Diagnostic errors have been a critical concern in healthcare, leading to substantial financial burdens and serious threats to patient safety. The Improving Diagnosis in Health Care report by the National Academies of Sciences, Engineering, and Medicine (NASEM) defines diagnostic errors, focusing on accuracy, timeliness, and communication, which are influenced by clinical knowledge and the broader healthcare system. This review aims to integrate existing literature on diagnostic error from a systems-based perspective and examine the factors across various domains to present a comprehensive picture of the topic. A narrative literature review was structured upon the Systems Engineering Initiative for Patient Safety (SEIPS) model that focuses on six domains central to the diagnostic process: Diagnostic Team Members, Tasks, Technologies and Tools, Organization, Physical Environment, and External Environment. Studies on contributing factors for diagnostic error in these domains were identified and integrated. The findings reveal that the effectiveness of diagnostics is influenced by complex, interconnected factors spanning all six SEIPS domains. In particular, socio-behavioral factors, such as team communication, cognitive bias, and workload, and environmental pressures, stand out as significant but difficult-to-capture contributors in traditional and commonly used data resources like electronic health records (EHRs), which limits the scope of many studies on diagnostic errors. Factors associated with diagnostic errors are often interconnected across healthcare system stakeholders and organizations. Future research should address both technical and behavioral elements within the diagnostic ecosystem to reduce errors and enhance patient outcomes.

Abstract Introduction Primary care clinicians (PCC) commonly make decisions in the context of time delay and uncertainty. Delay discounting (DD) and probability discounting (PD) are cognitive biases related to delay and uncertainty that are minimally explored in PCC. We assessed DD and PD in PCC and evaluated their association with low-value care (LVC) decision-making. Methods We administered a survey to PCC in a Southeastern U.S health system and within the American Academy of Family Physicians networks. The survey comprised standardized psychometric assessments of DD and PD and four LVC clinical vignettes. Outcomes included DD and PD discounting rates for two monetary rewards ($100 and $10,000) and ratings of LVC likelihood (0-100). We used regression analysis with model selection to evaluate the relationship between variables. Results 225 PCC (89% physicians, 11% advanced practice providers) participated. Heterogeneity in DD and PD rates was observed. For the $10,000 reward, ln k(DD)= -6.80, IQR:-7.60--6.10) and ln h(PD)= 1.75, IQR:1.75-2.36). The reward amount impacted DD and PD in opposing directions (i.e., lower DD/higher PD rates for $10,000 vs. $100). LVC likelihood was highest for low-value antibiotics and lowest for low-value cervical cancer screening (median 20, IQR:10-40 and 0, IQR:0-10, respectively). Model selection revealed demographic associations with LVC likelihood, but no association with DD or PD. Conclusions Consistent with effects previously reported in non-clinicians, PCC exhibited a range of DD and PD, which ranged by reward magnitude. Neither DD nor PD predicted vignette-based LVC likelihood. Further research should investigate actual clinical practice patterns and other LVC scenarios.

OBJECTIVES:Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) poses a risk to patients with chronic kidney disease (CKD), heart failure (HF), and hypertension (HTN). We evaluated changes in NSAID utilization among a large cohort of Virginia patients with CKD, HF, and/or HTN during the COVID-19 pandemic and assessed variation by patient demographic characteristics. STUDY DESIGN:Quasi-experimental difference-in-differences approach. METHODS:Using claims from the Virginia All-Payer Claims Database, we identified NSAID prescriptions dispensed to patients with CKD, HF, and/or HTN during the years 2019-2021. We applied Poisson regression to assess the impact of the COVID-19 pandemic (March 1, 2020- December 31, 2021) on NSAID utilization rates, stratifying incidence rate ratios (IRRs) by rurality, sex, and age. RESULTS:Extrapolated to the statewide population, approximately 3.8 million NSAID prescriptions were dispensed to Virginians with CKD, HF, and/or HTN between 2019 and 2021. Utilization rates declined by 23% during the first 2 years of the pandemic, were greater in rural vs urban areas (IRR, 1.594; 95% CI, 1.408-1.803) and among those aged 40 to 64 years, 65 to 79 years, and 80 years and older vs those aged 18 to 39 years (40-64 years: IRR, 6.366; 95% CI, 5.979-6.778; 65-79 years: IRR, 6.980; 95% CI, 6.568-7.417; ≥ 80 years: IRR, 5.223; 95% CI, 4.772-5.715); and were lower among men than women (IRR, 0.779; 95% CI, 0.758-0.800). The pandemic impacted rural and urban areas and women and men similarly but was associated with lower NSAID utilization among the 3 older age groups vs those aged 18 to 39 years (40-64 years: IRR, 0.869; 95% CI, 0.812-0.931; 65-79 years: IRR, 0.788; 95% CI, 0.733-0.847; ≥ 80 years: IRR, 0.769; 95% CI, 0.709-0.833). CONCLUSIONS:Despite a modest decline during the first 2 years of the pandemic, NSAID use remains prevalent among patients with CKD, HF, and/or HTN, especially in rural areas and among women. Results highlight the need for tailored deprescribing efforts.

