie E Raffel
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- The Institute for Healthcare Quality Safety and Efficiency, Denver, Colorado, USA
| | - Esteban F Gershanik
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Wellesley, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Sumant R Ranji
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco at San Francisco General Hospital, San Francisco, California, USA
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Auerbach AD, Astik GJ, O'Leary KJ, Barish PN, Kantor MA, Raffel KR, Ranji SR, Mueller SK, Burney SN, Galinsky J, Gershanik EF, Goyal A, Chitneni PR, Rastegar S, Esmaili AM, Fenton C, Virapongse A, Ngov LK, Burden M, Keniston A, Patel H, Gupta AB, Rohde J, Marr R, Greysen SR, Fang M, Shah P, Mao F, Kaiksow F, Sterken D, Choi JJ, Contractor J, Karwa A, Chia D, Lee T, Hubbard CC, Maselli J, Dalal AK, Schnipper JL. Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19. J Gen Intern Med 2023; 38:1902-1910. [PMID: 36952085 PMCID: PMC10035474 DOI: 10.1007/s11606-023-08176-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN Retrospective cohort. SETTING Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.
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Affiliation(s)
- Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Gopi J Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter N Barish
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Molly A Kantor
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Katie R Raffel
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sumant R Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Stephanie K Mueller
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | | | - Esteban F Gershanik
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Abhishek Goyal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pooja R Chitneni
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Armond M Esmaili
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Anunta Virapongse
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Li-Kheng Ngov
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marisha Burden
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Angela Keniston
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hemali Patel
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ashwin B Gupta
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeff Rohde
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ruby Marr
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - S Ryan Greysen
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele Fang
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pranav Shah
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frances Mao
- Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Farah Kaiksow
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, WI, Madison, USA
| | - David Sterken
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, WI, Madison, USA
| | - Justin J Choi
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jigar Contractor
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Abhishek Karwa
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - David Chia
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Tiffany Lee
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Judith Maselli
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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Bersani K, Fuller TE, Garabedian P, Espares J, Mlaver E, Businger A, Chang F, Boxer RB, Schnock KO, Rozenblum R, Dykes PC, Dalal AK, Benneyan JC, Lehmann LS, Gershanik EF, Bates DW, Schnipper JL. Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR. Appl Clin Inform 2020; 11:34-45. [PMID: 31940670 PMCID: PMC6962088 DOI: 10.1055/s-0039-3402756] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/03/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems. OBJECTIVE This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation. METHODS The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption. RESULTS The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88). CONCLUSION This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.
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Affiliation(s)
- Kerrin Bersani
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Theresa E. Fuller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | | | - Jenzel Espares
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Eli Mlaver
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Alexandra Businger
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Frank Chang
- Partners Healthcare, Somerville, Massachusetts, United States
| | - Robert B. Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Kumiko O. Schnock
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Ronen Rozenblum
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Patricia C. Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Anuj K. Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - James C. Benneyan
- Healthcare Systems Engineering Institute, Colleges of Engineering and Health Sciences, Northeastern University, Boston, Massachusetts, United States
| | - Lisa S. Lehmann
- Veterans Affairs New England Healthcare System, Boston, Massachusetts, United States
| | - Esteban F. Gershanik
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
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O'Donnell-Luria AH, Lin AP, Merugumala SK, Rohr F, Waisbren SE, Lynch R, Tchekmedyian V, Goldberg AD, Bellinger A, McFaline-Figueroa JR, Simon T, Gershanik EF, Levy BD, Cohen DE, Samuels MA, Berry GT, Frank NY. Brain MRS glutamine as a biomarker to guide therapy of hyperammonemic coma. Mol Genet Metab 2017; 121:9-15. [PMID: 28408159 DOI: 10.1016/j.ymgme.2017.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 11/28/2022]
Abstract
Acute idiopathic hyperammonemia in an adult patient is a life-threatening condition often resulting in a rapid progression to irreversible cerebral edema and death. While ammonia-scavenging therapies lower blood ammonia levels, in comparison, clearance of waste nitrogen from the brain may be delayed. Therefore, we used magnetic resonance spectroscopy (MRS) to monitor cerebral glutamine levels, the major reservoir of ammonia, in a gastric bypass patient with hyperammonemic coma undergoing therapy with N-carbamoyl glutamate and the ammonia-scavenging agents, sodium phenylacetate and sodium benzoate. Improvement in mental status mirrored brain glutamine levels, as coma persisted for 48h after plasma ammonia normalized. We hypothesize that the slower clearance for brain glutamine levels accounts for the delay in improvement following initiation of treatment in cases of chronic hyperammonemia. We propose MRS to monitor brain glutamine as a noninvasive approach to be utilized for diagnostic and therapeutic monitoring purposes in adult patients presenting with idiopathic hyperammonemia.
