CMSS_Diagnostic Excellence_Summaries

The Penicillin Allergy Testing Improving & Expanding Needed Treatment (PATIENT) Program

American Academy of Allergy, Asthma & Immunology

Goals and Motivation

An estimated 35 million people in the United States have a documented penicillin allergy, yet more than 95% of them are able to take penicillin.1 Patients may erroneously self-report a penicillin allergy due to mislabeling a side effect (e.g., gastrointestinal upset) or a coincidental event (e.g., headache or cutaneous eruption due to underlying infection).

Unverified penicillin allergy in hospitalized patients is associated with longer hospital stays, increased rates of serious drug-resistant infections, and higher mortality.2 Verifying through allergy testing that a patient labeled with a reported penicillin allergy can safely tolerate penicillin (i.e., “delabeling”) significantly improves individual patient outcomes, reduces healthcare expenditures, and helps fight antimicrobial resistance.

Given the benefits of accurate penicillin allergy labeling, the American Academy of Allergy, Asthma & Immunology (AAAAI) designed their Diagnostic Excellence Initiative, the Penicillin Allergy Testing Improving & Expanding Needed Treatment (PATIENT) program, to:

1. Improve patient outcomes by enabling usage of the most effective antibiotic available for a particular patient for a broad range of conditions;

2. Reduce healthcare expenditures by facilitating prescribing of lower cost antibiotics and returning patients to a lower level of resource utilization more quickly;

3. Support efforts to combat antimicrobial resistance; and

4. Mitigate a factor increasing healthcare costs for some patients who frequently require antibiotics and whose comorbidities can cause significant challenges accessing evidence-based care and achieving best possible outcomes.

American Academy of Allergy, Asthma & Immunology SOCIETY SUMMARIES

Through the PATIENT program, AAAAI developed tools and guidance for penicillin allergy evaluation, developed educational materials to share these diagnostic strategies, and promoted the educational materials to clinicians.

AAAAI formed a PATIENT steering committee to guide this work. The committee was comprised of adult and pediatric allergy/immunology drug allergy specialists, an advanced practice provider, and an infectious disease specialist. This steering committee met regularly via videoconference to determine what tools should be developed, assist in the development of these tools, and discuss implementation strategies.

Accomplishments

AAAAI developed a series of eight videos with supporting documents focused on delabeling penicillin through allergen challenges: three for clinicians serving adults, three for pediatric clinicians, one for adult patients, and one for parents of pediatric parents. They promoted these videos widely, including through booths and presentations at professional meetings (AAAAI, Infectious Diseases Society of America, Infectious Disease Week, American College of Obstetricians and Gynecologists, American Academy of Pediatrics), podcast episodes (AAAAI, American Academy of Emergency Medicine), and National Penicillin Allergy Day.

There are multiple signs of this project’s success. Clinicians responded positively to the PATIENT videos, with many saying that they planned to apply the guidance to their practice. In 2024, the American Medical Association approved a resolution to support penicillin allergy delabeling. In addition, AAAAI’s educational efforts supported their broader work on the Penicillin Verification and Evaluation (PAVE) Act, a bill introduced in Congress in September 2024 that would add penicillin allergy delabeling to the Medicare intake and annual exam process. No grant funds were expended in support of the legislation, indicating the far-reaching impact of the PATIENT program’s educational activities.

AAAAI plans to update and continue to promote the resources developed under the PATIENT project.

SOCIETY SUMMARIES

American Academy of Allergy, Asthma & Immunology

Project Products

Eight videos about:

• Identifying patients at low risk of penicillin allergy,

• Implementing adult inpatient amoxicillin challenges,

• Conducting inpatient oral amoxicillin challenges,

• Why most children can safely undergo amoxicillin challenges,

• Conducting pediatric office-based oral amoxicillin challenges,

• Implementing pediatric amoxicillin challenges,

• Amoxicillin challenges (for patients), and

• Pediatric amoxicillin challenges (for patients’ parents).

Five resource documents:

• Penicillin Oral Challenge Dilution Directions

• Clinic Visit Note: Amoxicillin Challenge

• Coding for Oral Amoxicillin Challenge Testing

• Consent for Amoxicillin Challenge

• How to Conduct Challenge to Delabel Penicillin Allergy in Children in Outpatient Setting

Key Learnings

• Anticipate and address resistance to change: AAAAI found that clinicians were reluctant to change their current practices because they were skeptical about the simplicity of delabeling patients and they expected patients to resist delabeling. AAAAI responded by adopting new, more concise PATIENT messaging: “Penicillin Allergy? Think again.”

• Emphasize benefits for vulnerable populations: Physicians expressed concerns about already having too much to do in limited time with patients. AAAAI responded by acknowledging this concern and presenting delabeling as a fairly simple way to impact patients who stand to gain the most from delabeling, including pregnant and geriatric patients.

• Get early buy-in from everyone involved to ensure a diverse and broad perspective is represented: Although AAAAI developed their project with a leading expert, their Task Force wanted to take a different approach from what was originally proposed. This required adjustments.

• Collaborate with other specialties: AAAAI found that multidisciplinary collaboration contributed to their project’s success, as clinicians with a wide variety of backgrounds need to be involved in delabeling efforts.

