Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Implementing a COVID-19 Discharge Pathway to Improve Patient Safety.

The posthospital discharge period is vulnerable for patients with coronavirus disease 2019 (COVID-19). The authors implemented a COVID-19 discharge pathway in the electronic medical record for UCHealth, a 12-hospital health care system, including an academic medical center (University of Colorado Hospital [UCH]), to improve patient safety by standardizing discharge processes for COVID-19 patients. There were 3 key elements: (1) building consensus on discharge readiness criteria, (2) summarizing discharge criteria for disposition locations, and (3) establishing primary care follow-up protocols. The discharge pathway was opened 821 times between April 20, 2020, and June 7, 2020. Of the 436 patients discharged from the hospital medicine service at UCH from April 20, 2020, and June 7, 2020, 18 (4%) were readmitted and 13 (3%) had a 30-day emergency department visit. The main trend observed was venous thromboembolism. This pathway allowed real-time integration of clinical guidelines and complex disposition requirements, decreasing cognitive burden and standardizing care for a complex population.

Self-Identified Social Determinants of Health during Transitions of Care in the Medically Underserved: a Narrative Review.

BACKGROUND: Medically underserved or low socioeconomic status (SES) patients face significant vulnerability and a high risk of adverse events following hospital discharge. The environmental, social, and economic factors, otherwise known as social determinants, that compound this risk have been ineffectually described in this population. As the underserved comprise 30% of patients discharged from the hospital, improving transitional care and preventing readmission in this group has profound quality of care and financial implications. METHOD: EMBASE and MEDLINE searches were conducted to examine specific barriers to care transitions in underserved patients following an episode of acute care. Articles were reviewed for barriers and categorized within the context of five general themes. RESULTS: This review yielded 17 peer-reviewed articles. Common factors affecting care transitions were cost of medications, access to care, housing instability, and transportation. When categorized within themes, social fragility and access failures, as well as therapeutic misalignment, disease behavior, and issues with accountability were noted. DISCUSSION: Providers and health systems caring for medically underserved patients may benefit through dedicating increased resources and broadening collaboration with community partners in order to expand health care access and enhance coordination of social services within this population. Future studies are needed to identify potential interventions targeting underserved patients to improve their post-hospital care.

Coding and billing issues in hospital neurology compensation.

BACKGROUND: Accurate coding and billing are critical for the financial health of hospitals. Neurologic inpatient services have specific, complex documentation requirements, which can result in inadequate billing. METHODS: We retrospectively compared coding practices from July 2013 to June 2014 (FY2014) using evaluation and management codes for initial inpatient encounters (CPT 99221-3) of a neurohospitalist group (NHG) to a hospital medicine group (HMG) and to national benchmarks. We further examined a sample of the lowest level encounters (CPT 99221) from the 4th quarter of FY2014 for specific deficiencies and compared these among groups. RESULTS: Low codes (CPT 99221) were more common in the NHG than the HMG and national benchmarks (54% vs 7% vs 4%, p < 0.01). Deficiencies in the examination were the most common reason for low coding in the NHG compared to the HMG (62% vs 5%, p < 0.001). Deficiencies in social history were more common in the NHG than the HMG (11% vs 0%, p < 0.003) but deficiencies in family history (34% vs 37%, p = 0.75) and review of systems (30% vs 30%, p = 1.0) were common in both groups. In the NHG group, documentation did not reflect the acuity of patients' medical conditions. CONCLUSIONS: Neurologists should pay close attention to documentation requirements-especially the neurologic examination-in order to allow for accurate coding and billing.

Electronic health records and malpractice claims in office practice.

BACKGROUND: Electronic health records (EHRs) may improve patient safety and health care quality, but the relationship between EHR adoption and settled malpractice claims is unknown. METHODS: Between June 1, 2005, and November 30, 2005, we surveyed a random sample of 1884 physicians in Massachusetts to assess availability and use of EHR functions, predictors of use, and perceptions of medical practice. Information on paid malpractice claims was accessed on the Massachusetts Board of Registration in Medicine (BRM) Web site in April 2007. We used logistic regression to assess the relationship between the adoption and use of EHRs and paid malpractice claims. RESULTS: The survey response rate was 71.4% (1345 of 1884). Among 1140 respondents with data on the presence of EHR and available BRM records, 379 (33.2%) had EHRs. A total of 6.1% of physicians with an EHR had a history of a paid malpractice claim compared with 10.8% of physicians without EHRs (unadjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86; P = .01). In logistic regression analysis controlling for sex, race, year of medical school graduation, specialty, and practice size, the relationship between EHR adoption and paid malpractice settlements was of smaller magnitude and no longer statistically significant (adjusted odds ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .18). Among EHR adopters, 5.7% of physicians identified as "high users" of EHR had paid malpractice claims compared with 12.1% of "low users" (P = .14). CONCLUSIONS: Although the results of this study are inconclusive, physicians with EHRs appear less likely to have paid malpractice claims. Confirmatory studies are needed before these results can have policy implications.

Cost-effectiveness of a vaccine to prevent herpes zoster and postherpetic neuralgia in older adults.

BACKGROUND: A vaccine to prevent herpes zoster was recently approved by the United States Food and Drug Administration. We sought to determine the cost-effectiveness of this vaccine for different age groups. METHODS: We constructed a cost-effectiveness model, based on the Shingles Prevention Study, to compare varicella zoster vaccination with usual care for healthy adults aged >60 years. Outcomes included cost in 2005 US dollars and quality-adjusted life expectancy. Costs and natural history data were drawn from the published literature; vaccine efficacy was assumed to persist for 10 years. RESULTS: For the base case analysis, compared with usual care, vaccination increased quality-adjusted life expectancy by 0.0007-0.0024 quality-adjusted life years per person, depending on age at vaccination and sex. These increases came almost exclusively as a result of prevention of acute pain associated with herpes zoster and postherpetic neuralgia. Vaccination also increased costs by $94-$135 per person, compared with no vaccination. The incremental cost-effectiveness ranged from $44,000 per quality-adjusted life year saved for a 70-year-old woman to $191,000 per quality-adjusted life year saved for an 80-year-old man. For the sensitivity analysis, the decision was most sensitive to vaccine cost. At a cost of $46 per dose, vaccination cost <$50,000 per quality-adjusted life year saved for all adults >60 years of age. Other variables related to the vaccine (duration, efficacy, and adverse effects), postherpetic neuralgia (incidence, duration, and utility), herpes zoster (incidence and severity), and the discount rate all affected the cost-effectiveness ratio by >20%. CONCLUSIONS: The cost-effectiveness of the varicella zoster vaccine varies substantially with patient age and often exceeds $100,000 per quality-adjusted life year saved. Age should be considered in vaccine recommendations.