Achieving Excellence in the Diagnosis of Acute Cardiovascular Events Proceedings of a Workshop–in Brief (2021) / Chapter Skim
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Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop - in Brief
Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop - in Brief
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The workshop highlighted system improvement strategies for diagnosis, approaches to promote equity in diagnosis, and novel diagnostic tools. This workshop was the second in a series on diagnostic excellence funded by the Gordon and Betty Moore Foundation.2 This Proceedings of a Workshop -- in Brief highlights the presentations and discussions that occurred at the workshop.3 BACKGROUND Daniel Yang from the Gordon and Betty Moore Foundation described the concept of diagnostic excellence, noting that it goes beyond the avoidance of diagnostic error and encompasses "getting to the right diagnosis, in the shortest amount of time, with the least amount of resources, in a way that is patient-centered." He added that the diagnostic process often requires trade-offs among these objectives, but innovations in diagnostic systems and technologies have the potential to improve quality across all domains of diagnosis and increase clarity for front-line clinicians tasked with critical decision making.
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Safdar suggested that future diagnostic strategies for ACS should incorporate the evolving understanding of ACS pathophysiology and the differences in disease and symptom presentation among different patient populations. She also suggested that future work should ensure that existing protocols for diagnosis are adapted to incorporate new data from technological advancements and that future research should investigate all phenotypes of ACS and their influence on patient outcomes, diagnostic precision and risks of diagnostic errors, and health care costs.
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Liberman suggested multiple strategies to improve stroke diagnosis, such as community education on stroke detection, better understanding of the heterogeneity of stroke symptoms and presentation, and providing clinicians with the tools to recognize atypical symptoms that may reduce the time between stroke diagnosis and treatment. Opeolu Adeoye, professor and chair of emergency medicine at Washington University, said that individuals experiencing a stroke in minority communities are often less likely to recognize symptoms of stroke and are less likely to use EMS transport.
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Christine Goeschel, system leader at the MedStar Health Institute for Quality and Safety, reviewed health system–level initiatives to improve diagnosis. She noted that cardiovascular disease is a devastating and costly chronic illness, and is "fraught with errors in diagnosis and treatment." She added that meaningful progress toward diagnostic excellence requires engagement and accountability from the entire health care team, including clinical and administrative leaders: "Accountability in any area of health care involves all of us." Goeschel emphasized the critical importance of involving patient and family voices in the diagnostic process.
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He suggested that it may be more effective to develop guidelines for diagnostic evaluation and management strategies that cover multiple conditions. ACHIEVING EQUITY IN DIAGNOSIS AND MITIGATING DISPARITIES IN ACUTE CARDIOVASCULAR EVENTS Clyde Yancy, vice dean of diversity and inclusion at the Northwestern University Feinberg School of Medicine, discussed racial and ethnic disparities in acute decompensated heart failure, noting that the condition disproportionately affects middle-aged Black men (Virani et al., 2021)
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Herman Taylor, professor of cardiology at the Morehouse School of Medicine, discussed disparities in the earliest stages of identifying and diagnosing acute cardiovascular events, noting that it is crucial to better understand the "epidemiology of delay." He said that Black patients often experience delays in diagnosis relative to White patients. These delays are particularly salient for health outcomes after acute cardiovascular events; every 30 minutes of delayed treatment during an acute MI increases 1-year mortality by 7.5 percent (De Luca et al., 2004)
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She added, "we don't have mandatory reporting of diagnostic error, so it's hard to address something or fix something when we don't measure it." Building on Thomas's comments about measurement, Marina Del Rios, associate professor of emergency medicine at the University of Illinois at Chicago, stated that achieving diagnostic excellence should include equity as an outcome and offered three primary suggestions: diversify the health workforce to mitigate inequities in diagnosis and outcomes; diversify discovery science, especially in the design and use of new technology; and include equity as an outcomes measure to achieve diagnostic excellence. Gari Clifford, professor of biomedical informatics and biomedical engineering at Emory University and the Georgia Institute of Technology, agreed and reflected on the importance of diversity in discovery science, adding "the coding teams and the data wranglers need to be diverse and see themselves in the data." Del Rios discussed other strategies to mitigate inequalities in diagnosis, including the increased use of evidence-based guidelines, though she cautioned that these tools are used primarily for treatment after diagnosis and much of the evidence is based on clinical trials that lack diversity.
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Bindman closed the workshop with a cross-cutting observation from the discussions: "it is no longer acceptable to pursue improvement in diagnosis for some, we must pursue diagnostic excellence for all." BOX 1 Suggestions from Individual Workshop Participants to Achieve Excellence in the Diagnosis of Acute Cardiovascular Events Improving Patient and Clinician Education • Enhance disease-specific knowledge and features that distinguish between similar presenting diseases to counteract cognitive biases (Zwaan)
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. • Improve education on how cardiovascular conditions affect different patient populations and how implicit bias among clinicians can influence patient outcomes (Sarkar, Yancy)
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2012. Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.
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STAFF: Jennifer Lalitha Flaubert, Emily Zevon, Erin Balogh, Ruth Cooper, Cyndi Trang, Anesia Wilks, and Sharyl Nass, Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine. SPONSOR: This workshop was supported by the Gordon and Betty Moore Foundation.
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