• Build conservative timelines: AAAAI found that project redesign and video production took longer than anticipated.

1 Shenoy E, Macy E, Rowe T, Blumenthal K. Evaluation and management of penicillin allergy: a review. JAMA. 2019;321(2):188-199.

2 Blumenthal KG, Lu N, Zhang Y, Walensky RP, Choi HK. Recorded penicillin allergy and risk of mortality: a population-based matched cohort study. J Gen Intern Med. 2019 Sep;34(9):1685-7. PMID: 31011962.

Diagnosing and Managing Skin Disease in a Spectrum of Skin Color - Question of the Week Special Edition

American Academy of Dermatology

Goals and Motivation

Medical textbooks, scientific literature, and medical images are critical tools for initial and continuing medical education. Unfortunately, darker skin colors are significantly underrepresented in these resources. This means that clinicians are often unfamiliar with how dermatologic conditions present in different skin colors.1 These educational gaps can cause delays in the diagnosis and treatment of dermatological conditions, which ultimately lead to health disparities among patients of color.

Given the need to improve diagnosis and treatment of dermatologic conditions among patients of color, the American Academy of Dermatology (AAD) designed their Diagnostic Excellence Initiative to:

1. Provide education to member dermatologists that will enable them to (a) compare and contrast the visual presentation of dermatologic conditions across a spectrum of skin colors, (b) improve visual recognition of dermatologic conditions in dark skin colors, and (c) identify knowledge gaps in diagnosing dermatologic conditions in darker skin colors;

2. Engage at least 3,000 learners per case within the first six months of release; and

3. Collect 90 images through the Special Edition Question of the Week that can be used for other learning resources, such as the AAD’s Image Collection.

Accomplishments

AAD routinely produces Questions of the Week, which are online cases with images, multiple-choice self-assessment questions, learner feedback, and references for further study. AAD distributes Questions of the Week via links in weekly emails to its members.

American Academy of Dermatology

For this project, AAD’s Education team partnered with several subject matter experts to develop 30 Special Edition Questions of the Week specific to the diagnosis and management of skin disease in darker skin. These modules focused on ten dermatologic conditions that are often misdiagnosed in patients of color: atopic dermatitis, vitiligo, melasma, hidradenitis suppurativa, acne keloidalis, melanoma, psoriasis, sarcoidosis, pseudofolliculitis barbae, and alopecia.

AAD delivered the 30 cases to its more than 15,000 member dermatologists over a 10-week period. By the end of the project, more than 2,400 learners had engaged with the Special Edition Questions of the Week. AAD also integrated the case images into its existing Clinical Image Collection, a repository of dermatologic images that AAD members and staff can use for professional and patient education.

Learners who completed Special Edition Question of the Week post-tests rated the overall quality of the activity highly (4.7 out of 5.0) and also felt that the content did a good job of meeting the objectives of the activity (4.6 out of 5.0).

Key Learnings

• Clinicians valued continuing education about darker skin tones: Project editors, reviewers, and subject matter experts were enthusiastic, and learners provided many positive comments.

• Participating clinicians plan to improve their skills: Specifically, learners emphasized improving diagnosis of psoriasis and vitiligo, increasing the use of biopsy for uncertain diagnoses, and undertaking focused interventions for alopecia and melasma.

• Securing patient images is challenging: Although AAD’s subject matter experts were enthusiastic about the project and had access to suitable patient populations, securing a sufficient number of images and ensuring that the images conveyed teaching points was quite challenging. Image acquisition ended up being a large cost for the project.

• The Question of the Week format was very popular: Participants appreciated that it used a digital platform, gamification, and feedback.

• 30 Special Edition Question of the Week cases

• 103 project images included in AAD Image Collection Project Products

1 Kaundinya T, Roopal VK. Diversity of skin images in medical texts: recommendations for student advocacy in medical education. J Med Educ Curr Dev. 2021;8:238212052110258.

American Academy of Ophthalmology SOCIETY SUMMARIES

Ophthalmology’s First Diagnostic Excellence Initiative

Goals and Motivation

Distinguishing between inflammatory and infectious ocular disease can be challenging in a clinical setting. Ophthalmologic diagnoses that are not timely, that are inaccurate or that lead to incorrect treatment may pose significant, vision-threatening risks for patients.

Because it is important to promptly initiate therapy, an inflammatory cause is presumed if an infectious disease is considered unlikely, and corticosteroids or other immunosuppressive agents are often prescribed on an empirical basis. Should the underlying disease be caused by a viral, bacterial, parasitic, or fungal infection, this approach can lead to a worsening of the patient’s condition.

Given the challenges associated with accurate diagnosis and associated risks, the American Academy of Ophthalmology (Academy) designed their Diagnostic Excellence Initiative to:

1. Improve the timeliness and quality – and reduce the cost – of ocular infection diagnosis;

2. Enhance ophthalmologist training and education related to the diagnosis of ocular infections; and

3. Identify and address inequities in the care of ocular infections.

The core of the Academy’s strategy involved analyzing data from the IRIS® Registry (Intelligent Registry in Sight), a comprehensive eye disease clinical registry that includes data from more than 15,000 clinicians and 73 million patients. The project also produced and curated educational content, including podcasts, videos, case presentations, and articles.

