Michael Usher1, Nishant Sahni2, Dana Herrigel3, Gyorgy Simon2,4, Genevieve B Melton4,5, Anne Joseph2, Andrew Olson6. 1. Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA. mgusher@umn.edu. 2. Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA. 3. Department of Hospital Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA. 4. Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, MN, USA. 5. Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA. 6. Division of General Internal Medicine, Department of Medicine, and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA.
Abstract
BACKGROUND: Studying diagnostic error at the population level requires an understanding of how diagnoses change over time. OBJECTIVE: 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. DESIGN: 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. PARTICIPANTS: Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013. MAIN MEASURES: 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. KEY RESULTS: 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). CONCLUSIONS: 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.
BACKGROUND: Studying diagnostic error at the population level requires an understanding of how diagnoses change over time. OBJECTIVE: 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. DESIGN: 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. PARTICIPANTS: Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013. MAIN MEASURES: 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. KEY RESULTS: 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). CONCLUSIONS: 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.
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