Diagnostic Error in Medicine
Bibliographic record
Abstract
Background: Delays in cancer diagnosis can result from lack of timely follow-up of positive fecal occult blood tests (FOBT) and iron-deficiency anemia (IDA) for colorectal cancer (CRC) and elevated serum alpha-fetoprotein (AFP) levels for hepatocellular carcinoma (HCC). The VA implemented the patient-centered medical home (PCMH) model in 2010-2011 to provide patient-driven, team-based care with goals of improving healthcare outcomes. We hypothesized that PCMH will improve timely follow up of FOBT, IDA and AFP tests nationally in the VA. Methods: To identify patients with delayed follow-up after abnormal results, we applied previously validated electronic "trigger" algorithms to VA's national repository of electronic health record data. The trigger included patients with newly abnormal test results, excluding patients for whom follow-up was not required or action had been completed within 60 days of result. Positive predictive values of 57.0%, 55.1% and 82.3% for FOBT, IDA and AFP respectively, were higher than other known measures of diagnostic safety. We applied each trigger to all patients from 130 VA facilities across 18 national VA networks from 2006-2015. We derived yearly counts of trigger-positive patients based on VA facility and VA network to assess annual percent changes beginning in 2006. Negative binomial regression models were applied to assess overall and yearly changes in number of trigger-positive patients while accounting for clustering by VA network, over-dispersion and correlation due to repeated measures. An offset was created using expected number of trigger-positive patients by facility that adjusted for year and number of patients with primary care provider (PCP) visits that year. Final models were adjusted for VA network and PCP visits that year. Results: After excluding patients not meeting inclusion criteria, 5,887,006 and 37,762,419 patients had tests for FOBT and IDA from 2006-2015, respectively. Of patients who received FOBT tests, 245,776 patients met trigger-positive criteria and of those who received IDA tests, 303,323 met trigger-positive criteria. Similarly, 888,033 patients received AFP tests, with 12,098 patients meeting trigger-positive criteria. The trigger-positive count means for FOBT, IDA and AFP tests increased immediately following PCMH implementation, however the trigger-positive count means in subsequent years fluctuated between and among tests. Variability was also found by VA network, most likely due to facility size and complexity. Conclusion: Primary care medical home implementation does not appear to improve follow-up of abnormal test results that warrant cancer evaluation. Further contextual evaluation to explore lack of impact from this teamwork-based intervention is warranted.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.054 | 0.291 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.006 | 0.005 |
| Science and technology studies | 0.003 | 0.015 |
| Scholarly communication | 0.008 | 0.007 |
| Open science | 0.003 | 0.008 |
| Research integrity | 0.006 | 0.007 |
| Insufficient payload (model declined to judge) | 0.017 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".