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Diagnostic Concordance by Berger

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Diagnostic Concordance by Berger

  1. 1. 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
  2. 2. Doctors and patients think differently.
  3. 3. Doctor-patient diagnostic concordance <ul><ul><li>Mr. Gonzalez says he’s more tired now because he’s getting old . Dr. Patel says Gonzalez has unstable angina . </li></ul></ul><ul><ul><li>Are they talking about the same thing? </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  4. 4. Ripped from the Bellevue Hospital casefiles: The real story of Ms. D <ul><li>Ms. D’Angelo is a 61 year old English-speaking woman from New York. She has a twelfth-grade education. </li></ul><ul><li>Why did her doctors admit her? </li></ul><ul><li>They say : atrial tachycardia, right-sided hemiparesis, and Broca's aphasia. </li></ul><ul><li>She says : Because I can't speak. </li></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  5. 5. Doctor-patient communication in the hospital <ul><ul><li>Why is it important? </li></ul></ul><ul><ul><li>Why isn’t it important? </li></ul></ul><ul><ul><li>What are the goals? </li></ul></ul><ul><ul><li>How do we know we’ve done a good job? </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  6. 6. Diagnostic concordance: a previous study (Tisnado 2006) <ul><li>Diagnosis Percent agreement </li></ul><ul><li>MI 93% </li></ul><ul><li>Cancer 92% </li></ul><ul><li>Diabetic retinopathy 79% </li></ul><ul><li>Depressed mood 73% </li></ul><ul><li>Arthritis 69% </li></ul><ul><li>Angina 65% </li></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  7. 7. Diagnostic discordance among medicine inpatients: specific aims <ul><li>What proportion of medicine inpatients don’t know the physicians’ reason for admitting them? </li></ul><ul><li>What proportion give a doctors’ reason for admitting which doesn’t concord with the reason in the EMR? </li></ul><ul><li>What are the covariates associated with concordance? Discordance? </li></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  8. 8. Diagnostic discordance among medicine inpatients: hypotheses <ul><li>Ignorance/discordance associated with </li></ul><ul><ul><li>Not speaking English </li></ul></ul><ul><ul><li>Less education (fewer completed years of schooling) </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  9. 9. Study design, setting, and population <ul><ul><li>Design : Cross-sectional </li></ul></ul><ul><ul><li>Setting : Bellevue Hospital (New York) </li></ul></ul><ul><ul><li>Population : Internal Medicine Inpatients </li></ul></ul><ul><ul><ul><li>Excluding those who </li></ul></ul></ul><ul><ul><ul><ul><li>Did not speak English or Spanish </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Were cognitively unable to participate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Were incarcerated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Were severely ill </li></ul></ul></ul></ul><ul><ul><li>Study measures : via patient interview; medical record abstraction </li></ul></ul><ul><ul><li>IRB approval : oral consent from all patients </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  10. 10. Patient interview <ul><ul><ul><li>Do you know the reason why your doctors say you’re in the hospital ? </li></ul></ul></ul><ul><ul><ul><li>Ud. sabe el razón porque los doctores dicen que Ud. está en hospital? </li></ul></ul></ul><ul><ul><ul><li>What was that reason? </li></ul></ul></ul><ul><ul><ul><li>Also collected information about age, gender, race/ethnicity, years of education </li></ul></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  11. 11. Medical record abstraction <ul><ul><li>Hierarchy of notes to abstract doctors’ reason for admission (most to least preferred): </li></ul></ul><ul><ul><ul><ul><li>Daily progress note (housestaff or PA) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Daily progress note (attending) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Face sheet </li></ul></ul></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  12. 12. How do we define EMR-patient diagnostic concordance? <ul><ul><li>Agreement on </li></ul></ul><ul><ul><ul><li>Organ system </li></ul></ul></ul><ul><ul><ul><li>Pathophysiology </li></ul></ul></ul><ul><ul><li>Examples </li></ul></ul><ul><ul><ul><li>“ Lung infection” and “colitis” </li></ul></ul></ul><ul><ul><ul><ul><li>Agree neither on organ system nor on pathophysiology </li></ul></ul></ul></ul><ul><ul><ul><li>“ Stomach pain” and “dysphagia” </li></ul></ul></ul><ul><ul><ul><ul><li>Agree on organ system but not on pathophysiology </li></ul></ul></ul></ul><ul><ul><ul><li>“ Blood clot” and “deep venous thrombosis” </li></ul></ul></ul><ul><ul><ul><ul><li>Agree on organ system and pathophysiology </li></ul></ul></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  13. 13. Patient characteristics (N=46) <ul><ul><li>51% women </li></ul></ul><ul><ul><li>50% older than 60 </li></ul></ul><ul><ul><li>41% interviewed in Spanish </li></ul></ul><ul><ul><li>9 mean years completed schooling </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  14. 14. “ No sé porque estoy en hospital” <ul><ul><li>Eleven percent of patients can’t give any reason why the doctors admitted them to the hospital </li></ul></ul><ul><ul><li>Sixty percent of these are Spanish-speaking </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  15. 15. Diagnostic discordance <ul><li>The diagnosis the patient reports as the doctors’ reason for admission doesn’t match the diagnosis in the computer chart… 54% of the time . </li></ul><ul><li>15% disagree on organ system and pathophysiology </li></ul><ul><li>39% agree on organ system but not pathophysiology </li></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  16. 16. 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%)
  17. 17. 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)
  18. 18. Summary <ul><ul><li>There is significant doctor-inpatient diagnostic discordance on the medicine service of a large public city hospital </li></ul></ul><ul><ul><li>About ten percent of patients can’t give any reason why they were admitted to the hospital </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  19. 19. Limitations <ul><li>Small sample size doesn’t allow us to examine patient characteristics associated with concordance/discordance </li></ul><ul><ul><li>Future research could expand study population </li></ul></ul><ul><li>Single institution in New York City </li></ul><ul><ul><li>Future research could replicate study in other settings </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  20. 20. Future questions <ul><ul><li>“ Has the doctor told you?” </li></ul></ul><ul><ul><li>Controlling for physicians’ diagnostic uncertainty (“rule-out” admissions) </li></ul></ul><ul><ul><li>Diagnostic knowledge or concordance at admission vs. discharge </li></ul></ul><ul><ul><li>Concordance ↔ better outcomes? </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  21. 21. Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  22. 22. How do we address the problem of diagnostic discordance? <ul><ul><li>Discussion of admission diagnosis between doctors and patients </li></ul></ul><ul><ul><li>Auditing medical records to improve diagnostic cordance with patient </li></ul></ul>Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
  23. 23. Make way for Diagnostic Reconciliation!

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