Diagnosis最新文献

Objectives: Although cognitive biases are one of the most frequent causes of diagnostic errors, their influence remains underestimated in allied health professions, especially in osteopathy. Yet, a part of osteopathic clinical reasoning and diagnosis rely on the practitioner's intuition and subjective haptic perceptions. The aim of this study is to highlight links between the cognitive biases perceived by the practitioner to understand cognitive patterns during osteopathic diagnosis, and to suggest debiasing strategies.

Methods: A mixed method based on an explanatory sequential type is used. (QUAN→QUAL). A quantitative cross-sectional survey of 272 French osteopaths and three focus groups including 24 osteopaths were carried out. The quantitative analysis includes multinominal logistic regression models and multiple correspondence analysis. The qualitative analysis is based on the framework method (within thematic analysis) and followed a step-by-step guide (Gale et al.).

Results: Among 19 selected biases, osteopaths feel to be affected by 9.4 ± 0.28 biases (range [1-19], median=9). Some presumed biases would be associated, and socio-demographic (gender, age) and professional (experience and types of practice) factors would modify how practitioners perceive the presence of biases. Main debiasing solutions are supervision and transcultural clinical competences.

Conclusions: Osteopaths believe their diagnosis is impaired by the presence of cognitive biases as observed in clinical reality. Some biases are shared with medical doctors, but others are more specific to osteopaths, such as confirmation bias. To reduce their effect, the practitioner needs to be aware of these cognitive patterns of clinical reasoning, understand the patient and himself better, and use objective tests.

Objectives: Diagnostic error is a global emergency. Context specificity is likely a source of the alarming rate of error and refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and examination findings, but due to the presence of contextual factors, decides on two different diagnoses. Studies have not empirically addressed the potential role of context specificity in management reasoning and errors with a diagnosis may not consistently translate to actual patient care.

Methods: We investigated the effect of context specificity on management reasoning in individuals working within a simulated internal medicine environment. Participants completed two ten minute back to back common encounters. The clinical content of each encounter was identical. One encounter featured the presence of carefully controlled contextual factors (CF+ vs. CF-) designed to distract from the correct diagnosis and management. Immediately after each encounter participants completed a post encounter form.

Results: Twenty senior medical students participated. The leading diagnosis score was higher (mean 0.88; SEM 0.07) for the CF- encounter compared with the CF+ encounter (0.58; 0.1; 95 % CI 0.04-0.56; p=0.02). Management reasoning scores were higher (mean 5.48; SEM 0.66) for the CF- encounter compared with the CF+ encounter (3.5; 0.56; 95 % CI 0.69-3.26; p=0.01). We demonstrated context specificity in both diagnostic and management reasoning.

Conclusions: This study is the first to empirically demonstrate that management reasoning, which directly impacts the patient, is also influenced by context specificity, providing additional evidence of context specificity's role in unwanted variance in health care.

Objectives: To examine factors impacting diagnostic evaluation of suspected deep vein thrombosis (DVT) by analyzing the test ordering patterns and provider decision-making within a universal health coverage system in Hungary.

Methods: We analyzed test orders for suspected DVT between 2007 and 2020, and the financial framework influencing diagnostic practices. An anonymous survey was also conducted among Emergency Department physicians to explore factors influencing diagnostic decision-making.

Results: A total of 6,821 patients were identified. From 2008 to 2013, the most common diagnostic approach combined D-dimer and duplex ultrasound tests (64.5 %), followed by sole ultrasound (20.5 %) and sole D-dimer (15 %) testing. A marked shift occurred from 2014 onward, with sole ultrasound rising to 88 % of cases by 2018-2020, while combined testing and sole D-dimer orders decreased to 7.9 and 4 %, respectively. In survey results, time efficiency emerged as a key factor for bypassing D-dimer testing, cited by 75 % of physicians. 45 % believed D-dimer costs were comparable to or higher than duplex ultrasound. Financial analysis revealed that the outdated performance points system misrepresented actual costs, resulting in duplex ultrasound being significantly underfunded, which impacts the Radiology Department. This discrepancy contributes to higher national level expenses, driven by the increased reliance on ultrasound.

