Diagnosis Code and Health Care Utilization Patterns Associated With Diagnostic Uncertainty.

BACKGROUND AND OBJECTIVES: Diagnostic uncertainty is challenging to identify and study in clinical practice. This study compares differences in diagnosis code and health care utilization between a unique cohort of hospitalized children with uncertain diagnoses (UD) and matched controls. PATIENTS AND METHODS: This case-control study was conducted at Cincinnati Children's Hospital Medical Center. Cases were defined as patients admitted to the pediatric hospital medicine service and having UDs during their hospitalization. Control patients were matched on age strata, biological sex, and time of year. Outcomes included type of diagnosis codes used (ie, disease- or nondisease-based) and change in code from admission to discharge. Differences in diagnosis codes were evaluated using conditional logistic regression. Health care utilization outcomes included hospital length of stay (LOS), hospital transfer, consulting service utilization, rapid response team activations, escalation to intensive care, and 30-day health care reutilization. Differences in health care utilization were assessed using bivariate statistics. RESULTS: Our final cohort included 240 UD cases and 911 matched controls. Compared with matched controls, UD cases were 8 times more likely to receive a nondisease-based diagnosis code (odds ratio [OR], 8.0; 95% confidence interval [CI], 5.7-11.2) and 2.5 times more likely to have a change in their primary International Classification of Disease, 10th revision, diagnosis code between admission and discharge (OR, 2.5; 95% CI, 1.9-3.4). UD cases had a longer average LOS and higher transfer rates to our main hospital campus, consulting service use, and 30-day readmission rates. CONCLUSIONS: Hospitalized children with UDs have meaningfully different patterns of diagnosis code use and increased health care utilization compared with matched controls.

Declaring Uncertainty: Using Quality Improvement Methods to Change the Conversation of Diagnosis.

BACKGROUND: Diagnostic uncertainty may be a sign that a patient's working diagnosis is incorrect, but literature on proactively identifying diagnostic uncertainty is lacking. Using quality improvement methodologies, we aimed to create a process for identifying patients with uncertain diagnoses (UDs) on a pediatric inpatient unit and communicating about them with the interdisciplinary health care team. METHODS: Plan-do-study-act cycles were focused on interdisciplinary communication, structured handoffs, and integration of diagnostic uncertainty into the electronic medical record. Our definition of UD was as follows: "you wouldn't be surprised if the patient had a different diagnosis that required a change in management." The primary measure, which was tracked on an annotated run chart, was percentage agreement between the charge nurse and primary clinician regarding which patients had a UD. Secondary measures included the percentage of patient days during which patients had UDs. Data were collected 3 times daily by text message polls. RESULTS: Over 13 months, the percentage agreement between the charge nurse and primary clinician about which patients had UDs increased from a baseline of 19% to a median of 84%. On average, patients had UDs during 11% of patient days. CONCLUSIONS: We created a novel and effective process to improve shared recognition of patients with diagnostic uncertainty among the interdisciplinary health care team, which is an important first step in improving care for these patients.

Uncertain diagnoses in a children's hospital: patient characteristics and outcomes.

BACKGROUND: A quality improvement initiative at our institution resulted in a new process for prospectively identifying pediatric hospital medicine (PHM) patients with uncertain diagnoses (UD). This study describes the clinical characteristics and healthcare utilization patterns of patients with UD. METHODS: This single center cross-sectional study included all PHM patients identified with UD during their admission. A structured chart review was used to abstract patient demographics, primary symptoms, discharge diagnoses, and healthcare utilization patterns, including consult service use, length of stay (LOS), escalation in care, and 30-day healthcare reutilization. Appropriate descriptive statistics were used for categorical and continuous variables. RESULTS: This study includes 200 PHM patients identified with UD. Gastrointestinal symptoms were the primary finding in 45% of patients with UD. Consult service use was highly variable, with a range of 0-8 consult services for individual patients. The median LOS was 1.6 days and only 5% required a rapid response team evaluation. As for reutilization, 7% of patients were readmitted within 30 days. CONCLUSIONS: This descriptive study highlights the heterogeneity of patients with uncertain diagnoses. Ongoing work is needed to further understand the impact of UD and to optimize the care of these patients.