Testing Pediatric Rheumatology Diagnostic Decision Support in Clinical Use

本研究旨在通过使用决策支持软件来缓解儿科风湿病专家的严重短缺 提高全科医师的风湿病诊断能力。在我们的SBIR1“赋权 儿科血液流变学循证决策支持的医生”血液流变学信息是 添加到SimulConsult诊断决策支持工具。使用儿科流变学病例进行测试 插图显示，使用该工具后，各组临床医生的诊断效率都有所提高。诊断 错误减少，错误定义为在鉴别诊断中缺乏正确的诊断或其类别 诊断.错误率从28%下降到15%（相对减少45%），其中初级医生的减少幅度最大 (69%相对减少）和急诊科医生（62%相对减少）。 在改进诊断工具后，SBIR2提案将SBIR1研究扩展到实际临床实践 按照SBIR1的建议。我们假设在实际实践中的改进类似于使用案例 小插曲。这种能力的广泛使用将缓解儿科风湿病学家的严重短缺， 减少延误或虐待造成的不良后果。 目标1是通过基于案例的质量改进来改进决策支持 使用SBIR1中测试的8个案例开发的方法。将正式确定这一方法， 进一步改进，使用100个额外的案例。使用这种方法已经出现的改进将 在这方面，我们建议，在具体说明疾病出现的时间和速度方面，增加一个新的层面。其他 改进将是资源，以协助非专家在确定关键的调查结果，“捆绑”的几个 一个测试的结果，可以结合起来，以更好地代表获得该测试的有用性，增加 在叙述性资源中通常没有提到的进一步发现，例如对特定治疗的反应， 排除性发现，并在风湿性疾病的鉴别诊断中增加其他疾病。 目的2是临床护理的有效性试验。这将在波士顿的急诊室完成 儿童医院，12个月以上的病人约500人，医院的风湿病诊所，约500人 患者，共1000例。病例将被随机分配至对照条件，在该条件下，测试者可以 使用所有常用的资源，如教科书或网络搜索，或干预条件，其中 使用诊断工具，并且也可以使用相同的常用资源。学员将记录他们的 鉴别诊断和试验前后的计划检查。这些名单将被比作“黄金 根据高级风湿病学家的评估、实验室检测和随访， 随后的几个月。误差，相关性，全面性和成本影响，将进行分析。 证明非风湿病学家和受训者提高了他们在儿科风湿病诊断中的水平， 节省成本将使诊断决策支持商业化，以医院和儿科医生。

This research aims to ease the critical shortage of pediatric rheumatologists by using decision support software to improve the ability of generalist physicians to make rheumatologic diagnoses. In our SBIR1 “Empowering Physicians with Evidence-Based Decision Support for Pediatric Rheumatology” rheumatology information was added to the SimulConsult diagnostic decision support tool. Testing using pediatric rheumatology case vignettes showed that all groups of clinicians were more effective in diagnosis after using the tool. Diagnostic error was reduced, with error defined as the absence of the correct diagnosis or its category in the differential diagnosis. Error fell from 28% to 15% (45% relative reduction), with largest reductions among junior physicians (69% relative reduction) and Emergency Medicine physicians (62% relative reduction). This SBIR2 proposal extends the SBIR1 research to actual clinical practice, after improving the diagnostic tool in ways suggested by the SBIR1. We hypothesize improvements in actual practice similar to those using case vignettes. Wide use of such capabilities would ease the critical shortage of pediatric rheumatologists, and reduce instances of bad outcomes from delay or mistreatment. Aim 1 is to improve the decision support in ways suggested by a case-based quality improvement methodology developed using the 8 cases tested in the SBIR1. That methodology will be formalized to guide further improvement, using 100 additional cases. Improvements already surfaced using this methodology will be implemented, including a new dimension to specifying time, speed of emergence of a disease. Other improvements will be resources to assist non-specialists in identification of key findings, “bundles” of several results of one test that can be combined to better represent the usefulness of obtaining that test, addition of further findings often not mentioned in narrative resources such as responses to particular treatments, adding exclusionary findings, and adding further diseases in the differential diagnosis of rheumatologic conditions. Aim 2 is a trial of effectiveness in clinical care. This will be done in the emergency department of Boston Children's Hospital, with ~500 patients over 12 months, and in rheumatology clinic at the hospital, with ~500 patients, for a total of 1000 cases. Cases will be randomized to a Control condition, in which the tester may use all usual resources such as textbooks or web searches, or an Intervention condition, in which the diagnostic tool is used and the same usual resources may be used, as well. Trainees will record their differential diagnosis and planned workup before and after the trial. These lists will be compared to the “gold standard” diagnosis and workup, based on assessments of senior rheumatologists, lab testing and follow-up in subsequent months. Error, relevance, comprehensiveness, and cost impact, will be analyzed. Demonstrating that non-rheumatologists and trainees improve their diagnoses in pediatric rheumatology and save costs will enable the diagnostic decision support to be commercialized to hospitals and pediatricians.