Conclusions: We found diagnostic practices deviating from international diagnostic guidelines, with an increase in duplex ultrasound over D-dimer. This shift, allowed by an outdated financing structure, increases overall costs for the healthcare system. Revising financial frameworks to reflect true costs is essential for sustainable operations in universal health coverage systems.

Objectives: Published clinical reasoning curricula are limited, and measuring curricular impact has proven difficult. This study aims to evaluate the impact of a broad-reaching, multi-level reasoning curricula by measuring utilization of clinical reasoning terminology in published abstracts.

Methods: In 2014, the University of Pittsburgh Medical Center (UPMC) created a clinical reasoning curriculum with interventions at the student, resident, and faculty levels with the goal of bringing reasoning education to the forefront. This study was a retrospective analysis of published clinical vignettes of the Society of General Internal Medicine prior to local curricular intervention (2014), post-curricular intervention (2018), and on follow-up (2022). UPMC-affiliated abstracts were compared to abstracts containing reasoning terms from all other institutions, at each time point.

Results: There was a statistically significant increase in the use of clinical reasoning terms by UPMC-affiliated participants from 2014 to 2018. Non-UPMC submissions, saw a smaller, but still significant increase in the use of clinical reasoning terms. There was a decline in clinical reasoning term use from 2018 to 2022, both at UPMC and nationally.

Conclusions: This study demonstrates that widespread clinical reasoning curricula can increase interest in and use of clinical reasoning terminology. Further work is needed to develop creative assessment tools for reasoning curricula.

Objectives: Competency in diagnostic reasoning is integral to medical training and patient safety. Situativity theory highlights the importance of contextual factors on learning and performance, such as being informed of a provisional diagnosis prior to a patient encounter. This study aims to determine how being informed of a provisional diagnosis affects an intern's approach to diagnostic reasoning.

Methods: This mixed methods study was conducted in a real-time workplace learning environment at a large teaching hospital. Interns were randomized to the Chief Complaint (CC) only or chief complaint with Provisional Diagnosis (PD) group. One blinded researcher assessed intern diagnostic reasoning using a validated tool. Mean group scores were compared using the two-sample t-test. The researcher was unblinded for think aloud interviews analyzed via thematic analysis.

Results: There was no difference in performance between the CC and PD groups (mean ± SD): 47.8 ± 8.1 vs. 43.9 ± 10.9, p=0.24. Thematic analysis identified that interns aware of the provisional diagnosis 1) invested less effort in diagnostic reasoning, 2) formulated a differential through a narrowly focused frame, 3) accepted a provisional diagnosis as definitive, and 4) sought to confirm rather than refute the provisional diagnosis.

Conclusions: Our discordant results highlight the complex interplay between a provisional diagnosis and diagnostic reasoning performance in early learners. Though an accurate provisional diagnosis may enhance diagnostic reasoning outcomes, our qualitative results suggest that it may pose certain risks to the diagnostic reasoning process. Metacognitive strategies may be a ripe field for exploration to optimize this complex interplay.