American Academy of Ophthalmology

Accomplishments

The analysis of IRIS Registry data helped the Academy identify areas that are ambiguous in diagnostic decision-making. The team was able to identify and characterize disease presentation, diagnostic tests, time to treatment, treatment patterns, complications of treatment, and visual outcomes for the following diseases: posterior vitreous detachment, panuveitis, posterior uveitis, toxoplasmic chorioretinitis, acute retinal necrosis, syphilitic retinitis, bacterial endophthalmitis, and bacterial or atypical keratitis. They also examined racial and ethnic differences in care and treatment but did not detect any disparities.

The Academy formulated two practical clinical recommendations to improve gaps and delays in the diagnosis of infectious eye diseases:

1. Perform an anterior chamber paracentesis for suspected anterior viral uveitis to confirm diagnosis and appropriate treatment; and

2. Perform a scleral depression within 42 days of initial presentation for patients with posterior vitreous detachment for timely diagnosis of any subsequent retinal breaks or retinal detachments, and earlier than 42 days in the presence of risk factors.

The Academy also developed and curated many educational products related to the diagnosis of eye disease, including a website, ten ophthalmology newsmagazine articles, four podcast episodes, thirteen videos, two interactive cases, and two peer-reviewed journal articles.

This project was an important first step in the Academy’s diagnostic journey. They expect to do more of this work in the future and hope to study other areas of diagnostic uncertainty, such as ocular cancer.

Key Learnings

• Employ existing infrastructure: The Academy made use of supporting infrastructure in place from the outset of this project. The IRIS Registry was already in use, and its development had been spurred by ophthalmologists’ shared goal of continual improvement in the delivery of eye care.

• Connect to clinician pain points: Diagnostic excellence also had tangible relevance to clinician pain points, such as the cost of malpractice insurance. In addition, relevant educational materials already existed, and the Academy was able to curate them on their diagnostic excellence website.

• Collaborate: The project was bolstered by teamwork and collaboration within the Academy and beyond, including with volunteer content creators. The Academy also learned from, and was inspired by, their fellow diagnostic excellence grantees.

American Academy of Ophthalmology

• Communicate intentionally: Diagnostic errors are a challenging topic for clinicians, as they are used to being treated as highly competent professionals. The Academy learned that using a non-blaming communication approach, highlighting diagnostic excellence and best practices rather than errors, was a productive approach. The Academy also learned the importance of repeating messages via multiple media channels (e.g., article, podcast, website) and to use images to support verbal communication.

• Recognize the limits of existing data: Although the IRIS Registry was an important asset for this project, electronic health records do not fully capture clinician logic and reasoning with regards to diagnosis and treatment.

Project Products

• Diagnostic Excellence in Ophthalmology website: https://www.aao.org/education/diagnostic-excellence

• Newsmagazine articles about:

o Infectious uveitis (Part 1, Part 2),

o Megalocornea,

o Ocular syphilis,

o Peripheral exudative hemorrhagic chorioretinopathy,

o Post-operative aqueous misdirection,

o Sjögren syndrome,

o Using ultrasound in intraocular diagnosis (Part 1, Part 2), and

o Visual pathway lesions.

• Peer-reviewed journal articles about:

o Acute posterior vitreous detachment and

o Viral anterior uveitis.

• Podcast episodes about:

o Herpetic uveitis,

o Infectious keratitis,

o Intermediate uveitis, and

o Ocular syphilis.

• Videos from presentations on diagnostic acumen and challenges at the AAO 2022 Annual Meeting, related to the following topics:

o Neuro-ophthalmology,

o Ocular syphilis,

o The optic nerve (Video 1, Video 2)

o Pythium insidiosum keratitis,

o Retina (Video 1, Video 2, Video 3)

o Scleritis, and

o Uveitis (Video 1, Video 2, Video 3, Video 4).

• Interactive Patient Cases

o Diagnosis of a Painful, Red Eye After a Bug Bite

o Diagnosis of Ocular Motility and Corneal Ulcer

Improving Diagnostic Excellence in Ambulatory Pediatrics

American Academy of Pediatrics

Goals and Motivation

Most pediatric clinicians (82%) self-report having made a diagnostic error that harmed a patient.1 About a third of pediatric primary care practices report making a diagnostic error at least monthly, and a third report making a diagnostic error resulting in an adverse event at least once per year.2

There are several reasons to focus on reducing diagnostic errors in outpatient pediatric settings specifically. First, pediatric outpatient visits are much more common than hospitalizations. Second, multiple features of the outpatient setting may increase the risk of diagnostic errors, including time constraints, the general nature of outpatient complaints, the large volumes of care episodes, and the involvement of only a single decision-making clinician.

Given the prevalence of and risk factors for diagnostic errors in the pediatric outpatient setting, the American Academy of Pediatrics (AAP) designed their Diagnostic Excellence Initiative to:

1. Provide practicing primary care pediatricians and pediatric subspecialists insight into the impact of diagnostic excellence on child health;

2. Provide clinicians with information on the main contributing factors to diagnostic errors and a systematic framework of proven best practices to address these common causes while using an equity and patient-centered lens to improve clinician cognitive skills and systems-related factors; and

3. Provide focused information on the most common pediatric conditions that offer the greatest opportunity for improvement in diagnostic excellence.

