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I don’t know why I’m in the hospital! Patient-Doctor Diagnostic Concordance by Berger
 

I don’t know why I’m in the hospital! Patient-Doctor Diagnostic Concordance by Berger

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    I don’t know why I’m in the hospital! Patient-Doctor Diagnostic Concordance by Berger I don’t know why I’m in the hospital! Patient-Doctor Diagnostic Concordance by Berger Presentation Transcript

    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • “ 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Make way for Diagnostic Reconciliation!