Personalized medicine, aiming to tailor treatments based on individual patient characteristics, holds immense potential in oncology. However, its widespread adoption in Europe faces numerous challenges, as illustrated by the case study of the Oncotype DX Breast Recurrence Score^® assay, a genomic test for breast cancer. This manuscript delineates the multifaceted obstacles encountered during the introduction of the Oncotype DX^®test (Oncotype DX Breast Recurrence Score test) in Europe from 2004 to 2018. In June 2018, the TAILORx results were published in the New England Journal of Medicine Sparano JA, Gray RJ, Makower DF, Pritchard KI, Albain KS, Hayes DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med 2018;379:111-21, Sparano JA, Gray RJ, Ravdin PM, Makower DF, Pritchard KI, Albain KS, et al. Clinical and genomic risk to guide the use of adjuvant therapy for breast cancer. N Engl J Med 2019;380:2395-405, and reported that among 6,711 women with hormone-receptor-positive, HER2-negative, node-negative breast cancer and a midrange recurrence score of 11-25 on the Oncotype DX assay, endocrine therapy was not inferior to chemoendocrine therapy, which provides evidence that adjuvant chemotherapy was not beneficial in these patients. Through a comprehensive analysis of clinical evidence, commercial presence, reimbursement mechanisms, guideline recommendations, regulatory pathways, and local experiences, this study sheds light on the intricate dynamics influencing the adoption of personalized medicine technologies. This article examines the various obstacles encountered during the introduction of the Oncotype DX Breast Cancer Assay in Europe from 2004 to 2018. By analyzing clinical evidence, commercial presence, reimbursement mechanisms, guideline recommendations, regulatory pathways, and local experiences, this study reveals the complex factors that influence the adoption of personalized medicine technologies. By highlighting these challenges, this article offers valuable insights into strategies to facilitate the integration of innovative diagnostic tools into clinical practice across Europe, ultimately leading to improved treatment decision-making for cancer patients.

Objectives: Validation and performance assessment of novel ESR analyzer is required before implementation. The objective of this study was to assess the correlation between three ESR measurement methods. Full validation and performance assessment of an alternate method (TEST1) were also evaluated.

Methods: Three-way correlation assessment for the Westergren (WG), modified Westregren (Mixrate), and alternate (TEST1) methods were performed. Analytical performance of TEST1 including precision, carryover, sample stability, potential interferences as well as effect of hematocrit (Hct) and mean corpuscular volume (MCV) were also determined.

Results: Strong correlation between three ESR measurement methods were observed. Correlation coefficient (r) was 0.902, 0.977, and 0.949 for WG vs. TEST1, WG vs. Mixrate, and TEST1 vs. Mixrate, respectively with absolute bias <5 mm. For TEST1, precision and carryover were within the manufacturer's claim. Samples were stable upto 24 h and 48 h when they were stored at room temperature or 2-8 °C, respectively. No effect of trigyceride and cholesterol was observed. In low Hct samples, no significant different between the results obtained from Fabry's formula corrected WG values and from TEST1.

Conclusions: Three-way comparison study yielded a strong correlation between methods. As part of the method validation before implementing a new analyzer, full validation of TEST1 showed that all validated parameters met the manufacturer's specifications. A negative bias was observed but remains within the acceptable criteria. Difference in values for samples with low hematocrit were noted, but these can be corrected by Fabry's formula applied to the values from WG method.

Objectives: To identify clinical presentations that acted as harbingers for future sepsis hospitalizations in pediatric patients evaluated in the emergency department (ED) using the Symptom Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

Methods: We identified patients in the Pediatric Health Information Systems (PHIS) database admitted for sepsis between January 1, 2004 and December 31, 2023 and limited the study cohort to those patients who had an ED treat-and-release visit in the 30 days prior to admission. Using the look-back approach of the SPADE methodology, we identified the most common clinical presentations at the initial ED visit and used an observed to expected (O:E) analysis to determine which presentations were overrepresented. We then employed a graphical, temporal analysis with a comparison group to identify which overrepresented presentations most likely represented harbingers for future sepsis hospitalization.

Results: We identified 184,157 inpatient admissions for sepsis, of which 15,331 hospitalizations (8.3 %) were preceded by a treat-and-release ED visit in the prior 30 days. Based on the O:E and temporal analyses, the presentations of fever and dehydration were both overrepresented in the study cohort and temporally clustered close to sepsis hospitalization. ED treat-and-release visits for fever or dehydration preceded 1.2 % of all sepsis admissions.

Conclusions: In pediatric patients presenting to the ED, fever and dehydration may represent harbingers for future sepsis hospitalization. The SPADE methodology could be applied to the PHIS database to develop diagnostic performance measures across a wide range of pediatric hospitals.