Post on 15-Jan-2015
description
transcript
I don’t know why I’m in the hospital!
I don’t know why I’m in the hospital!
Zackary Berger, MD PhD
Assistant Professor
Johns Hopkins General Internal Medicine
Zackary Berger, MD PhD
Assistant Professor
Johns Hopkins General Internal Medicine
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
Welcome to America General Hospital
Welcome to America General Hospital
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
6
Another busy day at AGHAnother busy day at AGH
• Calling consults
• Calling consults
• Calling consults
• And…
• Talking to patients
• Calling consults
• Calling consults
• Calling consults
• And…
• Talking to patients
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
7
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?
• Are the goals different from clinic?
• Why is it important?
• Why isn’t it important?
• What are the goals?
• How do we know we’ve done a good job?
• Are the goals different from clinic?
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
8
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
9
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 reason which doesn’t concord with the doctors’ reason?
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 reason which doesn’t concord with the doctors’ reason?
What are the covariates associated with concordance? Discordance?
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
10
Diagnostic discordance among medicine inpatients:
hypotheses
Diagnostic discordance among medicine inpatients:
hypothesesIgnorance/discordance associated
with Not speaking English Lower SES
Ignorance/discordance associated with Not speaking English Lower SES
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
11
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
• 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
• IRB approval: oral consent from all patients
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
12
Study measures: patient interviewStudy measures: patient 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?
oThen: What 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?
oThen: What 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
13
Study measures: medical record abstractionStudy measures: medical record abstraction
Hierarchy of notes to decide on doctors’ reason for admission (from most to least preferred):oDaily progress note (housestaff or PA)
oDaily progress note (attending)oFace sheet
Hierarchy of notes to decide on doctors’ reason for admission (from 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
14
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
15
Patient Characteristics (N=46)
Patient Characteristics (N=46)
• 51% women
• 50% older than 60
• 41% interviewed in Spanish
• 9 mean years education
• 51% women
• 50% older than 60
• 41% interviewed in Spanish
• 9 mean years education
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
16
Diagnostic DiscordanceDiagnostic Discordance The diagnosis the patient reports
doesn’t match the diagnosis in the computer chart…65% of the time.
• 11% cannot give any diagnosis• 15% disagree on organ system and
pathophysiology• 39% agree on organ system but not
pathophysiology
The diagnosis the patient reports doesn’t match the diagnosis in the computer chart…65% of the time.
• 11% cannot give any diagnosis• 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
17
“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
18
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
19
Discordant patients are less educated
Discordant patients are less educated
Concordant Discordant
Mean years of education (SD)
10.6 (4.4) 8.9 (4.7)
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
20
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
21
LimitationsLimitations
• Small sample size doesn’t allow us to examine patient characteristics associated with 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 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
22
Is Diagnostic Discordance a Problem?
Is Diagnostic Discordance a Problem?
• Discussion• Is ‘getting old’ close enough to
‘unstable angina’? • Is someone wrong? • Can they both be right?
• Future studies should examine the effects of discordance on patient outcomes
• Discussion• Is ‘getting old’ close enough to
‘unstable angina’? • Is someone wrong? • Can they both be right?
• Future studies should examine the effects of discordance on patient outcomes
Future questionsFuture questions
• Ask the question: “Has the doctor told you?”
• Controlling for physicians’ diagnostic uncertainty (“rule-out” admissions)
• Diagnostic knowledge/concordance at admission vs. discharge
• Concordance ↔ better outcomes?
• Ask the question: “Has the doctor told you?”
• Controlling for physicians’ diagnostic uncertainty (“rule-out” admissions)
• Diagnostic knowledge/concordance at admission vs. discharge
• Concordance ↔ better outcomes?
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
23
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
24
Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH
25
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 of medical records to improve diagnostic discordance with patient• i.e., “diagnostic reconciliation”
• Discussion of admission diagnosis between doctors and patients
• Auditing of medical records to improve diagnostic discordance with patient• i.e., “diagnostic reconciliation”