AAP’s strategy centered on the development and dissemination of brief educational videos and accompanying written content for pediatric clinicians.

American Academy of Pediatrics

Accomplishments

AAP partnered with subject matter experts in diagnostic safety and with other organizations – Patients for Patient Safety US, Children’s Hospital Association, Solutions for Patient Safety, and the Society to Improve Diagnostic Medicine – to develop a series of 10 educational video modules. All videos were accompanied by a one-page summary document that highlighted key lessons and included links to additional tools and resources. AAP promoted the series through its social media accounts, news publications, and listservs, as well as through digital advertisements.

As of the close of their grant-funded effort, more than 300 learners had registered for AAP’s course series. Most clinicians who responded to a brief evaluation survey reported that the video series was well-received, their knowledge of the impact of diagnostic errors increased, they learned a new tool or skill to reduce diagnostic errors in practice, they planned to share information with colleagues, and they would recommend the video series to their colleagues.

In addition to the video modules, AAP developed a diagnostic safety toolkit geared towards the ambulatory setting. The toolkit offered additional resources and implementation strategies for pediatricians and other clinicians to implement in practice.

AAP plans to continue their partnerships with external organizations to expand upon the work of this initiative.

Key Learnings

• Incorporate patient and family voice in clinician education: Patient representatives brought their lived experience to AAP’s project.

• Communication builds patient trust and partnership: The project’s patient representatives stressed the importance of listening to and communicating with patients and families/caregivers. This establishes trust and promotes patient/family willingness to actively partner with clinicians on their care.

• Make specific requests of project partners: Be very explicit about the action being requested, the time commitment, and any stipend. Clarify whether an individual is being asked to represent their organization or their personal experience.

• Video production requires flexibility: It was challenging to align taping schedules between staff, faculty, and family/patient representatives. AAP staff had to provide alternative taping options and additional video editing to finalize the modules.

SOCIETY SUMMARIES

American Academy of Pediatrics

Project Products

• Videos and companion infographics about:

o The importance of diagnostic excellence,

o Patient and family engagement,

o Cognitive reasoning,

o Building a culture of safety,

o Learning systems,

o Intra-cranial conditions,

o Hypertension,

o Diagnostic uncertainty,

o Appendicitis, and

o Equity

• The Diagnostic Safety Toolkit

1 Grubenhoff JA, Ziniel SI, Cifra CL, Singhal G, McClead RE Jr, Singh H. Pediatric clinician comfort discussing diagnostic errors for improving patient safety: a survey. Pediatr Qual Saf. 2020;5(2):e259. https://doi.org/10.1097/pq9.0000000000000259

2 Rinke ML, Singh H, Ruberman S, et al. Primary care pediatricians’ interest in diagnostic error reduction. Diagnosis (Berl). 2016;3(2):65–69.

Promoting Diagnostic Excellence Across Medicine in the Older Adult – rAAA Missed Vascular Event

American College of Emergency Physicians

Goals and Motivation

Patients with a ruptured abdominal aortic aneurysm (rAAA) experience intense abdominal pain, often prompting them to visit an emergency department. An rAAA is fatal for about 4 in 5 patients, with at least 15,000 people dying from this condition each year. However, the odds of surviving an rAAA are better if there is a shorter time between the rupture and surgical repair. In addition, if an AAA is detected and surgery occurs before the aneurysm ruptures, the chance of survival improves to about 97%.

Rapid bedside ultrasound screening is extremely effective in detecting rAAA. The US Preventive Services Task Force recommends rAAA screening for all men older than 65 who have ever smoked, as well as selective screening of male and female non-smokers. However, this screening occurs in only 4 to 26% of appropriate individuals, with disparities for individuals of color and with lower socioeconomic status. Low screening rates may be due, in part, to the rare nature of rAAA; clinicians typically only see a few cases in their career, and their education on the topic may be outdated.

The American College of Emergency Physicians (ACEP) previously developed a quality measure for rapid diagnosis of rAAA. The measure underwent rigorous feasibility and validity testing using a database of more than 50 million visits representing more than 1,100 emergency departments.

ACEP sought to build on their initial efforts to improve the early diagnosis of rAAA by using their Diagnostic Excellence Initiative to:

1. Develop rAAA diagnosis content for a podcast episode, webinar, ACEP Scientific Assembly course, and ACEP Now article;

2. Create a podcast episode, webinar, ACEP Scientific Assembly course, and ACEP Now Article; and

3. Disseminate the podcast episode, webinar, course, Sonoguide (ACEP’s Ultrasound Guide for Emergency Physicians), and new rAAA quality measure through ACEP’s and partners’ communication channels.

American College of Emergency Physicians

Accomplishments

ACEP produced a 30-minute podcast episode about rAAA. As of January 2025, the episode had been listened to more than 1,600 times. ACEP also developed and delivered a webinar with continuing medical education (CME) credits, available both live and recorded in the ACEP Online Learning Center (Precision in Practice: Achieving Diagnostic Excellence in Patients with Ruptured Abdominal Aortic Aneurysm). An article, New Quality Measure Improves Screening for Abdominal Aortic Aneurysm, was published in ACEP Now magazine.

