I don’t know why I’m in the hospital! Patient-doctor diagnostic concordance Zackary Berger, MD, PhD Assistant Professor Johns Hopkins General Internal Medicine

Doctors and patients think differently.

Doctor-patient diagnostic concordance Mr. Gonzalez says he’s more tired now because he’s getting old . Dr. Patel says Gonzalez has unstable angina . Are they talking about the same thing? Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Mr. Gonzalez says he’s more tired now because he’s getting old . Dr. Patel says Gonzalez has unstable angina .

Are they talking about the same thing?

Ripped from the Bellevue Hospital casefiles: The real story of Ms. D Ms. D’Angelo is a 61 year old English-speaking woman from New York. She has a twelfth-grade education. Why did her doctors admit her? They say : atrial tachycardia, right-sided hemiparesis, and Broca's aphasia. She says : Because I can't speak. Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Ms. D’Angelo is a 61 year old English-speaking woman from New York. She has a twelfth-grade education.

Why did her doctors admit her?

They say : atrial tachycardia, right-sided hemiparesis, and Broca's aphasia.

She says : Because I can't speak.

Doctor-patient communication in the hospital Why is it important? Why isn’t it important? What are the goals? How do we know we’ve done a good job? Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Why is it important?

Why isn’t it important?

What are the goals?

How do we know we’ve done a good job?

Diagnostic concordance: a previous study (Tisnado 2006) Diagnosis Percent agreement MI 93% Cancer 92% Diabetic retinopathy 79% Depressed mood 73% Arthritis 69% Angina 65% Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Diagnosis Percent agreement

MI 93%

Cancer 92%

Diabetic retinopathy 79%

Depressed mood 73%

Arthritis 69%

Angina 65%

Diagnostic discordance among medicine inpatients: specific aims What proportion of medicine inpatients don’t know the physicians’ reason for admitting them? What proportion give a doctors’ reason for admitting which doesn’t concord with the reason in the EMR? What are the covariates associated with concordance? Discordance? Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

What proportion of medicine inpatients don’t know the physicians’ reason for admitting them?

What proportion give a doctors’ reason for admitting which doesn’t concord with the reason in the EMR?

What are the covariates associated with concordance? Discordance?

Diagnostic discordance among medicine inpatients: hypotheses Ignorance/discordance associated with Not speaking English Less education (fewer completed years of schooling) Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Ignorance/discordance associated with

Not speaking English

Less education (fewer completed years of schooling)

Study design, setting, and population Design : Cross-sectional Setting : Bellevue Hospital (New York) Population : Internal Medicine Inpatients Excluding those who Did not speak English or Spanish Were cognitively unable to participate Were incarcerated Were severely ill Study measures : via patient interview; medical record abstraction IRB approval : oral consent from all patients Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Design : Cross-sectional

Setting : Bellevue Hospital (New York)

Population : Internal Medicine Inpatients

Excluding those who

Did not speak English or Spanish

Were cognitively unable to participate

Were incarcerated

Were severely ill

Study measures : via patient interview; medical record abstraction

IRB approval : oral consent from all patients

Patient interview Do you know the reason why your doctors say you’re in the hospital ? Ud. sabe el razón porque los doctores dicen que Ud. está en hospital? What was that reason? Also collected information about age, gender, race/ethnicity, years of education Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Do you know the reason why your doctors say you’re in the hospital ?

Ud. sabe el razón porque los doctores dicen que Ud. está en hospital?

What was that reason?

Also collected information about age, gender, race/ethnicity, years of education

Medical record abstraction Hierarchy of notes to abstract doctors’ reason for admission (most to least preferred): Daily progress note (housestaff or PA) Daily progress note (attending) Face sheet Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Hierarchy of notes to abstract doctors’ reason for admission (most to least preferred):

Daily progress note (housestaff or PA)

Daily progress note (attending)

Face sheet

How do we define EMR-patient diagnostic concordance? Agreement on Organ system Pathophysiology Examples “ Lung infection” and “colitis” Agree neither on organ system nor on pathophysiology “ Stomach pain” and “dysphagia” Agree on organ system but not on pathophysiology “ Blood clot” and “deep venous thrombosis” Agree on organ system and pathophysiology Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Agreement on

Organ system

Pathophysiology

Examples

“ Lung infection” and “colitis”

Agree neither on organ system nor on pathophysiology

“ Stomach pain” and “dysphagia”

Agree on organ system but not on pathophysiology

“ Blood clot” and “deep venous thrombosis”

Agree on organ system and pathophysiology

Patient characteristics (N=46) 51% women 50% older than 60 41% interviewed in Spanish 9 mean years completed schooling Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

51% women

50% older than 60

41% interviewed in Spanish

9 mean years completed schooling

“ No sé porque estoy en hospital” Eleven percent of patients can’t give any reason why the doctors admitted them to the hospital Sixty percent of these are Spanish-speaking Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Eleven percent of patients can’t give any reason why the doctors admitted them to the hospital

Sixty percent of these are Spanish-speaking

Diagnostic discordance The diagnosis the patient reports as the doctors’ reason for admission doesn’t match the diagnosis in the computer chart… 54% of the time . 15% disagree on organ system and pathophysiology 39% agree on organ system but not pathophysiology Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

The diagnosis the patient reports as the doctors’ reason for admission doesn’t match the diagnosis in the computer chart… 54% of the time .

15% disagree on organ system and pathophysiology

39% agree on organ system but not pathophysiology

Discordance is greater among older patients Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH Concordant (N, %) Discordant (N, %) Age >= 60 Age < 60 5 (17%) 18 (83%) 11 (48%) 12 (52%) 30 (65%) Total 16 (35%)

Discordant patients are less educated Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH Concordant Discordant Mean years of schooling (SD) 10.6 (4.4) 8.9 (4.7)

Summary There is significant doctor-inpatient diagnostic discordance on the medicine service of a large public city hospital About ten percent of patients can’t give any reason why they were admitted to the hospital Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

There is significant doctor-inpatient diagnostic discordance on the medicine service of a large public city hospital

About ten percent of patients can’t give any reason why they were admitted to the hospital

Limitations Small sample size doesn’t allow us to examine patient characteristics associated with concordance/discordance Future research could expand study population Single institution in New York City Future research could replicate study in other settings Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Small sample size doesn’t allow us to examine patient characteristics associated with concordance/discordance

Future research could expand study population

Single institution in New York City

Future research could replicate study in other settings

Future questions “ Has the doctor told you?” Controlling for physicians’ diagnostic uncertainty (“rule-out” admissions) Diagnostic knowledge or concordance at admission vs. discharge Concordance ↔ better outcomes? Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

“ Has the doctor told you?”

Controlling for physicians’ diagnostic uncertainty (“rule-out” admissions)

Diagnostic knowledge or concordance at admission vs. discharge

Concordance ↔ better outcomes?

Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

How do we address the problem of diagnostic discordance? Discussion of admission diagnosis between doctors and patients Auditing medical records to improve diagnostic cordance with patient Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

Discussion of admission diagnosis between doctors and patients

Auditing medical records to improve diagnostic cordance with patient

Make way for Diagnostic Reconciliation!