Black Clouds vs Random Variation in Hospital Admissions.

BACKGROUND AND OBJECTIVES: Physicians often accuse their peers of being "black clouds" if they repeatedly have more than the average number of hospital admissions while on call. Our purpose was to determine whether the black-cloud phenomenon is real or explainable by random variation. METHODS: We analyzed hospital admissions to the University of Iowa family medicine service from July 1, 2010 to June 30, 2015. Analyses were stratified by peer group (eg, night shift attending physicians, day shift senior residents). We analyzed admission numbers to find evidence of black-cloud physicians (those with significantly more admissions than their peers) and white-cloud physicians (those with significantly fewer admissions). The statistical significance of whether there were actual differences across physicians was tested with mixed-effects negative binomial regression. RESULTS: The 5-year study included 96 physicians and 6,194 admissions. The number of daytime admissions ranged from 0 to 10 (mean 2.17, SD 1.63). Night admissions ranged from 0 to 11 (mean 1.23, SD 1.22). Admissions increased from 1,016 in the first year to 1,523 in the fifth year. We found 18 white-cloud and 16 black-cloud physicians in simple regression models that did not control for this upward trend. After including study year and other potential confounding variables in the regression models, there were no significant associations between physicians and admission numbers and therefore no true black or white clouds. CONCLUSIONS: In this study, apparent black-cloud and white-cloud physicians could be explained by random variation in hospital admissions. However, this randomness incorporated a wide range in workload among physicians, with potential impact on resident education at the low end and patient safety at the high end.

Patient Beliefs About Colon Cancer Screening.

Only about half of eligible individuals undergo colon cancer screening. We have limited knowledge about the patient beliefs that adversely affect screening decisions and about which beliefs might be amenable to change through education. As part of a clinical trial, 641 rural Iowans, aged 52 to 79 years, reported their beliefs about colon cancer screening in response to a mailed questionnaire. Consenting subjects were randomized into four groups, which were distinguished by four levels of increasingly intensive efforts to promote screening. Two of the groups received mailed educational materials and completed a follow-up questionnaire, which allowed us to determine whether their beliefs about screening changed following the education. We also completed a factor analysis to identify underlying (latent) factors that might explain the responses to 33 questions about readiness, attitudes, and perceived barriers related to colon cancer screening. The strongest predictors of a patient's stated readiness to be screened were a physician's recommendation to be screened (1 point difference on 10-point Likert scale, 95 % confidence interval [CI], 0.5 to 1.6 point difference), a family history of colon cancer (0.85-point Likert scale difference, 95 % CI, 0.1 to 1.6), and a belief that health-care decisions should be mostly left to physicians rather than patients (Spearman correlation coefficient 0.21, P < .001). Of the 33 questionnaire items about screening beliefs, 11 (33 %) changed favorably following the educational intervention. In the factor analysis, the 33 items were reduced to 8 underlying factors, such as being too busy to undergo screening and worries about screening procedures. We found a limited number of underlying factors that may help explain patient resistance to colon cancer screening.

Methodologies for evaluating strategies to reduce diagnostic error: report from the research summit at the 7th International Diagnostic Error in Medicine Conference.

In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-post designs, in favor of stepped wedge and interrupted time series; (6) Leverage best practices for patient safety research and engage experts from relevant domains; and (7) Consider sources of bias and design studies and their analyses to minimize selection and information bias and control for confounding. Areas of diagnostic error mitigation research identified for further attention include: role of competing diagnoses, understanding the impacts of organizational culture, timing of diagnosis, and sequencing of research studies. Future research will likely require novel clinical, health services, and qualitative research methods to address the age-old problem of arriving at an accurate diagnosis.

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

BACKGROUND: Many diagnostic errors are caused by premature closure of the diagnostic process. To help prevent premature closure, we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care. METHODS: We enrolled 14 primary care physicians and 100 patients in a randomized clinical trial. The study took place in an emergency department (5 physicians) and a same-day access clinic (9 physicians). The physicians were randomized to usual care vs. diagnostic checklist. After completing the history and physical exam, checklist physicians read aloud a differential diagnosis checklist for the chief complaint. The primary outcome was diagnostic error, which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review. RESULTS: There were 17 diagnostic errors. The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians (11.2% vs. 17.8%; p=0.46). In a post-hoc subgroup analysis, emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group (19.1% vs. 45.0%; p=0.04). Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters (6.5 diagnoses [SD 4.2] vs. 3.4 diagnoses [SD 2.0], p<0.001). CONCLUSIONS: Checklists did not improve the diagnostic error rate in this study. However further development and testing of checklists in larger studies may be warranted.