ABSTRACTIntroductionIndividuals living in rural areas experience limited access to safe and effective pain management. Using insurance claims for 1.3 million Virginians, we evaluated variation in high-risk nonsteroidal anti-inflammatory drug (NSAID) prescribing by rurality during 2019-2021.MethodsWe applied a difference-in-differences model to analyze the effect of the COVID-19 pandemic on high-risk NSAID prescribing rates, stratifying incidence rate ratios (IRR) by rurality.ResultsAlthough high-risk NSAID prescribing rates decreased modesty during 2020-2021, rural areas experienced significantly higher prescribing rates throughout the study period (IRR: 1.594 [95% CI: 1.408, 1.803], p<.001).ConclusionsContext-driven efforts to de-implement high-risk NSAID prescribing in rural Virginia are needed.

Background Chronic kidney disease (CKD) affects over 10% of people globally. Despite its prevalence, CKD is persistently under-recognized and under-documented in healthcare settings. Previous studies have shown that patients who meet laboratory-based criteria for CKD but have no formal CKD diagnosis in their medical record are less likely to receive guideline-directed medical care for CKD. However, it is unclear whether CKD documentation status influences receipt of medications that may be high-risk for patients with CKD, including nonsteroidal anti-inflammatory drugs (NSAIDs). Objective We evaluated variation in NSAID prescribing based on CKD documentation status over a 10-year period, hypothesizing that patients who met diagnostic criteria for CKD but had no corresponding ICD diagnosis on record were more likely to receive long-term prescription NSAIDs. Methods This retrospective cohort study used electronic health record (EHR) data from the TriNetX Research Network representing 67 U.S. healthcare organizations (2013–2023). Adult patients with CKD were classified by CKD documentation status (diagnosis on record vs. criteria for CKD but no diagnosis on record). We applied logistic regression to assess the relationship between CKD documentation status and receipt of long-term NSAIDs, adjusting for demographics, comorbidities, and year. Results Among 1,777,336 patients, 52.9% met diagnostic criteria for CKD but had no CKD diagnosis on record. Overall, 9.0% of patients were prescribed long-term NSAIDs (6.3% of patients with a CKD diagnosis on record and 11.5% of those without). Patients with no CKD diagnosis on record were at 1.76 [95% CI: 1.74–1.79] times greater odds of receiving long-term NSAIDs compared to patients with a diagnosis on record. Female sex and Black/African American race were independently associated with higher odds of receiving long-term NSAIDs (1.47 [95% CI:1.46–1.49] and 1.37 [95% CI:1.30–1.44], respectively). Conclusions Across 67 US healthcare organizations, more than half of patients with laboratory-based evidence of CKD did not have a CKD diagnosis on record in the EHR. Absence of CKD documentation was associated with increased likelihood of receiving long-term NSAIDs. These findings suggest improved EHR documentation as a target for reducing potentially harmful prescribing in patients with CKD.

