Methods for Evaluating Diagnostic Processes in Outpatient Care

评估门诊护理诊断过程的方法

• 批准号: 9242842
• 负责人: Michael BARTON LAWS
• 金额: $ 10万
• 依托单位: BROWN UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-09-30 至 2017-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9242842
• 关键词: Methods; Evaluating; Diagnostic; Processes; Outpatient

ABSTRACT Diagnostic errors are estimated to affect 12 million patients in the U.S. each year and are an important source of preventable morbidity and mortality. One study concluded most errors involved process breakdowns in the patient-provider clinical encounter (78.9%), based on review of the EHR, but there are no studies linking diagnostic errors with actual observation of clinical encounters. Literature on diagnostic process is largely based on experiments using simulated situations, or experience in medical education. Diagnostic errors are commonly ascribed to cognitive biases or synthesis errors on the part of the physician, but in fact the clinical encounter is a dyadic interaction in which a patient complaint ordinarily initiates the diagnostic process and patient reports are an important source of information. The information patients volunteer, questions physicians ask and how they ask them, how patients express information, patients own opinions, all may be contribute to the diagnostic outcome. Linking recordings of outpatient encounters with subsequent information about diagnostic accuracy is a logistical challenge in that is impossible to know in advance what encounters will result in errors. However, members of our group have been involved in studies in which hundreds of encounters were audio recorded. It is feasible to record even larger numbers of encounters with the stipulation that only those in which diagnostic performance issues are subsequently identified will be analyzed. As preliminary work, we will generate descriptive information about real-world diagnostic processes using 147 transcripts of outpatient encounters we have previously collected and coded for other purposes. The coding systems isolate provider's information gathering processes, and diagnostic and treatment outcomes, with detailed information about elements such as symptoms, lab tests, physical examination, disease labels, and interactions within the diagnostic process – e.g., types of questions, information giving, expression of goals or affect, concern, reassurance, and instructions. Physical examinations can be deduced from the dialogue, and physicians generally announce their observations. We will build on the existing coding, specifically focusing on diagnostic processes. We will examine the diagnostic process within the clinical encounter and identify points of vulnerability for diagnostic failure such as premature closure, presumptive interpretation of ambiguous representations, or discounting of inconsistent evidence. The long term goal of this research is to develop and test physician, patient, and system-focused interventions to improve diagnostic accuracy in primary care and other routine outpatient care. The objective of this proposal is to analyze diagnosis-related elements of the clinical encounter for vulnerabilities, develop a taxonomy of diagnostic process failures identified and understand diagnostic performance within the patient- provider encounter using existing audiotaped data. Our team includes both social science expertise in analysis of communication, and clinical expertise in diagnosis.

摘要 据估计，美国每年有1200万名患者受到诊断错误的影响，这是一个重要的 可预防的发病率和死亡率的来源。一项研究得出结论，大多数错误与流程故障有关 在患者-提供者的临床接触中(78.9%)，基于对EHR的回顾，但没有研究表明 诊断错误与临床接触的实际观察。关于诊断过程的文献主要是 基于模拟情境的实验，或医学教育中的经验。诊断错误包括 通常归因于医生的认知偏差或合成错误，但实际上临床上 相遇是一种二元互动，在这种互动中，患者的主诉通常会启动诊断过程，并且 病人报告是重要的信息来源。患者自愿提供的信息，质疑医生 询问以及他们如何询问他们，患者如何表达信息，患者自己的意见，所有这些都可能是有助于 诊断结果。将门诊就诊记录与后续信息联系起来 诊断的准确性是一个后勤挑战，因为不可能提前知道遇到什么 会导致错误。然而，我们小组的成员参与了数百项研究 他们的遭遇被录音了。按照这一规定记录更多的遭遇是可行的 只有在随后发现诊断性能问题的情况下才会进行分析。 作为前期工作，我们将使用以下工具生成有关真实诊断过程的描述性信息 我们之前收集了147份门诊会面的记录，并将其编码用于其他目的。这个 编码系统隔离提供者的信息收集过程以及诊断和治疗结果， 具有关于症状、实验室测试、体检、疾病标签、 以及诊断过程中的交互作用--例如，问题类型、信息提供、目标表达 或影响、关心、安慰和指示。体检可以从对话中推断出来， 医生通常会公布他们的观察结果。我们将在现有编码的基础上进行构建，特别是 专注于诊断过程。我们将在临床会诊中检查诊断过程，并 确定诊断失败的易受攻击点，例如过早关闭、推定解释 模棱两可的陈述，或对不一致证据的轻视。 这项研究的长期目标是开发和测试以医生、患者和系统为重点的 在初级保健和其他常规门诊护理中提高诊断准确性的干预措施。的目标是 这项建议是为了分析临床遇到的脆弱性的诊断相关元素，开发一个 已识别的诊断过程故障的分类，并了解患者的诊断性能- 提供商遇到使用现有录音数据的情况。我们的团队在分析中既有社会科学方面的专业知识 沟通和诊断方面的临床专业知识。