Improving Diagnostic Performance in Pediatrics: Three Steps Ahead

Abstract

There is an urgent need to develop interventions to improve diagnostic performance—both with respect to quality and safety—on a scale commensurate with the public health impact of diagnostic errors.1 There is now a solid—and growing—body of evidence showing that diagnostic errors occur with substantial frequency in inpatients, out\xad patients, and even children.2–4 The causa\xad tive factors contributing to diagnostic errors are both complex and increasingly understood across multiple contexts. Cognitive factors—\xad related to both lack of and misapplication of knowledge as well as faulty cognition—contribute substantially to diagnostic errors as do factors related to the flawed “non\xad system” that is the US health care system.5,6 There is also an increasing focus on the interactions between individu\xad als (teamwork) and between individuals and the “nonsys\xad tem” that lead to suboptimal diagnostic performance.7,8 Much of the focus on diagnostic safety and quality has been in acute care settings, such as emergency depart\xad ments, inpatient wards, and intensive care units. Some of this focus is a natural outgrowth of the foundational studies in patient safety that launched the movement, in\xad cluding the landmark Harvard Medical Practice Study.9,10 Not only did these studies shine a light on the substantial frequency of diagnostic error, but they also demonstrated the validity of retrospective chart review in identifying adverse health care events. Also, the relatively encap\xad sulated period, acuity, and extensive documentation associated with acute care visits create a conven\xad ient and pragmatic context for studying diag\xad nostic error. However, most health care in the United States is not delivered in acute care set\xad tings. Especially in pediatrics, most con\xad tact that individuals have with the health care “nonsystem” is in primary care set\xad tings and studies to improve diagnostic performance must begin to shift to these settings. Fortunately, this issue contains 3 ar\xad ticles that constitute a major step forward in prag\xad matically improving diagnostic performance in pediatric primary care.11–13 The Reducing Diagnostic Errors in Pe\xad diatric Primary Care project was a national collaboration within the American Academy of Pediatrics Quality Im\xad provement Innovation Network that employed codified Quality Improvement Collaborative (QIC) methodolo\xad gies to attempt to improve the diagnostic performance in 3 areas in pediatrics: hypertension, depression, and missed or delayed action on laboratory tests. These 3 top\xad ics have substantial face validity as early targets for im\xad provement, given multiple descriptions of underdiagnosis of hypertension and depression and the fact that missed and/or delayed action on laboratory studies continues to be a source of diagnostic errors. The ambitious breadth of this study deserves commendation—43 practices were initially randomized to participate in this project, and 30 or 31 (depending on the area of focus) practices were in\xad cluded in the data analysis. Further, the fact that the study was conducted in primary care clinics, not only major academic children’s hospitals, is fundamental in consid\xad ering the generalizability of the findings. The step\xadwedge cluster\xadrandomized trial described was an excellent study design to analyze the implementation and effectiveness of previously known and well\xaddescribed best practices that have been previously implemented ineffectively, es\xad pecially concerning the diagnosis and management of hy\xad pertension and the diagnosis of depression. The authors show that the well\xaddescribed yet com\xad plex QIC methodology improved—sustainably—the di\xad agnosis and management of elevated blood pressure and the diagnosis of depression during the study period. The intervention did not reduce the rate of missed or delayed action on a subset of abnormal laboratory test results when comparing the control and intervention periods, al\xad though there did appear to be an improvement at later Improving Diagnostic Performance in Pediatrics: Three Steps Ahead