Professional guidelines advise against regular or long-term NSAID use in most patients with chronic kidney disease (CKD), heart failure (HF), and hypertension (HTN) due to risk of adverse events. Nevertheless, over-the-counter (OTC) NSAIDs are broadly accessible and frequently used among this population. Efforts to decrease high-risk OTC NSAID use have the potential to improve safety and reduce chronic disease burden. This randomized controlled trial evaluated the effectiveness of a brief, electronically-administered educational video in reducing high-risk OTC NSAID use. Adult participants with CKD, HF, and/or HTN who self-identified as regular NSAID users (≥3 times/week for 3 months) were invited to participate. Participants (n = 425) were randomized to either view an electronically-administered educational video informed by the COM-B behavioral change model (VIDEO, n = 223) or the FDA Drug Facts label for NSAIDs (CONTROL, n = 202). Intent to decrease OTC NSAIDs was evaluated via 11-point contemplation ladder immediately and 4 weeks post-intervention, with self-reported NSAID Exposure assessed at 4 weeks. We also evaluated current and recent pain levels at baseline and 4 weeks. Intent to decrease OTC NSAID use (4.28 (SD: 3.45) ladder rungs) and NSAID exposure (20.14 (SD: 13.66) dose-days per month) did not differ between groups at baseline. Intent to decrease OTC NSAID use increased more from baseline to immediately post-intervention in VIDEO vs. CONTROL (1.32 (SD: 2.80) vs. 0.55 (SD: 1.99) rungs, p < 0.001), with greater improvements for those with lower baseline intent. VIDEO and CONTROL were associated with a similar rise in intent to decrease OTC NSAID use (1.92 (SD: 4.41) vs. 1.36 (SD: 3.46), p = 0.150) and a similar decrease in NSAIDs exposure (−32.8% in VIDEO and −36.5% in CONTROL, p = 0.520) 4 weeks post-intervention. Pain levels did not differ between groups. Results suggest that a low-burden, electronically-administered intervention reduce high-risk medication use among patients with CKD, HF, and/or HTN.

Antibiotic stewardship hopes to address the "great public health irony"-the golden age of antibiotics in clinical medicine has turned into a global antibiotic resistance threat. This overview summarizes the problem of antibiotic resistance and antibiotic prescribing trends in outpatient primary care in the United States, then reviews the major antibiotic stewardship campaigns and interventions with a focus on primary care practice. The lessons of these campaigns and interventions can provide guidance for clinicians in practice to better integrate patient-focused primary care with population-oriented population health to address the threat of inappropriate antibiotic prescribing and antibiotic resistance.

BackgroundDigital twin (DT) technology holds significant promise for healthcare systems (HSs) due to real-time monitoring based on streaming operational data and a priori analysis capabilities without interrupting clinical workflows. However, the sociotechnical complexity of HSs presents challenges for effective DT implementation. A dichotomy also exists between the engineering and implementation science (IS) communities regarding DT implementation challenges. This study assesses the efficacy of the updated Consolidated Framework for Implementation Research (CFIR 2.0) in identifying DT implementation challenges, aiming to bridge the knowledge gap between IS and DT communities.MethodsThis study presents findings from a DT implementation case study in a family medicine clinic, an operational healthcare microsystem. It adopts CFIR 2.0 to guide semi-structured interviews with four key stakeholder groups (e.g., family medicine specialists, engineers, organizational psychologists, and implementation scientists). Participants (N = 8) were purposively sampled based on their roles in DT implementation. Thematic coding categorized interview data into seven themes: technological, data-related, financial and economic, regulatory and ethical, organizational, operational, and personnel. Thematic data were then cross-analyzed with challenges documented in DT literature to assess how effectively CFIR 2.0 identifies DT implementation challenges.ResultsChallenges were grouped into three categories: (i) shared challenges captured by both IS and DT communities, (ii) CFIR 2.0-identified challenges overlooked in DT literature, and (iii) challenges documented in DT research but not captured through CFIR 2.0-guided interviews. While there was strong overlap between the communities, a formidable gap also remains. CFIR 2.0 effectively identified a diverse set of issues—predominantly in organizational, financial, and operational themes—including many overlooked by the DT community. However, it was less effective in capturing technological and data-related barriers critical to DT performance, such as modeling, real-time synchronization, and sensor reliability.ConclusionsCFIR 2.0 effectively identifies organizational and operational barriers to DT implementation in healthcare but falls short in addressing technological and data-related complexities. This study highlights the need for interdisciplinary collaboration for the successful transition of emerging DT technologies into practice to maximize their impact on HS efficiency and patient outcomes.

