Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study
- 317 Downloads
Studying diagnostic error at the population level requires an understanding of how diagnoses change over time.
To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.
Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.
Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.
We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.
Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10–1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89–0.99, p < 0.001).
Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.
We would like to thank Anne Marie Webber-Main PhD for her critical review of a draft of this paper writing clarification. This paper was presented at the Society of General Internal Medicine National Meeting in May 2016.
Funding support for this study was provided by the NIH Clinical and Translational Science Award at the University of Minnesota: 8UL1TR000114-02.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
- 5.Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M. Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey. J Hosp Med. 2016.Google Scholar
- 7.Mahmoud KD, Gu YL, Nijsten MW, de Vos R, Nieuwland W, Zijlstra F, et al. Interhospital transfer due to failed prehospital diagnosis for primary percutaneous coronary intervention: an observational study on incidence, predictors, and clinical impact. Eur Heart J Acute Cardiovasc Care. 2013;2(2):166–75.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS, et al. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD); 2005.Google Scholar
- 24.HCUP State Inpatient Satabase (SID) and State Emergency Department Database (SEDD). Agency for Healthcare Research and Quality, Rockville, MD. at: www.hcup-us.ahrq.gov/nisover-view.jsp.: Healthcare Cost and Utilizaltion Project (HCUP). 2011-2013.
- 28.Sullivan LM, Massaro JM, D'Agostino RB, Sr. Presentation of multivariate data for clinical use: The Framingham Study risk score functions. Stat Med. 2004;23(10):1631–60.Google Scholar
- 29.Olson APJ, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events. J Gen Intern Med. 2018.Google Scholar