Development and Implementation of a Digital Quality Measure of Emergency Cancer Diagnosis.

PURPOSE: Missed and delayed cancer diagnoses are common, harmful, and often preventable. Automated measures of quality of cancer diagnosis are lacking but could identify gaps and guide interventions. We developed and implemented a digital quality measure (dQM) of cancer emergency presentation (EP) using electronic health record databases of two health systems and characterized the measure's association with missed opportunities for diagnosis (MODs) and mortality. METHODS: On the basis of literature and expert input, we defined EP as a new cancer diagnosis within 30 days after emergency department or inpatient visit. We identified EPs for lung cancer and colorectal cancer (CRC) in the Department of Veterans Affairs (VA) and Geisinger from 2016 to 2020. We validated measure accuracy and identified preceding MODs through standardized chart review of 100 records per cancer per health system. Using VA's longitudinal encounter and mortality data, we applied logistic regression to assess EP's association with 1-year mortality, adjusting for cancer stage and demographics. RESULTS: Among 38,565 and 2,914 patients with lung cancer and 14,674 and 1,649 patients with CRCs at VA and Geisinger, respectively, our dQM identified EPs in 20.9% and 9.4% of lung cancers, and 22.4% and 7.5% of CRCs. Chart reviews revealed high positive predictive values for EPs across sites and cancer types (72%-90%), and a substantial percent represented MODs (48.8%-84.9%). EP was associated with significantly higher odds of 1-year mortality for lung cancer and CRC (adjusted odds ratio, 1.78 and 1.83, respectively, 95% CI, 1.63 to 1.86 and 1.61 to 2.07). CONCLUSION: A dQM for cancer EP was strongly associated with both mortality and MODs. The findings suggest a promising automated approach to measuring quality of cancer diagnosis in US health systems.

Carboxymethyl cellulose-based materials as an alternative source for sustainable electrochemical devices: a review.

In electrochemistry, bio-based materials are preferred over the traditional costly and synthetic polymers due to their abundance, versatility, sustainability and low cost. One of the bio-based polymers is carboxymethyl cellulose (CMC) which has become an overarching material in electrochemical devices pertaining to its amphiphilic nature with multi-carbon functional groups. Owing to its flexible framework with fascinating groups on its surface like hydroxide (-OH) and carboxylate (-COO-), CMC is able to be modified into conducting materials by blending it with other biopolymers, synthetic polymers, salts, acids and others. This blending has improved the profile of CMC by exploiting the ability of hydrogen bonding, swelling, adhesiveness and dispersion of charges and ions. These properties of CMC have made it possible to utilize this bio-sourced polymer in several applications as a conducting electrolyte, binder in electrodes, detector, sensor and active material in fuel cells, actuators and triboelectric nanogenerators (TENG). Thus, CMC based materials are cheap, environment friendly, hydrophilic, biodegradable, non-toxic and biocompatible which render it a desirable material in energy storage devices.

Influence of baking and frying conditions on acrylamide formation in various prepared bakery, snack, and fried products.

The core objective of the present study was to evaluate the influence of baking/frying times and temperatures on the formation of acrylamide in bakery, snack, and fried products such as biscuits, muffins, pizza, cakes, samosa, paratha rolls, nuggets, and potato cutlets during baking/frying at different times and temperature conditions. First of all, the raw material, especially flour, was tested for its proximate composition and rheological characteristics. The quantification of acrylamide produced during the processing of different products was carried out through the HPLC method. A sensory evaluation of these food samples was also carried out to find out the acceptability differences. The raw material was found to have good rheological properties and proximate composition. The results revealed that different times and temperature regimes influenced the formation of acrylamide in those products. Among the bakery products, the highest concentrations of acrylamide were observed in biscuits (126.52 µg/kg) followed by muffins (84.24 µg/kg), cake (71.21 µg/kg), and pizza (62.42 µg/kg). The higher contents of acrylamide were found in paratha roll (165.92 µg/kg) compared to samosa (100.43 µg/kg), whereas among snacks, potato cutlets (135.71 µg/kg) showed higher concentrations than nuggets (43.04 µg/kg). It was observed that baking or frying all the investigated products at higher temperatures produced slightly more acrylamide concentrations. The prepared products in the present study were also accepted sensorially by the panel of judges. So, it was concluded that baking or frying at higher temperatures resulted in higher concentrations of acrylamide compounds in different products in the present study.

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to Address Diagnostic Errors.

BACKGROUND: Most health care organizations (HCOs) find diagnostic errors hard to address. The research team developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error. METHODS: First, the team identified potential practices based on reviews of recent literature, reports by national and international organizations, and interviews with quality/safety leaders. Then a Delphi panel was conducted, followed by an online expert panel, to prioritize 10 practices. The prioritization process considered impact on safety and feasibility of practice implementation within a one- to three-year time frame. Finally, cognitive walkthroughs were conducted for a face-validity check with end users. The team also conducted content analysis in each step to look for themes that influenced prioritization or checklist implementation. RESULTS: A total of 71 practices for prioritization were identified through the Delphi panel of 28 experts; 65% of participants reached consensus on 28 practices. A multidisciplinary panel of 10 experts helped prioritize and refine the top 10 practices, which were then developed into a checklist paired with implementation guidance. Practices included themes related to creating organizational and leadership accountability for improving diagnosis, including patients in diagnostic safety work, and developing and implementing organizational infrastructure for measurement and improvement activities. Qualitative analysis revealed insights for implementation. End users at three different HCOs helped refine implementation guidance for the checklist. CONCLUSION: The researchers identified 10 safety practices to help organizations conduct a proactive, systematic assessment of risks to timely and accurate diagnosis. The Safer Dx Checklist can enable HCOs to begin implementing strategies to address diagnostic error.

Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations.

OBJECTIVE: To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data. RESULTS: Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions. CONCLUSIONS: Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.

Why Test Results Are Still Getting "Lost" to Follow-up: a Qualitative Study of Implementation Gaps.

BACKGROUND: Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm. OBJECTIVE: As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff. DESIGN: We used a semi-structured interview guide to collect qualitative data from Veterans Affairs (VA) facility staff who had experience with test results management and patient safety. SETTING: Twelve VA facilities across the USA. PARTICIPANTS: Facility staff members (n = 27), including clinicians, lab and imaging professionals, nursing staff, patient safety professionals, and leadership. APPROACH: We conducted a content analysis of interview transcripts to identify perceived barriers and high-risk areas for effective test result management, as well as recommendations for improvement. RESULTS: We identified seven themes to guide further development of interventions to improve test result follow-up. Themes related to trainees, incidental findings, tracking systems for electronic health record notifications, outdated contact information, referrals, backup or covering providers, and responsibility for test results pending at discharge. Participants provided recommendations for improvement within each theme. CONCLUSIONS: Perceived barriers and recommendations for improving test result follow-up often reflected previously known problems and their corresponding solutions, which have not been consistently implemented in practice. Better policy solutions and improvement methods, such as quality improvement collaboratives, may bridge the implementation gaps between knowledge and practice.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

OBJECTIVE: Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs). METHODS: Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit. RESULTS: We applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for "missed" = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen's kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%). CONCLUSION: In a large national EHR repository, a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.