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

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

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Doctors and patients think

differently.

Doctors and patients think

differently.

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

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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?


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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.


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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?


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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%


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Diagnostic discordance among medicine inpatients:

specific aims


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?


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hypotheses


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)


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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


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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


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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


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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


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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


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“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


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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


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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%)


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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)


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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


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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?


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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!

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

Health & Medicine

hopkins gim

esten hospital

bellevue hospital casefiles

diagnostic discordance

icch concordant n

s porque estoy en hospital

abstract doctors reason

patient reports