- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05346523
Digitalized Differential Diagnosis Broadening in Emergency Rooms (DDX-BRO)
Effects of Digitalized Differential Diagnosis Broadening Using a Computerized Diagnostic Decision Support Tool on Diagnostic Quality in Emergency Room Patients - a Multi-centre Cluster Randomized Cross-over Trial.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Background:
Misdiagnosis occurs in about 5% of outpatients, and in 10% to 35% of emergency room (ER) patients, sometimes with devastating medical and economic consequences. Nowadays, computerized diagnostic decision support programs (CDDS) exist, which suggest differential diagnoses (DDx) to physicians and thus have potential to improve diagnoses and hence, outcomes of patient care. The effects of such CDDS in 'real-world' ER settings are unknown. Controlled clinical trials investigating their effectiveness and safety are absent. In addition, most available CDDS are overcautious and suggest a wide variety of diagnostic options, likely increasing diagnostic resource consumption.
Objectives:
With this project, the investigators aim to understand the intended and unintended consequences of CDDS use by physicians on diagnostic quality and workflow in emergency medicine
- on the micro-level, how CDDS affect diagnostic quality by physicians in individual emergency patients.
- on the meso-level, how CDDS affect the diagnostic workflow in emergency departments.
- on the macro-level, the economic and educational impact of CDDS utilization in ERs
Outcomes: Details given below
Design:
Cross sectional, multi-center, four-period cross-over controlled cluster-randomized trial. Four ER sites will randomly be allocated to one of two sequences with alternating intervention and control periods (ABAB vs. BABA) with each period lasting for two months. Recruitment will target 74 patients per period and cluster and 1'184 patients total.
Inclusion / Exclusion Criteria: Details given below
Intervention period: Details given below
Control period: Details given below.
Measurements and procedures:
For the primary outcome, data will be extracted from the electronic health records (i.e. ER diagnosis, intensive care unit admission or diagnosis after 14d if patients are still hospitalized). Additionally, patients and their general practitioner will be contacted via telephone by study nurses after 14d of study inclusion in order to collect information about patients' current diagnoses, and re-visits or hospitalization related to the initial ER visit. Data for secondary endpoints will be retrieved from the routinely collected data in the electronic health record system (e.g mortality, time to ER diagnosis, resource consumption). Additionally, interviews and focus groups with physicians will be performed to investigate diagnostic workflow changes, physician confidence and other process outcomes.
Statistical Analysis:
Statistical analysis will be based on multi-level general linear mixed modelling (GLMM) methods using appropriate post hoc techniques (e.g for subgroup analyses).
For the primary outcome (presence or no presence of a positive diagnostic quality risk score), a generalized linear mixed model (GLMM) with a binomial distribution family and exchangeable correlation structure will be performed. The GLMM takes into account a random effect for each site, resident and attending physician. Diagnosing resident and attending physicians are nested within sites. The condition (intervention and control) and the period (period 1 to 4) will be included as fixed factors under the assumption of equality of carry-over effects. Additionally, presenting chief complaint, patient's age, sex and comorbidity index will be added as covariates.
For all secondary endpoints, summary statistics appropriate to the distribution will be tabulated by treatment group. Analysis of secondary endpoints will parallel the primary analysis.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Wolf Hautz, Prof. MD
- Phone Number: +41 31 63 2 57 01
- Email: wolf.hautz@insel.ch
Study Contact Backup
- Name: Thimo Marcin, PhD
- Phone Number: +41 31 664 11 80
- Email: thimo.marcin@extern.insel.ch
Study Locations
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Bern, Switzerland, 3004
- Dept. of Internal and Emergency Medicine, Spital Tiefenau
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Bern, Switzerland, 3010
- Dept. of Emergency Medicine, Inselspital, University Hospital Bern
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Solothurn, Switzerland, 3004
- Dept. of Internal and Emergency Medicine, Buergerspital Solothurn
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Bern
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Münsingen, Bern, Switzerland, 3110
- Dept. of internal and emergency medicine, Spital Münsigen
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Informed Consent signed by the subject
- Presentation to the ER with fever, abdominal pain, syncope or Non-specific complaint (NSC) as chief complaint
- Triaged as "not vitally threatened"
- The study subject is 18 years old or older.
Exclusion Criteria:
- Trauma as chief complaint
- Pregnancy
- Worsening of a known pre-existing condition or medical referral with a definite diagnosis
- Inability to follow the informed consent and investigation procedures
- Previous enrolment into the current investigation
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Diagnostic
- Allocation: Randomized
- Interventional Model: Crossover Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Usual Care + CDDS usage
Patients presenting to the ER and included in the study during the ER's intervention period will be treated and diagnosed by the ER physicians as usual but with support of the CDDS.
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Isabel Pro - the DDx generator is a software developped for health professionals with the intention to support them in broadening their differential diagnoses.