Diagnosis and management of tinea infections.

Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). The clinical diagnosis can be unreliable because tinea infections have many mimics, which can manifest identical lesions. For example, tinea corporis can be confused with eczema, tinea capitis can be confused with alopecia areata, and onychomycosis can be confused with dystrophic toenails from repeated low-level trauma. Physicians should confirm suspected onychomycosis and tinea capitis with a potassium hydroxide preparation or culture. Tinea corporis, tinea cruris, and tinea pedis generally respond to inexpensive topical agents such as terbinafine cream or butenafine cream, but oral antifungal agents may be indicated for extensive disease, failed topical treatment, immunocompromised patients, or severe moccasin-type tinea pedis. Oral terbinafine is first-line therapy for tinea capitis and onychomycosis because of its tolerability, high cure rate, and low cost. However, kerion should be treated with griseofulvin unless Trichophyton has been documented as the pathogen. Failure to treat kerion promptly can lead to scarring and permanent hair loss.

"Preflight Checklists" for diagnosis: a personal experience.

As physicians, we take pride in our ability to generate, from memory, a complete differential diagnosis for our patients' presenting symptoms. We expect this of ourselves and our trainees, but we do not do it reliably. Studies have found that the most common cause of diagnostic error is the physician's failure to consider the correct diagnosis as a possibility. Other professionals, like airline pilots and nuclear plant operators, have accepted the fallibility of their memories and have learned how to ensure reliable completion of critical tasks by using checklists. But our culture in medicine glorifies physicians who complete the critical task of diagnosis using their memories and disparages those who cheat by referring to a list. Recent studies have supported the use of checklists in the operating room and intensive care unit, but so far they have not been used to make diagnosis more reliable. This essay explores a possible use for differential-diagnosis checklists by describing the author's experience with them in a primary care clinic.

A randomized controlled trial to improve colon cancer screening in rural family medicine: an Iowa Research Network (IRENE) study.

BACKGROUND: Many adults have not been screened for colon cancer, a potentially preventable cause of death. METHODS: This was a randomized controlled trial conducted between December 2008 and April 2011 to improve CRC screening in 16 rural family physician offices. Subjects due for CRC screening were randomized within each practice to 1 of 4 groups: (1) usual care; (2) physician chart reminder; (3) physician chart reminder, mailed education, CRC reminder magnet, and fecal immunochemical test (FIT) (mailed education/FIT); or (4) all the preceding plus a structured telephone call to the patient from project staff to provide education, assess interest in screening, explain the screening tests, and address barriers (mailed education/FIT plus phone call). The main outcome was completion of any CRC screening. RESULTS: This study enrolled 743 patients. CRC screening was completed by 17.8% in the usual care group, 20.5% in the chart reminder group, 56.5% in the mailed education/FIT group, and 57.2% in the mailed education/FIT plus phone call group. We found no effect from the chart reminder compared with usual care (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.7-2.0); and a beneficial effect from the mailed education/FIT (OR, 6.0; 95% CI, 3.7-9.6) and the mailed education/FIT plus phone call (OR, 6.2; 95% CI, 3.8-9.9). Both FIT and colonoscopy rates increased significantly in both mailed education groups. CONCLUSION: CRC screening rates increased significantly among patients who were overdue for screening after they received mailed educational materials and a FIT. The addition of a phone call did not further increase screening rates.

A randomized colorectal cancer screening intervention trial in the Iowa Research Network (IRENE): study recruitment methods and baseline results.

