Emergency physicians' acute coronary syndrome testing threshold and diagnostic performance: acute coronary syndrome critical pathway with return visit feedback.
Emergency physicians' acute coronary syndrome testing threshold and diagnostic performance: acute coronary syndrome critical pathway with return visit feedback.
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DOI：
10.1097/hpc.0000000000000021
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发表时间：
2014-09-01
影响因子：
--
通讯作者：
Radford, Martha
中科院分区：
文献类型：
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作者：
Graff, Louis G;Chern, Chii-Hwa;Radford, Martha
目的：急诊医生对急性冠脉综合征的诊断阈值直接关系到急性冠脉综合征的诊断率，与漏诊率呈负相关。向急诊医生反馈其先前未确诊的急性冠脉综合征患者的信息可能会提高医生的诊断性能。方法：对评估急性冠脉综合征患者的关键路径进行了修改，以包括对回访且在先前急诊科就诊时未发现其急性冠脉综合征诊断的医生的反馈。反馈包括具体病例的细节，每月发病率和死亡率会议上对病例的讨论，以及每年向每位医生提交一份报告，将他们的表现与同行进行比较(ACS评估率、ACS诊断率和ACS漏诊率)。结果：在研究期间，29名急诊医生评估了295758名患者，确定了6472例急性冠脉综合征患者。在研究期间，个体医生对ACS的年评估率为19%~70%(平均40.3%；95%可信区间为39.5%~41.1%)，个体医生年ACS诊断率为1.1%~4.2%(平均1.7%；95%可信区间，1.65%~1.75%)，年漏诊率为0%~17%(平均2.8%；95%可信区间，2.3%~3.3%)。医生个体急性冠脉综合征评价率与医生急性冠脉综合征诊断率呈正相关(r0.76，P=0.00012)，与医生漏诊率呈负相关(r0.45，P=0.001)。实施关键路径后，急性冠脉综合征的诊断率从30%提高到48%，漏诊率从1.5%下降到0.3%。结论：急诊医生对急性冠脉综合征的评估门槛越低，诊断急性冠脉综合征的频率越高，漏诊率越低。向急诊医生反馈患者回访的信息和他们自己的诊断表现可能会改善ACS患者的预后。
OBJECTIVES: Emergency physician threshold to test for acute coronary syndrome (ACS) is directly related to ACS diagnosis rate and inversely related to ACS missed diagnosis rate. Feedback to emergency physicians of information on their prior patients whose ACS diagnosis was not identified may improve physician diagnostic performance.METHODS: A critical pathway for evaluation of patients for ACS was modified to include feedback to physicians on their cases who had a return visit and did not have their ACS diagnosis identified at their prior emergency department visit. Feedback included case-specific details, discussion of the case at the monthly Morbidity and Mortality conference, and a yearly a report to each physician comparing their performance to their peers (ACS evaluation rate, ACS diagnosis rate, and ACS missed diagnosis rate). Cases were identified, and physician-specific performance was calculated from a computerized encounter database at 2 community teaching hospitals.RESULTS: During the study period, 29 emergency physicians evaluated 295,758 patients and identified 6472 ACS cases. During the study, the yearly ACS evaluation rate for individual physician ranged from 19% to 70% (average 40.3%; 95% confidence interval [CI], 39.5%-41.1%), the yearly ACS diagnosis rate for individual physician ranged from 1.1% to 4.2% (average 1.7%; 95% CI, 1.65%-1.75%), and the yearly missed ACS diagnosis rate for individual physician ranged from 0% to 17% (average 2.8%; 95% CI, 2.3%-3.3%). Individual physician ACS evaluation rate was directly related to physician ACS diagnosis rate (r 0.76, P = 0.00012) and was inversely related to that physician missed ACS rate (r 0.45, P = 0.001). During the study, implementation of the critical pathway increased the ACS evaluation rate from 30% to 48% and decreased the ACS missed diagnosis rate from 1.5% to 0.3%.CONCLUSIONS: Emergency physicians with lower threshold for ACS evaluation more frequently diagnose patients with ACS and less frequently miss the diagnosis of ACS. Feedback to emergency physicians of information on their patient's return visits and their own diagnostic performance may improve outcome for patients with ACS.