After the first patient examination, the resident is asked to enter patient symptoms into Isabel Pro, which returns a list of possible diagnoses from its underlying database that matches the entered data.
The diagnosing resident physicians will be asked to consult Isabel Pro at least once within the first hour after the first patient assessement.
After entering patient symptoms into the software, Isabel Pro will itself return a list with possible diagnoses derived from their underlying database.
It is then free to the physician to decide whether one or more of the suggested DDx should be considered for further diagnostic or treatment procedure based on clinical judgement.
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No Intervention: Usual Care
Patients presenting to the ER and included in the study during the ER's intervention period will be treated and diagnosed by the ER physicians as usual without support of the CDDS.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Diagnostic quality risk score
Time Frame: From emergency room discharge to 14 days after emergency room discharge
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Primary endpoint is a binary score indicating a diagnostic quality risk, composed of:
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From emergency room discharge to 14 days after emergency room discharge
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Death within 14 days after Emergency Room discharge (yes/no)
Time Frame: From emergency room discharge to 14 days after emergency room discharge
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Patient died within the timeframe of emergency discharge
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From emergency room discharge to 14 days after emergency room discharge
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Unexpected intensive care unit admission
Time Frame: Within 24 hours from emergency room transfer to hospital ward
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Number of patients with unexpected intensive care unit admission from ward within 24 hours when hospitalized (yes/no)
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Within 24 hours from emergency room transfer to hospital ward
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Diagnostic discrepancy
Time Frame: From emergency room discharge to 14 days after emergency room discharge
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Number of patients with diagnostic discrepancy between the Emergency Room discharge diagnosis and the current diagnosis 14 days after ER discharge (yes/no)
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From emergency room discharge to 14 days after emergency room discharge
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Unscheduled medical care 72 hours, 7 days and 14 days
Time Frame: From emergency room discharge to 72 hours, 7 days and 14 days after emergency room discharge
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Number of patients with unscheduled medical care 72 hours, 7 days and 14 days after emergency room discharge
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From emergency room discharge to 72 hours, 7 days and 14 days after emergency room discharge
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Length of emergency room stay
Time Frame: Time from emergency room admission to emergency room discharge, up to 24 hours
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Number of hours the patient spent in emergency room routine care
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Time from emergency room admission to emergency room discharge, up to 24 hours
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Diagnostic tests
Time Frame: Time from emergency room admission to emergency room discharge, up to 24 hours
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Number of diagnostic tests performed during emergency room routine care
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Time from emergency room admission to emergency room discharge, up to 24 hours
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Discharge destination
Time Frame: Timepoint of emergency room discharge (according to clinical routine, up to 24 hours)
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Home / Hospital (intern) / Hospital (extern) / Nursing home / Rehabilitation / Other
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Timepoint of emergency room discharge (according to clinical routine, up to 24 hours)
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Number of differential diagnoses
Time Frame: Timepoint of emergency room discharge (according to clinical routine, up to 24 hours)
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Number of differential diagnoses provided by the physicians at emergency room discharge
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Timepoint of emergency room discharge (according to clinical routine, up to 24 hours)
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CDDS potential
Time Frame: Time from emergency room admission to 14 days after emergency room discharge
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Number of cases where the generated differential diagnosis list entails the diagnoses after 14 days
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Time from emergency room admission to 14 days after emergency room discharge
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Diagnostic error
Time Frame: From emergency room discharge to 14 days after emergency room discharge
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Diagnostic error based on full chart review for a random subset
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From emergency room discharge to 14 days after emergency room discharge
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CDDS usage
Time Frame: Time from emergency room admission to emergency room discharge From 0 up to 24 hours.
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Number of CDDS queries
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Time from emergency room admission to emergency room discharge From 0 up to 24 hours.
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Physician confidence calibration, advice seeking and collaboration
Time Frame: Exact timepoints to be defined, up to a maximum of 9 months. From June 2022 to March 2023
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Assessed by qualitative methods such as observations of physicians or interviews and focus groups with physicians (no patients directly involved).
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Exact timepoints to be defined, up to a maximum of 9 months. From June 2022 to March 2023
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Length of hospital stay
Time Frame: Time from hospital admission to hospital discharge, up to 18 days
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Number of days the patient was hospitalized (if hospitalized)
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Time from hospital admission to hospital discharge, up to 18 days
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Resource consumption in the Emergency Department
Time Frame: Time from emergency room admission to emergency room discharge, up to 24 hours
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Resource consumption (total costs for personnel and diagnostics) during emergency room
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Time from emergency room admission to emergency room discharge, up to 24 hours
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Resource consumption
Time Frame: Time from emergency room admission to emergency room discharge, up to 18 days
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Resource consumption (total costs for personnel and diagnostics) during hospitalization
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Time from emergency room admission to emergency room discharge, up to 18 days
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Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: Wolf Hautz, Prof. MD, Prof. MD
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- 407740_187284/1
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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