BACKGROUND: Only about half of eligible Americans are adherent with colorectal cancer (CRC) screening. Because patients generally access CRC screening via their primary care physicians, interventions to improve screening should be tested in the primary care setting. This article describes the recruitment and baseline characteristics of patients from 16 practice-based research network practices for a study to improve CRC screening. METHODS: A total of 8327 invitations were mailed to patients of these practices, and 1685 returned consent forms and baseline surveys. RESULTS: Of those who consented, 942 were up to date with screening, which indicates that office databases were unable to provide information about those who were already screened. The 743 due for screening were younger (mean age, 61 vs. 63 years), less likely to have an immediate family member with CRC (11% vs. 19%), less likely to have Medicare (29% vs. 40%), more likely to have no insurance (5% vs. 1%), and less likely to report a physician/nurse recommendation for CRC screening (63% vs. 92%) for all comparisons. CONCLUSIONS: Our experiences for this practice-based research network randomized clinical intervention trial may be useful to others. Practice and patient recruitment processes were onerous with institutional review board issues, poorly prepared patient databases, and discarding of mail by the US Postal Service.

Diagnostic errors in primary care: lessons learned.

BACKGROUND: Diagnostic errors occur more commonly than other kinds of errors, they are more likely to harm patients, and they are more likely to be preventable. Little is known about the presenting complaints, initial (incorrect) diagnoses, and physicians' personal lessons learned related to diagnostic errors. METHODS: In 2009 and 2010, we invited a random sample of 200 family physicians, 200 general internists, and 200 general pediatricians practicing in Iowa to describe an important diagnostic error using a 1-page, mailed questionnaire. The data were analyzed using quantitative and qualitative methods. RESULTS: The response rate was 34% (202 of 600 physicians). Common presenting complaints included abdominal pain (n = 27 of 202 patients, 13%); fever (n = 19; 9%); and fatigue (n = 15, 7%). Common initial (incorrect) diagnoses included benign viral infections (n = 35, 17%); musculoskeletal pain (n = 21, 10%); and chronic obstructive pulmonary disease/asthma (n = 13, 6%). The 202 responding physicians described 254 personal lessons learned, which we used to develop a taxonomy of 24 generic lessons. Three common lessons were: (1) consider diagnosis X in patients presenting with symptom Y (n = 37 lessons, 15%; eg, "Any discomfort above the umbilicus may be coronary artery disease."); (2) look beyond the initial, most obvious diagnosis (n = 26 lessons, 10%); and (3) be alert to atypical presentations of disease (n = 24 lessons, 9%). CONCLUSIONS: In this study, diagnostic errors often were preceded by common symptoms and common, relatively benign initial diagnoses. The lessons learned often involved various aspects of broadening the differential diagnosis.

Mailed fecal immunochemical tests plus educational materials to improve colon cancer screening rates in Iowa Research Network (IRENE) practices.

INTRODUCTION: Only about half of all eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to test whether mailed educational materials and a fecal immunochemical test (FIT), with or without a scripted telephone reminder, led to FIT testing. In addition, we compared changes in attitudes toward, readiness for, and barriers to screening from baseline to follow-up after education about screening. METHODS: Subjects due for CRC screening were recruited from 16 Iowa Research Network family physician offices. Half of the subjects were randomized to receive mailed written and DVD educational materials, along with a FIT, either with or without a telephone call designed to encourage screening and address barriers. Subjects completed surveys regarding their attitudes and readiness for CRC screening at baseline and after education about screening. The main outcome was whether the subject completed FIT testing. RESULTS: A total of 373 individuals received educational materials (including a FIT) and 231 (62%) returned a posteducation survey. The mean age was 61.2 years; 52% were women, 99% were white, 39% had a high school education or less, 39% had a total family income of less than $40,000, and 7% had no insurance. The written materials were read by 82%, understood by 91% (of those who read them), and 82% felt their knowledge was increased. The DVD was viewed by 67%, understood by 94% of those who viewed it, and 86% felt the DVD increased their knowledge. Compared with baseline, individuals reported being significantly more likely to bring up CRC screening at their next doctor's visit (P < .0001) and being more likely to be tested for CRC in the next 6 months (P < .0001). Comparing baseline with follow-up, summary attitude scores improved (P < .0001), readiness scores improved (P < .0001), and there were fewer barriers (P = .034, Wilcoxon signed rank). The FIT return rate increased from 0% to 45.2% in the education alone group and from 0% to 48.7% for the group receiving education plus the telephone call (P < .0001 for each group individually and overall when compared with Medicare beneficiaries in Iowa). CONCLUSIONS: Mailing FIT kits with easy-to-understand educational materials improved attitudes toward screening and dramatically increased CRC screening rates among patients who were due for screening in a practice-based research network. A telephone call addressing barriers to screening did not result in increased FIT testing compared with mailed education alone.

