Evidence-based decision support for pediatric rheumatology reduces diagnostic errors

Michael M Segal, Balu Athreya, Mary Beth F Son, Irit Tirosh, Jonathan S Hausmann, Elizabeth Y N Ang, David Zurakowski, Lynn K Feldman, Robert P Sundel, Michael M Segal, Balu Athreya, Mary Beth F Son, Irit Tirosh, Jonathan S Hausmann, Elizabeth Y N Ang, David Zurakowski, Lynn K Feldman, Robert P Sundel

Abstract

Background: The number of trained specialists world-wide is insufficient to serve all children with pediatric rheumatologic disorders, even in the countries with robust medical resources. We evaluated the potential of diagnostic decision support software (DDSS) to alleviate this shortage by assessing the ability of such software to improve the diagnostic accuracy of non-specialists.

Methods: Using vignettes of actual clinical cases, clinician testers generated a differential diagnosis before and after using diagnostic decision support software. The evaluation used the SimulConsult® DDSS tool, based on Bayesian pattern matching with temporal onset of each finding in each disease. The tool covered 5405 diseases (averaging 22 findings per disease). Rheumatology content in the database was developed using both primary references and textbooks. The frequency, timing, age of onset and age of disappearance of findings, as well as their incidence, treatability, and heritability were taken into account in order to guide diagnostic decision making. These capabilities allowed key information such as pertinent negatives and evolution over time to be used in the computations. Efficacy was measured by comparing whether the correct condition was included in the differential diagnosis generated by clinicians before using the software ("unaided"), versus after use of the DDSS ("aided").

Results: The 26 clinicians demonstrated a significant reduction in diagnostic errors following introduction of the software, from 28% errors while unaided to 15% using decision support (p < 0.0001). Improvement was greatest for emergency medicine physicians (p = 0.013) and clinicians in practice for less than 10 years (p = 0.012). This error reduction occurred despite the fact that testers employed an "open book" approach to generate their initial lists of potential diagnoses, spending an average of 8.6 min using printed and electronic sources of medical information before using the diagnostic software.

Conclusions: These findings suggest that decision support can reduce diagnostic errors and improve use of relevant information by generalists. Such assistance could potentially help relieve the shortage of experts in pediatric rheumatology and similarly underserved specialties by improving generalists' ability to evaluate and diagnose patients presenting with musculoskeletal complaints.

Trial registration: ClinicalTrials.gov ID: NCT02205086.

Keywords: Computer software; Decision support; Diagnosis; Diagnostic errors; Medical informatics; Pediatric rheumatology.

Figures

Fig. 1
Fig. 1
Diagnostic errors by seniority (All 26 testers, 8 cases each = 208 testing instances)
Fig. 2
Fig. 2
Diagnostic errors by specialty (208 discrete tests)
Fig. 3
Fig. 3
Change in relevance of the diagnosis before and after decision support, by seniority and specialty
Fig. 4
Fig. 4
Net diagnostic errors by tester

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