Key Learnings

• Demonstrate the need for clinician education: Clinicians told ACEP that they “don’t miss” rAAA diagnoses, but this is not consistent with available data. ACEP had to give clinicians a reason to revisit this rare disorder.

• Meet patients where they are at: Some people think rAAA screening should not happen in emergency departments; however, preventive screening (for rAAA and other conditions) is not always being done in a primary care setting.

• Be proactive: Contact project partners early to ensure work is planned and deadlines are met.

Project Products

• ACEP Frontline podcast episode, On the Pulse of the Pulsatile Mass - rAAA Diagnosis and Management in the ED

• Webinar, Precision in Practice: Achieving Diagnostic Excellence in Patients with Ruptured Abdominal Aortic Aneurysm (rAAA)

• CME lecture at the 2024 ACEP Scientific Assembly, Precision in Practice: Achieving Diagnostic Excellence in Patients with Ruptured Abdominal Aortic Aneurysm (rAAA)

• ACEP Now article, New Quality Measure Improves Screening for Abdominal Aortic Aneurysm

Promoting Health Equity Through Excellence in Diagnostic Decision Making

American College of Physicians

Goals and Motivation

Diagnostic error is a significant cause of preventable harm for adult patients, and unconscious biases related to race/ethnicity, gender, and other identities are important factors in such diagnostic error, contributing to inequities in health and health care. Pragmatic strategies may reduce the influence of unconscious bias on diagnostic decision making, providing actionable educational goals for contemporary physicians.

The American College of Physicians (ACP) project goal was to promote health equity through improved physician clinical reasoning skills that minimize the impact of implicit biases on diagnostic decision making. Their objectives were to:

1. Disseminate information about diagnostic decision making to ACP’s 160,000 members and other medical professionals,

2. Improve knowledge about the principles of diagnostic decision making among internal medicine physicians,

3. Advance physician understanding of how implicit biases in diagnostic decision making contribute to inequities in health and healthcare,

4. Improve physician understanding of practical strategies and confidence in their ability to reduce the influence of implicit bias on their diagnostic decision making, and

5. Evaluate the effectiveness of the funded program.

ACP planned to accomplish their goals by producing two learning modules with interactive cases to promote excellence in diagnostic decision making for internal medicine physicians.

Accomplishments

ACP developed two interactive educational case study modules and a third introductory module. As of December 2023, more than 1,000 learners had accessed the learning modules. In evaluation surveys, most respondents reported the quality of the modules as excellent or very good. More than two thirds of respondents planned to implement changes to their practice based on the modules. Subsequent follow-up surveys indicated that 20% of respondents had immediately changed their behavior and 10% planned to change their behavior but had not yet done so. Of those who had implemented changes, most stated that the changes improved their practice.

American College of Physicians

Learners shared many positive comments about the modules, such as, “I get overwhelmed by this topic, and I feel like this module helped me just start the process” and “Change has to happen on multiple levels as described, from intrapersonal to system-wide. Recognizing the disparities and asking oneself how to start making a change on one or multiple levels will hopefully encourage physicians that despite a challenging workload and growing requirements…this is an impactful and necessary way to better care for our patients.”

The project’s learning hub also includes two supplementary podcasts focused on disparities in diagnosis. Most evaluation survey respondents reported the podcast quality as excellent or very good. Two thirds of respondents planned to implement changes to their practice based on the podcast episodes.

ACP plans to continue surveying learners to monitor module impact as more physicians discover the curriculum and begin implementing changes to their practice.

Key Learnings

• Collaborate: ACP found that teamwork across multiple teams, departments, and ACP divisions was critical for their project success.

• Consider multiple approaches to diagnostic excellence: ACP’s subject matter experts had different opinions regarding what constitutes diagnostic excellence, and ACP needed time to develop an approach they felt comfortable with for this project.

• Anticipate potential negative responses to sensitive topics: Learners can sometimes have sensitive or defensive reactions to discussions about unconscious bias. To address this, ACP strove to promote psychological safety and offer a safe place for learners to fail. They delivered content with a neutral, non-blaming tone. Modules started with general discussion of cognitive bias before narrowing to bias based on racial/ethnic/gender identity. The modules also included real-world cases rather than lectures.

• Revisit older educational materials: This project gave ACP a new lens for viewing their previously developed materials for other health topics. They realized that these materials included some assumptions and biases that could be corrected with updated materials.

Project Products

• Interactive online learning modules

o Introduction to understanding and addressing disparities in diagnosis

o Case study 1

o Case study 2

• Podcast episodes

o Core IM

o The DEI Shift

Diagnostic Excellence of Dementia and Cognitive Impairment in the Surgical Setting

American College of Surgeons

Goals and Motivation

Dementia and pre-existing cognitive impairment are risk factors for multiple postoperative complications, including delirium, cognitive decline, and escalation of functional decline. Dementia is also associated with longer hospitalizations and higher rates of discharge to facilities, which raise healthcare costs.

Given that older adults are the age group with the highest risk for dementia, that older patients make up a disproportionately large share of surgeries, and that the population of older Americans is projected to grow, surgeons will likely treat an increasing number of patients with dementia and cognitive impairment in the future.

