Building a New Model for Diagnosis of ED Dizzy Patients

描述(由申请人提供)： 调查人员提出研究的目的是改善对向急诊室提出头晕的患者的诊断，其中一些患者被误诊为可能造成严重医疗后果的患者。评估眩晕患者的主流诊断范例是基于“病理生理学”方法。这种方法开始了对病因学的研究，假设症状的性质(眩晕、晕厥前期、失衡或非特异性眩晕)反映了潜在的病理生理机制(眩晕=前庭、晕厥前期=心血管疾病、失衡=神经系统疾病、非特异性=精神病学)。虽然这一假设通常是正确的，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学搜索，而不仅仅是症状质量所建议的一个。这 该战略非常适合于制定该战略的转诊诊所环境，但不适合急诊室时间紧迫的环境，在这种环境中，疾病严重程度的高指数要求有效的分诊，而不是诊断的确定性。 候选人假设：1)头晕患者潜在的严重误诊在急诊室并不常见，但并不罕见，可能是由于过度依赖于对症状质量的诊断重要性；2)一种新的“分诊”诊断方法将减少误诊，并在头晕诊断方法的“体外”计算机模型中改善结果；以及3)基于该方法的临床决策支持系统将在模拟患者条件下减少误诊。 为了验证这些假设，候选人设计了三个具体目标：1)测量ED中眩晕患者的误诊频率、潜在严重性和可能的原因(通过收集每个ED眩晕患者的大量病例数据，并参考ED医生[EP]的诊断与多学科专家小组的诊断)；2)设计一个计算机化的决策模型，以测试新的‘分类’诊断方法(通过使用假设的病例情景比较两种诊断方法的‘体外’模拟)；和3)一个基于网络的决策支持系统，以减少对模拟ED眩晕患者的误诊(通过比较使用或不使用决策支持系统的基于视频病例的检查的EP性能，使用随机试验设计)。 这项研究的结果将为后续研究在眩晕患者中减少错误干预的有效性奠定基础。 这位研究生涯奖候选人致力于获得完成这一项目所需的临床和研究技能，并作为一名独立研究员开始了成功的职业生涯。他已经获得了他的临床部门和一个大型多学科团队的支持和热情，这将使他能够完成所宣布的目标。这项研究项目及其衍生的研究范式将构成致力于研究医疗决策、诊断错误的原因以及预防错误的方法的职业生涯的核心。

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.