Building a New Model for Diagnosis of ED Dizzy Patients

建立 ED 眩晕患者诊断新模型

• 批准号: 6508172
• 负责人: DAVID NEWMAN-TOKER
• 金额: $ 11.3万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2002
• 资助国家: 美国
• 起止时间: 2002-12-01 至 2007-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/6508172
• 关键词: balance; clinical research; computer assisted medical decision making; computer simulation; diagnosis design /evaluation; diagnosis quality /standard; disease /disorder etiology; emergency care; emergency health services; human subject; patient oriented research; physicians; questionnaires; vertigo

DESCRIPTION (provided by applicant): The goal of the investigators proposed research is to improve diagnosis of patients presenting to the ED with dizziness, some of whom are misdiagnosed with potentially grave medical consequences. The prevailing diagnostic paradigm for the evaluation of the dizzy patient is based upon a 'pathophysiologic' approach. This approach begins a search for etiology with the assumption that the quality of symptoms (vertigo, presyncope, imbalance, or nonspecific dizziness) reflects the underlying pathophysiologic mechanism (vertigo = vestibular, presyncope = cardiovascular, imbalance = neurologic, and nonspecific = psychiatric). Although this assumption often holds true, the 'pathophysiologic' approach mandates a thorough etiologic search in each organ system, not only the one suggested by symptom quality. This strategy is well suited to the referral clinic setting where it was developed, but poorly suited to the time-pressured environment of the ED, where the high index of illness severity demands effective triage rather than diagnostic certainty. The candidate hypothesizes that: 1) potentially serious misdiagnoses of dizzy patients are uncommon but not rare events in the ED and may result from an over-reliance on the diagnostic importance on symptom quality; 2) a novel 'triage' approach to diagnosis would reduce misdiagnoses and improve outcomes in an 'in vitro' computer model of the diagnostic approach to dizziness; and 3) a clinical decision-support system based on this approach would reduce misdiagnoses under simulated patient conditions. To test these hypotheses, the candidate has designed three specific aims to: 1) measure the frequency, potential severity, and possible cause of misdiagnosis of dizzy patients in the ED (by gathering extensive case data on each ED dizzy patient and referencing ED physician [EP] diagnoses against those of a multidisciplinary expert panel); 2) design a computerized decision model to test a new 'triage' approach to diagnosis (by comparing 'in vitro' simulations of the two diagnostic approaches using hypothetical case scenarios); and 3) 'pilot' a web-based decision support system to reduce misdiagnosis of simulated ED dizzy patients (by comparing EP performance on a video-case-based examination with or without the use of the decision support system, using a randomized trial design). Results of this study will form the foundation for subsequent research into the effectiveness of error-reduction interventions among dizzy patients. The research career award candidate has devoted himself to acquiring the clinical and research skills required to complete this project and launch a successful career as an independent investigator. He has garnered the support and enthusiasm of both his clinical department and a large, multidisciplinary team that will enable him to complete the stated objectives. This research project and the research paradigms derived from it will form the nucleus of a career devoted to research in medical decision-making, causes of diagnostic errors, and methods to prevent them.

描述（由申请人提供）： 研究人员提出的研究目标是改善对急诊科就诊的头晕患者的诊断，其中一些患者被误诊，可能造成严重的医疗后果。评估眩晕患者的流行诊断范例是基于“病理生理学”方法。这种方法开始寻找病因时假设症状的质量（眩晕、先兆晕厥、不平衡或非特异性头晕）反映了潜在的病理生理机制（眩晕=前庭，先兆晕厥=心血管，不平衡=神经系统，非特异性=精神病）。尽管这一假设通常成立，但“病理生理学”方法要求对每个器官系统进行彻底的病因学研究，而不仅仅是症状质量所暗示的系统。这 该策略非常适合其制定的转诊诊所环境，但不太适合急诊室的时间压力环境，因为疾病严重程度指数较高，需要有效的分诊而不是诊断确定性。 候选人假设：1）头晕患者的潜在严重误诊在急诊室中并不常见，但并非罕见，可能是由于过度依赖症状质量的诊断重要性而导致的； 2）一种新颖的“分类”诊断方法将减少误诊并改善头晕诊断方法“体外”计算机模型的结果； 3）基于这种方法的临床决策支持系统将减少模拟患者条件下的误诊。 为了检验这些假设，候选人设计了三个具体目标：1) 衡量急诊室眩晕患者误诊的频率、潜在严重程度和可能原因（通过收集每位急诊室眩晕患者的大量病例数据，并根据多学科专家小组的诊断参考急诊室医生 [EP] 的诊断）； 2) 设计一个计算机化决策模型来测试新的“分类”诊断方法（通过使用假设案例场景比较两种诊断方法的“体外”模拟）； 3)“试点”基于网络的决策支持系统，以减少模拟急诊室眩晕患者的误诊（通过使用随机试验设计，比较使用或不使用决策支持系统的视频病例检查中的 EP 表现）。 这项研究的结果将为后续研究减少眩晕患者错误干预措施的有效性奠定基础。 研究职业奖候选人致力于获得完成该项目所需的临床和研究技能，并作为一名独立研究者开启成功的职业生涯。他获得了临床部门和大型多学科团队的支持和热情，这将使他能够完成既定目标。该研究项目以及由此衍生的研究范式将构成致力于医疗决策、诊断错误原因以及预防方法研究的职业核心。