Surgical teams can improve pre- and post-operative care by properly identifying, diagnosing, and managing dementia and cognitive impairment. To meet this need, the American College of Surgeons (ACS) designed their Diagnostic Excellence Initiative to:

1. Improve surgical decision making and patient care through more precise, timely diagnosis of dementia and cognitive impairment in the older adult surgical patient; and

2. Provide support for patients diagnosed with dementia and/or cognitive impairment and caregivers so that their condition and subsequent care plan are understandable.

ACS addressed their project aims by developing and disseminating educational resources for clinicians, patients, and patient families.

Accomplishments

ACS developed educational materials that include:

• A written column on timely and accurate diagnosis of, and early intervention for, dementia and cognitive impairment;

• A podcast episode about safety, quality, and equity as they relate to diagnostic excellence for dementia and cognitive impairment;

• A best-practice, preoperative cognitive screening toolkit for teams caring for older adults undergoing surgery;

• A patient and caregiver brochure about what to expect when having surgery; and

• A panel session at the 2023 ACS Quality and Safety Conference about the impact of cognitive impairment on surgical decision making and care.

American College of Surgeons

ACS distributed their project materials to 88,000 members via the Bulletin of the American College of Surgeons and more than 700 people via their Geriatric Surgery Verification (GSV) newsletter. As of November 2024, ACS’s podcast episode had more than 500 downloads.

ACS’s project will inform their development of additional educational materials for patients and providers, as well as other efforts to improve outcomes for older adult surgical patients. In addition, ACS plans to develop materials for use in emergency medicine.

Key Learnings

• Leverage existing relationships: For this project, ACS worked with organizations and audiences that they had partnered with for many years. This contributed to their success.

• Capture feedback from diverse experts: This helped ACS develop strategies, identify gaps, and ensure that their educational materials were appropriate for their intended audience.

• Develop interactive and engaging products: Of all of the products they developed, ACS’s panel session and podcast were particularly well-received.

• Recognize the small successes that contribute to broader goals: ACS engaged the project team and other stakeholders by continuously demonstrating the importance of the educational materials they were developing. The positive feedback ACS has received to date is motivating them to continue developing and disseminating educational content for geriatric care.

• Maintain good communication with everyone involved, and set modest but achievable goals: This helped ACS ensure that the project team remained on track and did not lose sight of its end goal.

Project Products

• Member magazine article about the impact of preoperative cognitive impairment

• Podcast episode about preoperative detection of cognitive impairment and dementia

• Best-practice toolkit for teams caring for older adults undergoing surgery

• Patient and caregiver brochure about what to expect when having surgery

• Panel presentation at the 2023 ACS Quality & Safety conference

Improving Clinician Competence in Use and Interpretation of EEG: A Matter of Safety, Quality, and Equity

American

Epilepsy

Society

Goals and Motivation

In the United States, about 3.4 million people are living with epilepsy,1 and there about 150,000 new diagnoses each year.2 The electroencephalogram (EEG) is a baseline tool for diagnosing epilepsy. Unfortunately, there is a professional practice gap in the appropriate use of EEG and the accurate reading and interpretation of EEG results. An epilepsy diagnosis can often take a year or more,3 and the rates of misdiagnosis are estimated to be more than 20%.4 Delays in the accurate diagnosis and proper treatment of epilepsy can have negative consequences for quality of life, cognitive functioning, physical health, and mortality.5

Given the prevalence and consequences of delays and errors in epilepsy diagnosis, the American Epilepsy Society (AES) designed their Diagnostic Excellence Initiative to:

1. Assess and revise their current online, 9-module course into scaffolded microlearning courses for clinicians treating patient populations with epilepsy;

2. Target and engage an already established audience of 5,000 professionals who have expressed interest in the program, along with an additional 2,000 clinicians who are part of the epilepsy care team, with information about EEG issues and resources through an online program delivered in accessible formats (both long-form and micro-learning);

American Epilepsy Society

3. Deliver on-demand online training to neurology residents, epilepsy fellows, early-career epileptologists, and other early-career clinicians to improve diagnostic skills;

4. Provide patients with information about the role of EEGs in their diagnosis via a variety of modalities, including AES-produced and -distributed learning videos shared through social media channels, so they have more comfort and confidence in talking with their care team; and

5. Develop a one-pager for clinicians to help guide conversations about EEGs with their patients.

Accomplishments

AES collaborated with a team of subject matter experts to update their existing EEG course content, including improvements related to interactivity and diversity. They published the revised EEG Essentials course in August 2024. AES publicized the course through targeted e-mails, advertisements on the AES website, and social media posts on X and LinkedIn.

Within the first 11 weeks of its launch, the course website logged more than 11,000 views from more than 7,500 unique users. Nearly 1,500 unique individuals registered for one or more of the course’s three levels (foundation of 18-20 modules, intermediate, advanced). On average, across the 25 course modules, 78% of users who started a module completed it, and the average post-activity assessment score was 81%.

AES also developed and promoted a clinician handout, clinician discussion board, and two patient videos. Website visitors downloaded the handout PDF 28 times between August and October 2024. As of January 2025, the Getting an EEG? Be Prepared! video had 64 views on YouTube.

