False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery.

OBJECTIVES: To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. METHODS: This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). RESULTS: The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance. CONCLUSIONS: Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.

Implementing emergency department observation units within a multihospital network.

BACKGROUND: The proportion of emergency department (ED) chest pain patients who undergo an extended "rule out MI (myocardial infarction)" evaluation beyond the ED determines both the quality and cost of patient care. The higher an organization's rate of such evaluations, the lower the average miss rate for MI. Five of the 13 hospitals in the Voluntary Hospital Association Northeast multihospital network implemented ED observation units by June 1997 for outpatient rule out MI evaluations. RESULTS: Compared with historical and case controls, the five hospitals with ED observation units had a higher observation rate (16% versus 0% [p < .001] and 2% [p < .001]) and a higher rule out MI evaluation rate (61% versus 46% [p < .01] and 45% [p < .01]), without a significantly higher admission rate (47% versus 46% and 45%). For the three hospitals with observation units that collected charge data during 1997 on a consecutive series of chest pain patients who had negative rule out MI evaluations, charges for patient services were lower for patients evaluated in the ED observation unit ($2,214.80 +/- $80.40) than in the hospital ($5,464.30 +/- $393.60). CONCLUSIONS: ED observation units represent a cost-effective restructuring of the diagnostic approach to patients with acute chest pain. In an improvement of quality of patient care, a larger proportion of ED chest pain patients receive an extended evaluation than is possible with hospital admission as the only ED disposition option.

Improving chest pain evaluation within a multihospital network by the use of emergency department observation units.

BACKGROUND: Since 1993 the 13 VHA Southern New England (VHA-SNE) hospitals have been engaged in a regionally sponsored initiative to analyze and improve selected clinical processes. Nine of these hospitals have chosen to participate in an initiative in which observation units were postulated to offer a tool for improving the care of patients with chest pain-the VHA initiative to Implement Chest Pain Treatment in Observation Units. THE FIVE PHASES: In phase 1 of the initiative, the VHA-SNE's Clinical Benchmarking Work Group reviewed the medical literature, which confirmed longstanding systemic and pervasive problems in the evaluation of chest pain patients. The work group's preferred practice was the outpatient "rule out myocardial infarction [MI] evaluation" program during monitored observation; serial testing can accurately diagnose low- and moderate-probability patients with MI. In Phase 2 the study group surveyed the emergency departments in the nine hospitals, discovering significant variation in admission rates and practice patterns. During phase 3 the work group identified a health care organization demonstrating best-practice performance--one of the few hospitals in the nation with an operational outpatient "rule out MI evaluation" program. A team site-visited that organization and recorded information about its structure and processes. VHA-SNE then published a monograph that identified its current performance, described the best-practice approach, offered strategies to implement the model program, and analyzed the financial implications and return on investment. In phase 4 a pilot hospital implemented the model program, which in phase 5 is being extended to the other hospitals represented in the work group. Information regarding protocols, lessons learned, and barriers to implementation was freely provided.

The role of the coordinator of care.

Regardless of the specific outcome of the current health reform debate in Washington, it is likely that major changes to the health care system are in the offering. These changes, many of which are already in place or imminent in some locations, will have a major impact on the evolving relationships between physicians and hospitals. Most expect that these changes will accelerate the development of integrated health care delivery systems that will compete in the marketplace for a mixture of public and private health insurance dollars. In this system of "managed competition," health care dollars will flow to those systems that can ensure the best clinical outcomes while using the least economic resources. In this scenario, competing collaborative health networks that can manage the continuum of care will be central to the health care delivery system. The economic and political ties between physicians and hospitals will become more closely linked as government and private payers of health care services foster the development of these integrated, value-based health care delivery systems.

Experts discuss how benchmarking improves the healthcare industry. Roundtable discussion.

Healthcare Financial Management engaged four benchmarking experts in a discussion about benchmarking and its role in the healthcare industry. The experts agree that benchmarking by itself does not create change unless it is part of a larger continuous quality improvement program; that benchmarking works best when senior management supports it enthusiastically and when the "appropriate" people are involved; and that benchmarking, when implemented correctly, is one of the best tools available to help healthcare organizations improve their internal processes.

The analysis of clinical outcomes: getting started in benchmarking.

BACKGROUND: Computerized clinical outcomes measurement systems are now routinely available to help physicians and hospital administrators assess and improve the quality of care in their organizations. The Voluntary Hospitals of America, Pennsylvania (VHA/PA), used MedisGroups data to help understand the processes of care that contributed to different clinical outcomes at different network hospitals. METHOD: A physician subcommittee decided early on (1) to focus on the best outcomes rather than the poorest and (2) to determine the variations in processes of care that might have led to either superior or inferior clinical outcomes. For two common procedures, appendectomy and cesarean section, the subcommittee identified variation within comparative outcomes data, evaluated that variation, and studied and communicated to the rest of the hospital network the process that produced the best outcomes. CONCLUSION: These pilot projects set the stage for current clinical benchmarking within the VHA/PA system. The committee of physicians learned that each hospital develops its own approach to common clinical conditions. These approaches become standardized at each hospital in the form of institutional attitudes, beliefs, policies, and procedures. The methods of evaluation and treatment by hospital staff can significantly alter the clinical outcomes for the populations served.