Building a New Model for Diagnosis of ED Dizzy Patients

超出规定的空间。我们提出研究的目的是提高急诊部门对头晕患者的诊断，其中一些患者被误诊为潜在的严重医疗后果。评估眩晕患者的主要诊断范例是基于“病理生理学”方法。这种方法首先寻找病因，假设症状的性质（眩晕、晕厥前期、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，晕厥前期=心血管，不平衡=神经，非特异性=精神）。虽然这种假设通常是正确的，但“病理生理学”方法要求在每个器官系统中进行彻底的病因研究，而不仅仅是症状质量所提示的病因。这种策略非常适合转诊诊所的设置，但不适合急诊科的时间紧迫的环境，在那里，疾病严重程度的高指数需要有效的分诊，而不是诊断的确定性。我们假设：(a)在急诊科中，对眩晕患者的潜在严重误诊并不常见，但并不罕见，这可能是由于过度依赖对症状质量的诊断重要性；(b)一种新的“分诊”诊断方法将减少误诊，并改善眩晕诊断方法的“体外”计算机模型的结果；(c)基于该方法的临床决策支持系统可以减少模拟患者情况下的误诊。为了验证我们的假设，我们设计了三个具体目标：(1)测量急诊科眩晕患者误诊的频率、潜在的严重程度和可能的原因（通过收集每个急诊科眩晕患者的广泛病例数据，并参考急诊科医生[EP]的诊断与多学科专家小组的诊断）；(2)设计一个计算机化决策模型，以测试一种新的“分诊”诊断方法（通过使用假设的病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ED头晕患者的误诊（通过使用决策支持系统或不使用决策支持系统，使用随机试验设计，比较基于视频的检查中的EP表现）。本研究结果将为后续研究减少错误干预措施在眩晕患者中的有效性奠定基础。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始成功的职业生涯。他获得了他的临床部门和一个庞大的多学科团队的支持和热情，这将使他能够完成既定的目标。该研究项目及其衍生的研究范式将构成一个致力于医疗决策、诊断错误的原因和预防方法研究的职业生涯的核心。网站性能 ======================================== 节结束 ===========================================

EXCEEDTHE SPACE PROVIDED. The goal of our proposed research is to improve diagnosis of patients presenting to the Emergency Department [ED] with dizziness, some of whom are misdiagnosed with potentiallygrave 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 non-specific dizziness) reflects the underlying pathophysiologic mechanism (vertigo = vestibular, presyncope = cardiovascular, imbalance = neurologic, and non-specific = 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. We hypothesize that (a) 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; (b) 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 (c) a clinical decision-support system based on this approach would reduce misdiagnoses under simulated patient conditions. To test our hypotheses, we have 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 preventthem. PERFORMANCE SITE ========================================Section End===========================================