Variation In Diagnostic Practice Research Articles

What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. Level III.

EP01.05-009 Simulation-Based Sample Size Estimation for an Early Detection of Lung Cancer Clinical Utility Trial in Indeterminate Pulmonary Nodules

Indeterminate pulmonary nodules (IPN) are a common clinical challenge worldwide. Current management can result in delayed diagnosis and unnecessary invasive procedures, two important indicators of clinical utility (CU). Improved risk stratification using a combination of biomarkers and CT imaging was recently published, mandating a randomized clinical trial to assess its CU. Essential trial design considerations include prevalence of cancer and variation in diagnostic practices across sites. Here, we describe an approach to estimate the sample size for a randomized Phase IIb trial measuring CU of a validated combined risk prediction score (CBM; blood biomarker + radiomics + Mayo risk score).

Fylkesvise forskjeller i registrert forekomst av autisme, AD/HD, epilepsi og cerebral parese i Norge

In 2012, we published an overview of the prevalence of developmental disorders and neurological diseases in children in Norway, which was unknown at the time. In this article we will compare diagnostics and treatment across counties and institutions. The prevalence across counties of autism spectrum disorders, ADHD, epilepsy and cerebral palsy in children aged 0-12 was estimated with the aid of data from the Norwegian Patient Register for the years 2008-11. In the age group 6-12 years, nationwide prevalence amounted to 0.6% for autism spectrum disorders, 2.0% for ADHD, 0.9% for epilepsy and 0.3% for cerebral palsy. In total, 5.0% of all twelve-year-olds were registered with one or more of these diagnoses. The prevalence of autism spectrum disorders and ADHD varied between the counties, from 0.3% to 1.5% for autism spectrum disorders and from 1.1% to 3.5% for ADHD. For epilepsy and cerebral palsy there was little variation between the counties. Diagnostics and treatment of these four conditions are spread over 29 somatic hospitals and 102 units for child and youth psychiatry. The variations across counties in the prevalence of autism spectrum disorders and ADHD are most likely due to variations in diagnostic practices. We ask whether it is appropriate to spread the provision of treatment across such a high number of institutions.

Regional Variations in Diagnostic Practices

Regional Variations in Diagnostic Practices

Regional Variations in Diagnostic Practices

Current methods of risk adjustment rely on diagnoses recorded in clinical and administrative records. Differences among providers in diagnostic practices could lead to bias. We used Medicare claims data from 1999 through 2006 to measure trends in diagnostic practices for Medicare beneficiaries. Regions were grouped into five quintiles according to the intensity of hospital and physician services that beneficiaries in the region received. We compared trends with respect to diagnoses, laboratory testing, imaging, and the assignment of Hierarchical Condition Categories (HCCs) among beneficiaries who moved to regions with a higher or lower intensity of practice. Beneficiaries within each quintile who moved during the study period to regions with a higher or lower intensity of practice had similar numbers of diagnoses and similar HCC risk scores (as derived from HCC coding algorithms) before their move. The number of diagnoses and the HCC measures increased as the cohort aged, but they increased to a greater extent among beneficiaries who moved to regions with a higher intensity of practice than among those who moved to regions with the same or lower intensity of practice. For example, among beneficiaries who lived initially in regions in the lowest quintile, there was a greater increase in the average number of diagnoses among those who moved to regions in a higher quintile than among those who moved to regions within the lowest quintile (increase of 100.8%; 95% confidence interval [CI], 89.6 to 112.1; vs. increase of 61.7%; 95% CI, 55.8 to 67.4). Moving to each higher quintile of intensity was associated with an additional 5.9% increase (95% CI, 5.2 to 6.7) in HCC scores, and results were similar with respect to laboratory testing and imaging. Substantial differences in diagnostic practices that are unlikely to be related to patient characteristics are observed across U.S. regions. The use of clinical or claims-based diagnoses in risk adjustment may introduce important biases in comparative-effectiveness studies, public reporting, and payment reforms.

Geographic distribution of autism in California: A retrospective birth cohort analysis

Prenatal environmental exposures are among the risk factors being explored for associations with autism. We applied a new procedure combining multiple scan cluster detection tests to identify geographically defined areas of increased autism incidence. This procedure can serve as a first hypothesis-generating step aimed at localized environmental exposures, but would not be useful for assessing widely distributed exposures, such as household products, nor for exposures from nonpoint sources, such as traffic. Geocoded mothers' residences on 2,453,717 California birth records, 1996-2000, were analyzed including 9,900 autism cases recorded in the California Department of Developmental Services (DDS) database through February 2006 which were matched to their corresponding birth records. We analyzed each of the 21 DDS Regional Center (RC) catchment areas separately because of the wide variation in diagnostic practices. Ten clusters of increased autism risk were identified in eight RC regions, and one Potential Cluster in each of two other RC regions.After determination of clusters, multiple mixed Poisson regression models were fit to assess differences in known demographic autism risk factors between the births within and outside areas of elevated autism incidence, independent of case status.Adjusted for other covariates, the majority of areas of autism clustering were characterized by high parental education, e.g. relative risks >4 for college-graduate vs. nonhigh-school graduate parents. This geographic association possibly occurs because RCs do not actively conduct case finding and parents with lower education are, for various reasons, less likely to successfully seek services.