SOCIETY SUMMARIES

American Epilepsy Society

Key Learnings

• Proactively consider all expertise needed to complete a project: AES retained experts in EEGs and education to help develop and review project content. However, these individuals requested assistance with assessing content for biases in language and images. AES ultimately engaged members of its Diversity, Equity, and Inclusion committee in this task.

• Co-create timelines with full team: AES developed the original project timeline, but their subject matter experts requested more time to complete the required reviews, and the timeline needed to be adjusted.

• Conduct an early and comprehensive inventory of what required materials already exist vs. need to be developed: AES realized, after the subject matter expert review of content, that they needed to develop some new elements for their revised course modules. This required urgent asset development with a short and stressful timeline.

Project Products

• EEG Essentials free online curriculum, with 25 learning modules

• Improving Patient Understanding of EEG Procedures clinician handout

• EEG discussion board

• Two patient videos, including Getting an EEG? Be Prepared!

1 Zack MM, Kobau R. National and state estimates of the numbers of adults and children with active epilepsy - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66:821-825.

2 England MJ, Liverman CT, Schultz AM, Strawbridge LM. Summary: a reprint from epilepsy across the spectrum: promoting health and understanding. Epilepsy Curr. 2012;12(6):245-53.

3 Bensken WP, Navale SM, Andrew AS, Jobst BC, Sajatovic M, Koroukian SM. Delays and disparities in diagnosis for adults with epilepsy: findings from U.S. Medicaid data. Epilepsy Res. 2020;166:106406.

4 van Donselaar CA, Stroink H, Arts WF. How confident are we in the diagnosis of epilepsy? Epilepsia 2006;47(s1):9-13.

5 Pellinen, J, French J, Knupp KG. Diagnostic delay in epilepsy: the scope of the problem. Curr Neurol Neurosci Rep. 2021;21(12):71.

Narrowing Health Disparities in Diagnostic Evaluation of Iron Deficiency Anemia Through

Clinician-Directed and Patient-Focused Interventions

American Gastroenterological Association

Goals and Motivation

In the United States, approximately 5% to 11% of women and 1% to 4% of men are iron deficient, and about 5% and 2%, respectively, have iron deficiency anemia (IDA).1 IDA is an important but often overlooked early sign of gastrointestinal malignancy or chronic occult gastrointestinal bleeding. If undetected and untreated, these conditions can lead to unnecessary hospitalization, morbidity, and mortality.

In 2019, the American Gastroenterological Association (AGA) released new guidelines on gastrointestinal evaluation of IDA.2 These guidelines promote the use of endoscopy, colonoscopy, and non-invasive testing for etiologies of IDA, such as celiac disease and H. pylori infection. Unfortunately, despite these guidelines, many IDA patients still do not receive diagnostic evaluation.

To address the evidence-to-decision gap in IDA and gastrointestinal evaluation, AGA designed their Diagnostic Excellence Initiative to:

1. Develop a clinician-directed intervention through the electronic health record (EHR) system that a) automatically identifies patients with IDA who have not had prior evaluation and notifies clinicians through a health maintenance alert and b) develops a modified colonoscopy order set for patients which incorporates comprehensive testing for IDA to ensure complete evaluation is performed; and

2. Develop a patient-directed intervention to guide decision-making about IDA diagnostic testing.

Accomplishments

AGA developed a prototype clinician intervention embedded within Epic, the most widely-used EHR system. The intervention had two components:

• A standardized order set for diagnostic evaluation of IDA. This will be the default for patients for whom AGA strongly recommends evaluation (i.e., men and post-menopausal women). For other patients, clinicians will receive a notification to have a discussion with patients about IDA evaluation with a focus on shared decision-making.

American Gastroenterological Association

• An alert with information about the AGA guideline recommendations, sent to clinicians who do not order endoscopy for patients who need it (i.e., men and post-menopausal women).

The AGA team created an EHR-embedded intervention within one health system, informed and tested by primary care physicians.

In collaboration with physician partners, AGA also developed a patient-focused educational handout. The handout describes IDA as well as its causes, symptoms, diagnostic tests, and treatment options. A patient focus group provided feedback to validate and revise the content and appearance of the draft handout. After finalizing, AGA promoted the handout on Instagram, LinkedIn, and Twitter/X. By the end of AGA’s project, the handout had more than 1,044 views on the AGA GI Patient Center website.

As of February 2024, the project’s principal investigator had submitted an R01 grant application to the National Institutes of Health, with the goal of conducting a randomized control trial to test the effectiveness of these interventions.

Key Learnings

• Multi-specialty input is helpful: AGA received critical input and feedback from primary care physicians, the Association for Black Gastroenterologists and Hepatologists, and patients.

• Patients can have negative reactions to medical images: Although the project team anticipated favorable reactions to medical images, such as those of ulcers and polyps, patients found the images scary and distracting. This prompted revisions to the patient handout.

• Innovative EHR interventions can reduce “alert fatigue”: Initially, AGA planned for their clinician intervention to only involve a standardized order set in order to minimize alert fatigue. However clinicians noted that they sometimes forgot to utilize the appropriate order set during a clinical encounter, and a health maintenance alert was created. The trigger for the alert was only for patients who really need it, to minimize excess interruptions in clinical care.