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Affiliation(s)
- Anne H O'Donnell-Luria
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alexander P Lin
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Sai K Merugumala
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Frances Rohr
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Susan E Waisbren
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Rebecca Lynch
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Aaron D Goldberg
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Andrew Bellinger
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Tracey Simon
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | - Bruce D Levy
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - David E Cohen
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Martin A Samuels
- Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Gerard T Berry
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Natasha Y Frank
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Department of Medicine, VA Boston Healthcare System, Boston, MA 02115, USA.
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Dunne RM, Ip IK, Abbett S, Gershanik EF, Raja AS, Hunsaker A, Khorasani R. Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients. Radiology 2015; 276:167-74. [PMID: 25686367 DOI: 10.1148/radiol.15141208] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the effect of clinical decision support (CDS) on the use and yield of inpatient computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE). MATERIALS AND METHODS This HIPAA-compliant, institutional review board-approved study with waiver of informed consent included all adults admitted to a 793-bed teaching hospital from April 1, 2007, to June 30, 2012. The CDS intervention, implemented after a baseline observation period, informed providers who placed an order for CT pulmonary angiographic imaging about the pretest probability of the study based on a validated decision rule. Use of CT pulmonary angiographic and admission data from administrative databases was obtained for this study. By using a validated natural language processing algorithm on radiology reports, each CT pulmonary angiographic examination was classified as positive or negative for acute PE. Primary outcome measure was monthly use of CT pulmonary angiography per 1000 admissions. Secondary outcome was CT pulmonary angiography yield (percentage of CT pulmonary angiographic examinations that were positive for acute PE). Linear trend analysis was used to assess for effect and trend differences in use and yield of CT pulmonary angiographic imaging before and after CDS. RESULTS In 272 374 admissions over the study period, 5287 patients underwent 5892 CT pulmonary angiographic examinations. A 12.3% decrease in monthly use of CT pulmonary angiography (26.0 to 22.8 CT pulmonary angiographic examinations per 1000 admissions before and after CDS, respectively; P = .008) observed 1 month after CDS implementation was sustained over the ensuing 32-month period. There was a nonsignificant 16.3% increase in monthly yield of CT pulmonary angiography or percentage of CT pulmonary angiographic examinations positive for acute PE after CDS (P = .65). CONCLUSION Implementation of evidence-based CDS for inpatients was associated with a 12.3% immediate and sustained decrease in use of CT pulmonary angiographic examinations in the evaluation of inpatients for acute PE. for this article.