Validation of surgical site infection surveillance in orthopedic procedures

Valid data are essential for a national surveillance system of nosocomial infections. In 8 hospitals conducting surgical site infection (SSI) surveillance for orthopedic procedures, a validation team performed a blinded retrospective chart review (10 operations with reported infections, 40 without) and interviewed infection control nurses. In total, 397 patient charts were reviewed. Positive and negative predictive values for routine surveillance were 94% (95% CI: 89%-99%) and 99% (95% CI: 99%-100%), respectively. When these results were applied to the aggregated surveillance data (403 infections, 10,068 noninfections), sensitivity was 75% (95% CI: 56%-93%) and specificity 100% (95% CI: 97%-100%). The following case finding methods were used: ward visits (in 7/8 hospitals), microbiology reports (5/8), ward notifications by link nurses (8/8), and other nursing (7/8) and medical (5/8) staff. The wound culture rate ranged from 9 to 67 per 1000 patient-days. All hospitals carried out postdischarge surveillance on readmission and all but 1 at follow-up visits and by an additional questionnaire. Most SSIs reported by the hospitals were true infections, showing that, when an SSI was reported, the definitions were correctly implemented. Some SSIs were missed, which might be due to weaknesses in case finding. Variation in diagnostic practices may also affect SSI rates.

Diagnostic Practices for Attention Deficit Hyperactivity Disorder: A National Survey of Primary Care Physicians

The American Academy of Pediatrics (AAP) clinical practice guideline emphasizes the appropriate diagnosis of attention deficit hyperactivity disorder (ADHD) in school-aged children. Although previous studies have shown wide variation in diagnostic practices for ADHD, few recent studies have examined nationally representative samples. To describe practice patterns of primary care physicians evaluating school-aged children for ADHD in the late 1990s and compare the patterns with subsequently published AAP guidelines. We surveyed a national sample of 2000 primary care pediatricians and family physicians. Of the 1076 returned surveys, 861 (43%) met data quality criteria and were included in the analysis. We tabulated frequencies for each item and used a chi2 test to examine relationships between survey items and physician characteristics. Primary care physicians most commonly reported conducting 1-2 new evaluations for ADHD per month, the majority spending 15-45 minutes and at least 2 office visits to confirm a diagnosis of ADHD. Although 58% of physicians used formal diagnostic criteria, only 28% reported using criteria according to the Diagnostic and Statistical Manual of Mental Disorders. Eighty-three percent reported using any teacher or school information such as report cards and rating scales. Approximately 70% used ADHD-specific rating scales, and 60% used global behavior scales. A quarter of respondents obtained laboratory tests such as hematocrit, lead, and thyroid function profile. Most physicians reported routinely assessing for coexisting conditions, ranging from 74% for tic disorders to 91% for depression and conduct disorder. Before the publication of AAP guidelines, primary care physicians' evaluation practices for school-aged children with ADHD varied widely, especially with respect to use of Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria and inappropriate diagnostic tests.

Investigative methods for natural rubber latex allergy in the UK

Allergy to natural rubber latex (NRL) has become an important health issue in recent years, but little is known about how this condition is investigated by physicians in the UK. This postal questionnaire of British dermatology and allergy specialists shows substantial variation in diagnostic practice, most notably with regard to the utilization and choice of starting dose of commercial latex prick test dilutions, reliance on allergen-specific immunoglobulin E measurement, investigation of associated fruit allergy and provision of resuscitation equipment/method of consent when challenge testing. 17% of responding physicians who investigate for NRL allergy do not perform prick test or glove challenge because of the potential risk of anaphylaxis or lack of resuscitation facilities. 87% of allergy clinic specialists report no reduction in the number of patients presenting as new referrals with suspected NRL allergy. These findings suggest a need for robust guidance to achieve more consistent investigative practice by those dealing with this condition.

Variation in diagnoses: Influence of specialists' training on selecting and ranking relevant information in geriatric case vignettes

Variation in aspects of medical practice such as diagnosis, has been studied at different levels of aggregation. At the inter-practitioner aggregation level, attention is increasingly being paid to factors explaining medical variation which are attributed to ‘professional uncertainty’. The concept of ‘professional uncertainty’ refers to variability that is considered to be inherent to the nature and structure of medical knowledge which depend on the epistemological characteristics of medical science. In this study the relationship between specialty training and variation in diagnostic practice was examined at the inter-practitioner aggregation level. Determination of a direct relationship would support the thesis that specialization is a structuring factor in the inherent variability of medical practice. Three groups of medical specialists participated in the study: geriatricians, geriatric-psychiatrists and internists. Four case scenarios were submitted to the specialists. The cases used involved elderly patients presenting with problems in domains common to all the participating specialists. For each case the specialists were requested to select those facts they considered important for reaching diagnoses and to rank these facts in order of perceived salience. Subsequently they were asked to provide (tentative) diagnoses, ranked in order of perceived significance. The occurrence of variability in diagnostic practice due to ‘professional uncertainty’ and the influence of specialist specific factors and shared knowledge, respectively, are demonstrated. The results clearly show that these three groups of specialists focused on different elements of information, and formulated different diagnoses in the same case, but expressed similar ranking patterns.