Introduction:Family medicine (FM) residents spend hours working in the electronic health record (EHR). We implemented a multifaceted training program to improve their ability to utilize the EHR. This study analyzed Epic Signal data to assess the impact of that training on their proficiency and efficiency in the system. Methods:We performed a retrospective cohort study using 3 years of monthly data exported from Epic's Signal database for residents in our FM program and programs of internal medicine, obstetrics and gynecology, and pediatrics within our organization. The EHR training program was implemented in FM (and not the other residencies) incrementally across this time frame. We analyzed trends in Epic's proprietary Provider Efficiency Profile Score ("efficiency") and Proficiency Score ("proficiency") for differences in these scores. Results:FM residents demonstrated improved proficiency in EHR use over time compared to the other residencies. No significant changes in efficiency were seen for any group. Conclusion:Epic Signal data provides a tool to study curricular impacts. An EHR training program enhanced FM residents' proficiency but did not improve efficiency.

Introduction: Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions. Methods: The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years. Results: Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003). Conclusions: Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions. AJPM Focus 2024;3(4):100233. (c) 2024 The Authors. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine Board of Governors. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

A federally funded moonshot initiative with resources, commitment, and equity focus is needed to transform maternal health research, health services, and policies to reduce mortality. The National Institutes of Health's (NIH) Pathways to Prevention panel on postpartum health provides a consensus statement on the evidence, research gaps, and future priorities to prevent maternal morbidity and mortality. The panel reviewed an NIH-commissioned evidence review and workshop that included epidemiologic studies, demonstration interventions, and other maternal morbidity and mortality research to create these national recommendations. The panel concludes that a maternal morbidity and mortality crisis reflects a systemic failure of current U.S. health care, research efforts, and social policies. The panel recommends improving maternal health through a "maternal morbidity and mortality prevention moonshot" that adopts a comprehensive, multilevel life course conceptual framework; strengthens the research methods used within the science of maternal health; establishes and conducts national prevention, treatment, and policy interventions; and reimburses evidence-informed clinical approaches to improve maternal health across the life course. Without a national focus on fundamentally transformative interventions and other initiatives aimed at redressing structural racism and inequities in health care, current interventions and clinical advances in maternal morbidity and mortality prevention will remain tragically insufficient.

Objective 'Sludge' refers to administrative burdens or frictions that preclude people from getting what they want or need (eg, duplicative forms, complicated instructions, long waiting times). This mixed methods study evaluated patients' perceptions of sludge in the colorectal cancer (CRC) screening process and some impacts of this sludge. Design We employed an exploratory sequential mixed methods study design that comprised patient interviews and a patient survey. The interviews informed final survey revisions and captured contextual data about patients' experiences with sludge. Interview transcripts were inductively and deductively analysed to identify overarching themes. The survey quantified sludge, delayed or forgone screenings, screening experience (Net Promoter Score) and health system distrust (Health System Distrust Scale). We used chi 2 or t-tests for univariable comparisons and logistic or linear regressions to evaluate the association between cumulative sludge score and delayed or forgone screenings, screening experience and health system distrust. Results were integrated for interpretation. Setting Southeastern United States. Participants Patients who were 45-75 years of age, at average risk for CRC and had either completed or been referred for CRC screening (colonoscopy or stool-based test) within the previous 12 months. Results 22 interview participants and 255 survey participants completed the study. 38 (15%) survey participants rated their screening experience as poor (Net Promoter Score=0-7 out of 10). The mean (SD) Health System Distrust Scale score was 22.4 (6.3) out of 45 possible points (higher score=greater distrust). Perceptions of sludge in the CRC screening process varied, with long waiting times and burdensome communication being the most common sources (58% and 35% of participants, respectively). Sludge was positively associated with delayed or forgone screenings (OR=1.42, 95% CI 1.28, 1.57, p<0.001), poor screening experience (OR=1.15, 95% CI 1.04, 1.28, p=0.009) and health system distrust (beta=0.47, p<0.001). Qualitative findings add descriptive detail about sludge encountered, context to impacts experienced, and illustrate the heavy emotional impact of sludge: 'it just isn't worth it'. Conclusion Efforts to reduce sludge in the CRC screening process may improve timely completion of CRC screening, enhance patient experience and restore trust in the health system.

Objectives Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research.Design Scoping review.Data sources PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022).Study selection Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings.Data extraction Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation.Results From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients’ age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation.Conclusion Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.