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Affiliation(s)
- Ruth M Dunne
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ivan K Ip
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Sarah Abbett
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Esteban F Gershanik
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ali S Raja
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Andetta Hunsaker
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
| | - Ramin Khorasani
- From the Center for Evidence-Based Imaging (R.M.D., I.K.I., E.F.G., A.S.R., R.K.), Department of Radiology (R.M.D., I.K.I., E.F.G., A.S.R., A.H., R.K.), Department of Medicine (I.K.I., E.F.G.), Department of Emergency Medicine (A.S.R.), and Brigham and Women's Physician Organization (S.A.), Brigham and Women's Hospital, Harvard Medical School, 20 Kent St, 2nd Floor, Boston, MA 02120
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Shinagare AB, Silverman SG, Gershanik EF, Chang SL, Khorasani R. Evaluating hematuria: impact of guideline adherence on urologic cancer diagnosis. Am J Med 2014; 127:625-32. [PMID: 24565590 DOI: 10.1016/j.amjmed.2014.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 02/03/2014] [Accepted: 02/04/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study was to assess physician adherence to 2001 American Urological Association (AUA) guidelines for evaluating patients with asymptomatic hematuria and its impact on the diagnosis of urologic cancer. METHODS In this institutional review board-approved retrospective study of patients with asymptomatic hematuria evaluated in a large academic health center in 2004 (allowing for long-term follow-up), we randomly selected 100 of 1771 patients with asymptomatic hematuria (52 men; mean age 54 years; 58 microscopic, 39 macroscopic, three unknown-type hematuria; median follow-up 89 months, interquartile range 33-97 months). Multivariate logistic regression assessed effects of age, sex, hematuria type, and physician specialty on guideline adherence, the primary outcome. Secondary outcome measures were variability in evaluation among physician specialists, and the proportion of patients developing urologic cancer. RESULTS Only 36 of 100 patients had a guideline-adherent evaluation, of which 5 were diagnosed with urologic cancer (median 1 month, range 0-11). No urologic cancers were diagnosed in 64 patients with nonadherent evaluations. Only evaluation by a urologist significantly predicted guideline adherence (P <.0001). Patients with gross hematuria more often underwent intravenous or computed tomography urography (P = .009); urologist evaluation more often led to intravenous or computed tomography urography (P <.0001), cystoscopy (P <.0001), cytology (P = .009), and guideline-adherent evaluation (P <.0001). CONCLUSIONS Although most physicians did not adhere to 2001 AUA guidelines when evaluating patients with asymptomatic hematuria, no urologic cancers were diagnosed in patients without guideline-adherent evaluation, barring the possibility of occult cancers. Evaluation by a urologist was the only predictor of a guideline-adherent evaluation. Future studies are needed to determine the optimal evaluation of patients with asymptomatic hematuria.
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Affiliation(s)
- Atul B Shinagare
- Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Stuart G Silverman
- Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Esteban F Gershanik
- Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Steven L Chang
- Department of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ramin Khorasani
- Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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7
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Ip IK, Gershanik EF, Schneider LI, Raja AS, Mar W, Seltzer S, Healey MJ, Khorasani R. Impact of IT-enabled intervention on MRI use for back pain. Am J Med 2014; 127:512-8.e1. [PMID: 24513065 PMCID: PMC4035377 DOI: 10.1016/j.amjmed.2014.01.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 01/29/2014] [Accepted: 01/29/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to examine the impact of a multifaceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain. METHODS After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry, as well as 2 accountability tools: mandatory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing it with that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-squared, t-tests, and logistic regression were used to assess pre- and postintervention differences. RESULTS In the study cohort preintervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI, compared with 3.7% of visits postintervention (P <.0001, adjusted odds ratio 0.68). There was a 30.8% relative decrease (6.5% vs 4.5%, P <.0001, adjusted odds ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs 5.3%, P = .712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (P = .0002). CONCLUSIONS CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.
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Affiliation(s)
- Ivan K Ip
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Esteban F Gershanik
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Louise I Schneider
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ali S Raja
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Harvard Medical School, Boston, Mass
| | - Wenhong Mar
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass
| | - Steven Seltzer
- Department of Radiology, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael J Healey
- Department of Medicine, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Brigham and Women's Physician Organization, Harvard Medical School, Boston, Mass
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass; Department of Radiology, Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Gershanik EF, Lacson R, Khorasani R. Critical finding capture in the impression section of radiology reports. AMIA Annu Symp Proc 2011; 2011:465-9. [PMID: 22195100 PMCID: PMC3243237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Radiology reports communicate imaging findings to ordering physicians. The substantial information in these reports often causes physicians to focus on the summarized "impression" section. This study evaluated how often a critical finding is documented in the report's "impression" section and describes how an automated application can improve documentation. METHODS A retrospective review of all chest CT scan reports finalized between October, 2009 and September, 2010 at an academic institution was performed. A natural language processing application was utilized to evaluate the frequency of reporting a pulmonary nodule in the "impression" section, versus the "findings" section of a report. RESULTS Results showed 3,401 reports with documented pulmonary nodules in the "findings" section, compared to 2,162 in the "impression" section - a 36.4% difference. CONCLUSION The study revealed significant discrepant documentation in the "findings" versus "impression" sections. Automated systems could improve such critical findings documentation and communication between ordering physicians and radiologists.
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