Management of skin and soft tissue infections in community practice before and after implementing a "best practice" approach: an Iowa Research Network (IRENE) intervention study.

CONTEXT: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a major pathogen among skin and soft tissue infections (SSTIs). Most CA-MRSA infections are managed initially on an outpatient basis. It is critical that primary care clinicians recognize and appropriately treat patients suspected of having such infections. OBJECTIVE: To identify and evaluate best methods and procedures for primary care clinicians to manage skin and soft tissue infections. DESIGN, SETTING, AND PATIENTS: Preintervention/postintervention study in eight Iowa Research Network offices conducted between October 2007 and August 2010. We reviewed medical records of 216 patients with SSTI before a set of interventions (preintervention) and 118 patients after the intervention (postintervention). INTERVENTIONS: Included a focus group meeting at each office, distribution of a modified Centers for Disease Control and Prevention (CDC) algorithm, "Outpatient Management of MRSA Skin and Soft Tissue Infections," education handouts, and an office policy for patients with skin infections. MAIN OUTCOME MEASURES: Proportion of subjects who were prescribed an antibiotic that would cover MRSA at the initial visit and proportion who were prescribed an antibiotic that would cover MRSA at any time. RESULTS: Three hundred sixty-eight forms (244 preintervention and 124 postintervention) were returned; 216 (89%) preintervention forms and 118 (95%) postintervention forms were usable. Multivariable logistic regression models found statistically significant and independent factors associated with MRSA coverage at the initial visit included being in the postintervention rather than the preintervention group, having an abscess component compared with cellulitis alone, having a culture sent, being prescribed two or fewer antibiotics, and not being hospitalized. CONCLUSIONS: The CDC algorithm was feasible for offices to use. Following a discussion of SSTI management in the outpatient setting, use of MRSA coverage increased both initially and overall. Thus, involving clinicians in a discussion about guidelines rather than simply providing guidelines or a didactic session may be a useful way to change physician practices.

Primary care clinicians' perspectives on management of skin and soft tissue infections: an Iowa Research Network study.

UNLABELLED: An estimated 95,000 people developed methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005 of which 14% were community-associated and 85% were hospital or other health setting associated, and 19,000 Americans died from these infections that year. PURPOSE: To explore health care providers' perspectives on management of skin and soft tissue infections to gain a better understanding of the problems faced by busy providers in primary care settings. METHODS: Focus group meetings were held at 9 family physician offices in the Iowa Research Network. Seventy-eight clinicians including physicians, nurses, nurse practitioners, and house officers attended. Meeting audiotapes were transcribed and coded by 3 investigators, and a MRSA-management taxonomy was developed. FINDINGS: The main themes that emerged from the focus groups included epidemiology, diagnosis, treatment, management, prevention, special populations, and public relations. The incidence of MRSA infections was perceived to have increased over the past decade. However, diagnosis and treatment protocols for physicians in the outpatient setting have lagged behind, and no well-accepted diagnostic or treatment algorithms were used by physicians attending the focus groups. CONCLUSION: The clinicians in this study noted considerable confusion and inconsistency in the management of skin and soft tissue infections, particularly those due to MRSA.

Checklists to reduce diagnostic errors.

Diagnostic errors are common and can often be traced to physicians' cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and nuclear plant operators, but these professions have reduced errors by using checklists. Recently, checklists have gained acceptance in medical settings, such as operating rooms and intensive care units. This article extends the checklist concept to diagnosis and describes three types of checklists: (1) a general checklist that prompts physicians to optimize their cognitive approach, (2) a differential diagnosis checklist to help physicians avoid the most common cause of diagnostic error--failure to consider the correct diagnosis as a possibility, and (3) a checklist of common pitfalls and cognitive forcing functions to improve evaluation of selected diseases. These checklists were developed informally and have not been subjected to rigorous evaluation. The purpose of this article is to argue for the further investigation and revision of these initial attempts to apply checklists to the diagnostic process. The basic idea behind checklists is to provide an alternative to reliance on intuition and memory in clinical problem solving. This kind of solution is demanded by the complexity of diagnostic reasoning, which often involves sense-making under conditions of great uncertainty and limited time.

