Achieving Excellence in the Diagnosis of Acute Cardiovascular Events

The National Academies of Science, Engineering, and Medicine hosted a workshop, sponsored by the Gordon and Betty Moore Foundation, to examine the current scientific landscape and research opportunities for improving diagnosis of acute cardiovascular events within the U.S. health care system. This workshop was part of a series on diagnostic excellence. Below are key themes discussed by workshop participants.

 

“Diagnostic excellence is about getting to the right diagnosis, in the shortest amount of time, with the least amount of resources, and in a way that’s patient centered.”

— Daniel Yang, Gordon and Betty Moore Foundation

Watch the video: Daniel Yang

“Time is muscle, the earlier you diagnose, the earlier you intervene, the better the prognosis.” 

— Basmah Safdar, Yale University

Watch the video: Basmah Safdar

“We want excellent diagnosis to be available worldwide, not only at select medical centers where specialists or experts reside.”

— Rima Ananout, University of California, San Francisco

Watch the video: Rima Aranout

Improving Patient and Clinician Education   

  • Enhance disease-specific knowledge and features that distinguish between similar presenting diseases to counteract cognitive biases (Laura Zwaan).
  • Improve clinician recognition of the heterogeneous nature of acute cardiovascular events, including evolving phenotypes and atypical or minor symptoms, to avoid delays in diagnosis and treatment (Ava Liberman, Basmah Safdar, Herman A. Taylor, Carolyn Thomas).
  • Increase community engagement and patient awareness of stroke symptoms, including atypical and transient symptoms, to improve timely diagnosis and treatment (Opeolu Adeoye, Bernadette Boden-Albala, Jeffrey Kline, Ava Liberman).
  • Encourage and support effective communication between patients and their clinicians in the diagnostic process (Christine Goeschel, Urmimala Sarkar, Carolyn Thomas).
  • Prioritize interventions focused on prehospital settings and those that address patient-related factors that contribute to delays in seeking care for acute cardiovascular events (Opeolu Adeoye, Donald Casey, Ava Liberman, John Sather, Herman A. Taylor).

“There is ultimately a need for effective training and education campaigns to improve public awareness of stroke.”

— Opeolu Adeoye, Washington University School of Medicine

“What kind of messages are we providing people to ensure that they're using the right words, the right tools, to communicate with healthcare providers, but also that they're in tune as to what symptoms to look out for, what should be leading them to make a phone call to a physician, or showing up to the emergency department, or calling 911?” 

— Marina Del Rios, University of Illinois at Chicago

Developing Innovations in Technology and Care Delivery  

  • Provide guidance for data sharing and transparency to achieve the full potential of artificial intelligence and machine learning (Rima Arnaout, Derick En’Wezoh, John D. Halamka, Eric Topol).
  • Increase the use of D-dimer testing prior to computed tomography scans to reduce over-testing for pulmonary embolism (Jeffrey Kline). *D-dimer is a protein fragment that's made when a blood clot dissolves in the body. The test can help clinicians assess whether a patient may—or may not—be experiencing a pulmonary embolism.
  • Utilize telemedicine to make quicker diagnoses and provide health care access to resource-limited and rural communities (Ava Liberman, John Sather).
  • Employ community participatory research methods and more rigorous evaluation of the implementation of digital tools in diverse communities (Urmimala Sarkar).

“Artificial intelligence, deep learning, and machine learning is really well postured to enable great efficiencies in the way that we coordinate and deliver stroke care.”

— Derick En'Wezoh, Viz.ai

“Guidelines can help reduce inappropriate practice variation. It can speed translation of research into practice. Guidelines improve care, safety, and quality… and also can reduce disparities and cut costs. They are a win/win/win for everybody.”

— Elliott Haut, Johns Hopkins University School of Medicine and Bloomberg School of Public Health

Strategies to Improve Diagnostic Equity

  • Increase diversity in the clinical and discovery science workforce, and ensure patient diversity in clinical trials (Gari Clifford, Marina Del Rios, Urmimala Sarkar, Herman A. Taylor, Clyde W. Yancy).
  • Improve education on how cardiovascular conditions affect different patient populations and how implicit bias among clinicians can influence patient outcomes (Urmimala Sarkar, Clyde W. Yancy).
  • Utilize practice guidelines to avoid inappropriate variations in care and to reduce disparities in care (Elliott Richard Haut).
  • Implement evidence-based communication practices such as the teach-back method to ensure all patients understand their diagnosis and care plan (Urmimala Sarkar).

“The question then becomes: Are we able to apply these strategies in an equitable manner across the board? The question unfortunately leads to a disheartening no.”

— Clyde Yancy, Northwestern University Fineberg School of Medicine  

“The team needs to be diverse, the sensitivities and sensibilities that impact care at every step along the way need to be taken into full account, and there is no better way to do that than having the team that is taking care of the patients look like the people who are being taken care of.”

— Herman Taylor, Morehouse School of Medicine

“My job as a clinician, to make a diagnosis, is enhanced by working among a diverse workforce who can help me to overcome the implicit biases that we all have and to help me recognize variation in the presentations of conditions among different groups of people.”

— Andrew Bindman, Kaiser Permanente

Opportunities for Future Research Initiatives

  • Identify how symptom presentation varies among different patient populations (Basmah Safdar, Urmimala Sarkar, John Sather, Clyde W. Yancy).
  • Standardize data collection on the social determinants of health for cardiovascular disease (Rima Arnaout, Christine Goeschel).
  • Investigate how risk scores can be used to optimize diagnostic test use and reduce over-testing (Deborah Diercks).
  • Develop practices and tools to improve prehospital care, such as devices to detect hemorrhage and portable advanced imaging (Opeolu Adeoye).
  • Investigate the epidemiology of care delays, especially in minority communities (Herman A. Taylor).

“Understanding the epidemiology of delay is critically important and currently deficient. I think employing community-based participatory research to understand some of the nuances of that early interaction will bear much fruit.”

— Herman Taylor, Morehouse School of Medicine  

“Utilization of high-sensitive troponins provides us the opportunity to look at how we can utilize risk scores to reduce over-testing and actually re-evaluate our resource utilization for additional testing.”

— Deborah Diercks, University of Texas Southwestern Medical Center

Learn more:

Read the full Proceedings of a Workshop in Brief at nap.edu