I don’t know why I’m in the hospital! Patient-Doctor Diagnostic Concordance by Berger
Post on 22-Nov-2014
882 Views
Preview:
DESCRIPTION
Transcript
I don’t know why I’m in the hospital!Patient-doctor diagnostic
concordance
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
Zackary Berger, MD, PhD
Assistant Professor
Johns Hopkins General Internal Medicine
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Doctors and patients think
differently.
Doctors and patients think
differently.
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
3
Doctor-patient diagnostic concordance
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?
• 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
4
Ripped from the Bellevue Hospital casefiles:
The real story of Ms. DRipped 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.
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
5
Doctor-patient communication in the hospital
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 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
6
Diagnostic concordance: a previous study (Tisnado 2006)
Diagnostic concordance: a previous study (Tisnado 2006) Diagnosis Percent agreement
MI 93% Cancer 92% Diabetic retinopathy 79% Depressed mood 73% Arthritis 69% Angina 65%
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
7
Diagnostic discordance among medicine inpatients:
specific aims
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?
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
8
Diagnostic discordance among medicine inpatients:
hypotheses
Diagnostic discordance among medicine inpatients:
hypothesesIgnorance/discordance associated
with Not speaking English Less education (fewer completed
years of schooling)
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
9
Study design, setting, and population
Study design, setting, and population
• Design: Cross-sectional
• Setting: Bellevue Hospital (New York)
• Population: Internal Medicine Inpatients• Excluding those who
o Did not speak English or Spanisho Were cognitively unable to participateo Were incarceratedo Were severely ill
o Study measures: via patient interview; medical record abstraction
• IRB approval: oral consent from all patients
• Design: Cross-sectional
• Setting: Bellevue Hospital (New York)
• Population: Internal Medicine Inpatients• Excluding those who
o Did not speak English or Spanisho Were cognitively unable to participateo Were incarceratedo Were severely ill
o 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
10
Patient interviewPatient interview
oDo you know the reason why your doctors say you’re in the hospital?
oUd. sabe el razón porque los doctores dicen que Ud. está en hospital?
oWhat was that reason?
oAlso collected information about age, gender, race/ethnicity, years of education
oDo you know the reason why your doctors say you’re in the hospital?
oUd. sabe el razón porque los doctores dicen que Ud. está en hospital?
oWhat was that reason?
oAlso collected information about age, gender, race/ethnicity, years of education
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
11
Medical record abstractionMedical record abstractionHierarchy of notes to abstract doctors’ reason for admission (most to least preferred):
oDaily progress note (housestaff or PA)
oDaily progress note (attending)
oFace sheet
Hierarchy of notes to abstract doctors’ reason for admission (most to least preferred):
oDaily progress note (housestaff or PA)
oDaily progress note (attending)
oFace sheet
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
12
How do we define EMR-patient diagnostic concordance?
How do we define EMR-patient diagnostic concordance?
• Agreement ono Organ systemo Pathophysiology
• Exampleso “Lung infection” and “colitis”
Agree neither on organ system nor on pathophysiology
o “Stomach pain” and “dysphagia” Agree on organ system but not on
pathophysiologyo “Blood clot” and “deep venous thrombosis”
Agree on organ system and pathophysiology
• Agreement ono Organ systemo Pathophysiology
• Exampleso “Lung infection” and “colitis”
Agree neither on organ system nor on pathophysiology
o “Stomach pain” and “dysphagia” Agree on organ system but not on
pathophysiologyo “Blood clot” and “deep venous thrombosis”
Agree on organ system and pathophysiology
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
13
Patient characteristics (N=46)
Patient characteristics (N=46)
• 51% women
• 50% older than 60
• 41% interviewed in Spanish
• 9 mean years completed schooling
• 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
14
“No sé porque estoy en hospital”
“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
• 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
15
Diagnostic discordanceDiagnostic 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
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
16
Discordance is greater among older patients
Discordance is greater among older patients
Concordant(N, %)
Discordant(N, %)
Age >= 60
Age < 60
5 (17%) 18 (83%)
11 (48%) 12 (52%)
30 (65%)Total 16 (35%)
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
17
Discordant patients are less educated
Discordant patients are less educated
Concordant Discordant
Mean years of schooling (SD)
10.6 (4.4) 8.9 (4.7)
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
18
SummarySummary
• 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
• 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
19
LimitationsLimitations
• 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
• 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 questionsFuture 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?
• “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
20
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
21
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
22
How do we address the problem of diagnostic discordance?
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
•Discussion of admission diagnosis between doctors and patients
•Auditing medical records to improve diagnostic cordance with patient
Make way for Diagnostic
Reconciliation!
Make way for Diagnostic
Reconciliation!
top related