The generalized rash: part I. Differential diagnosis.

Physicians often have difficulty diagnosing a generalized rash because many different conditions produce similar rashes, and a single condition can result in different rashes with varied appearances. A rapid and accurate diagnosis is critically important to make treatment decisions, especially when mortality or significant morbidity can occur without prompt intervention. When a specific diagnosis is not immediately apparent, it is important to generate an inclusive differential diagnosis to guide diagnostic strategy and initial treatment. In part I of this two-part article, tables listing common, uncommon, and rare causes of generalized rash are presented to help generate an inclusive differential diagnosis. The tables describe the key clinical features and recommended tests to help accurately diagnose generalized rashes. If the diagnosis remains unclear, the primary care physician must decide whether to observe and treat empirically, perform further diagnostic testing, or refer the patient to a dermatologist. This decision depends on the likelihood of a serious disorder and the patient's response to treatment.

The generalized rash: part II. Diagnostic approach.

Although it is important to begin the evaluation of generalized rash with an inclusive differential diagnosis, the possibilities must be narrowed down by taking a focused history and looking for key clinical features of the rash. Part I of this two-part article lists the common, uncommon, and rare causes of generalized rashes. In part II, the clinical features that help distinguish these rashes are described. These features include key elements of the history (e.g., travel, environmental exposures, personal or family history of atopy); characteristics of individual lesions, such as color, size, shape, and scale; areas of involvement and sparing, with particular attention to palms, soles, face, nails, sun-exposed areas, and extensor and flexor surfaces of extremities; pruritic or painful lesions; systemic symptoms, especially fever; and dermatologic signs, such as blanching, and the Koebner phenomenon.

Diagnosis of ear pain.

Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most common causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist. Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation. Patients whose history or physical examination increases suspicion for a serious occult cause of ear pain or whose symptoms persist after symptomatic treatment should be considered for further evaluation, such as magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.

Answering clinical questions in the ED.

OBJECTIVES: The objective of the study was to determine how many patient-related questions emergency medicine physicians have and how they answer them at the point of care. METHODS: We conducted an observational study of 26 physicians at 2 institutions. All physicians were followed for at least 2 shifts. The number and type of questions were recorded. The percentage answered, resources used, and barriers to answering questions were also recorded. RESULTS: Physicians had 235 questions or approximately 5 questions per 8-hour shift . They attempted to answer 81% of them and were successful 87% of the time. The 2 most commonly used information sources were drug information resources (Personal digital assistant [PDA], pocket pharmacopeia [37% of the time]) followed by electronic resources (Google, UpToDate [29% of the time]). The most common reason for not pursuing a question was lack of time and distractions or interruptions, followed by a belief that an answer would not be found. When an answer was not found to a pursued question, non-emergency department physicians were the most common resource consulted (28%). CONCLUSIONS: Emergency department physicians in this study pursued and found answers for most questions posed at the point of care. Rapid access to electronic resources and drug-prescribing references were critical for answering questions at the point of care.

Factors contributing to maternal birth-related trauma.

The Agency for Healthcare Research and Quality Quality Indicator tools were used to identify risk factors for maternal birth-related trauma rates in the 2003 Nationwide Inpatient Sample and the 2002-2004 Iowa State Inpatient Database. Risk-adjusted analyses of these datasets isolated salient risk factors for maternal trauma. The rates of Iowa's risk factors for the most serious types of trauma--third/fourth-degree lacerations--were compared with national rates. The comparisons suggest that episiotomy, artificial rupture of membranes, obstructed labor, and late pregnancies are the most salient risk factors for third/fourth-degree lacerations within Iowa. Thus, this research suggested that a combination of maternal, baby, and episiotomy factors contributed to the high prevalence of third/fourth-degree lacerations in vaginal deliveries in Iowa. Finally, our risk-adjustment methodology could be used in a similar manner to analyze other discharge datasets for opportunities to improve maternal outcomes.