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

Why am I in the hospital? Z. Berger, Hopkins GIM, ICCH

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?

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.

Welcome to America General Hospital

Another busy day at AGHAnother busy day at AGH

• Calling consults

• And…

• Talking to patients

• Calling consults

• And…

• Talking to patients

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?

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%

Diagnostic discordance among medicine inpatients:

specific aims

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?

hypotheses

hypothesesIgnorance/discordance associated

with Not speaking English Lower SES

Ignorance/discordance associated with Not speaking English Lower SES

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

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

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

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

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

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

“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

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%)

Discordant patients are less educated

Concordant Discordant

Mean years of education (SD)

10.6 (4.4) 8.9 (4.7)

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

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

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?

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”

I don\'t know why I\'m in the hospital!

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