Project Products

• Epic health maintenance alert for IDA

• Epic order set for IDA

• IDA patient handout and webpage

• Research poster at the 2024 American College of Gastroenterology Annual Meeting (abstract)

1 Looker AC, Dallman PR, Carroll MD, et al. Prevalence of iron deficiency in the United States. JAMA 1997;277:973-6.

2 Ko CW, Siddique SM, Patel A, et al. AGA clinical practice guidelines on the gastrointestinal evaluation of iron deficiency anemia. Gastroenterology. 2020;159:1085-1094.

American Psychiatric Association SOCIETY SUMMARIES

Promoting Diagnostic Excellence in Eating Disorders

Goals and Motivation

An estimated 30 million Americans have experienced an eating disorder at some point in their lives. Individuals with eating disorders are more likely than the general population to die from any cause because they are at higher risk for medical complications and their illnesses tend to last longer. In addition, people with eating disorders often have co-occurring behavioral disorders, particularly depression and anxiety.

By screening for eating disorder symptoms, clinicians can identify eating disorders and reduce disparities in the receipt of treatment. Pediatricians and other primary care providers may be well-positioned to do this screening due to their regular contact with patients. However, early diagnosis of eating disorders can be challenging. In particular, clinicians may be hampered by limited knowledge of, or biases around, the “typical” eating disorder patient and potential symptoms they might exhibit.

Through their Diagnostic Excellence Initiative, the American Psychiatric Association (APA) aimed to improve diagnosis of eating disorders by creating and disseminating educational materials about the importance of early and proper diagnosis of eating disorders, particularly in underdiagnosed populations. These products were intended for use by APA members and other physicians, as well as individuals in psychiatry and primary care residency and fellowship programs. APA based their materials on the APA Practice Guideline on the Treatment of Eating Disorders.

American Psychiatric Association

Accomplishments

Products based on APA guidelines typically focus on treatment. This project was unique for the organization because it focused on diagnosis, specifically diagnostic dilemmas and cognitive biases in the recognition of eating disorders.

APA developed multiple tools for use in clinical practice. APA’s new web-based clinical decision support tool guides clinicians through eating disorder screening, diagnosis, and treatment. The tool has been used more than 6,100 times (4,600 unique users, about 600 average monthly users at the conclusion of APA’s project funding), with the screening component receiving the most use. APA developed a digital flip book and hard copy pocket guide that covers screening, assessment, and treatment planning; it has been viewed more than 40,000 times. Finally, APA developed a Performance in Practice tool to support quality improvement; it can be used for both chart review and for teaching quality improvement processes to trainees.

In addition to clinical tools, APA developed a set of educational products. APA created an asynchronous, interactive continuing medical education (CME) program that uses clinical vignettes and interactive cases to illustrate APA’s eating disorder guideline statements. By the end of APA’s funded project, nearly 600 individuals had participated in the program. APA also created training slides that can be used in presentations to students, residents, and fellows and for Grand Rounds. The slides had been viewed about 1,500 times by the end of the project. Finally, APA developed a digital flip book and hard copy pocket guide for patients and families. The guide covers what to expect when seeking treatment, as well as additional resources; it has been viewed more than 8,000 times.

APA plans to continue disseminating these eating disorder resources and work to develop decision support tools for other diagnoses.

Key Learnings

American Psychiatric Association SOCIETY SUMMARIES

• Leverage existing relationships: APA’s staff relationships helped them to secure an exhibit booth to promote their project at the American Academy of Pediatrics annual meeting.

• Anticipate and involve outside audiences: APA discovered that primary care and pediatric clinicians had a strong need for, and interest in, their materials. In retrospect, APA would have sought more involvement from these groups in product development and review.

• Give clinicians a variety of flexible tools: APA found that diagnostic challenges and information needs varied by specific eating disorder diagnosis, provider specialty, and provider level of expertise. APA’s asynchronous CME and combination of clinical tools and educational materials fit clinician learning needs.

• Continue research on the diagnosis and treatment of eating disorders: When attempting to translate guideline statements into workflow algorithms, APA realized that the clinical guidelines can be ambiguous and that it can be difficult to distinguish between different diagnoses. More and better studies of eating disorder diagnosis, diagnostic tools, and treatment will support the development of high-quality, effective decision support tools.

• Consider adaptations for other countries: Project staff met pediatricians from Latin American countries who have seen increases in the prevalence of eating disorders. APA is now working to identify project materials that would be most useful to translate into Spanish.

• Make materials easily accessible: APA offered their tools for free and promoted them with QR codes. They saw higher-than-normal uptake of their programs/ materials, both in general and by non-physicians.

• Build generous timelines: APA found that all project steps took longer than expected. This was particularly true for recruiting volunteers to help develop or review products, as well as working with a new partner for tool development.

Project Products

• Clinical decision support tool

• Interactive continuing medical education (CME) program

• Clinician guide (digital and hard copy)

• Patient/family guide (digital and hard copy)

• Training slides

• Performance in Practice tool

Perioperative Diagnostic Excellence for the Older Adult: An Educational Initiative

American Society of Anesthesiologists

Goals and Motivation

The population of older adults is growing, with individuals aged 65 or older projected to make up 20% of the US population by 2040,1 and older adults are more likely than younger individuals to have surgeries and outpatient procedures.2

Older adults are also more likely than their younger counterparts to experience postoperative complications,3 such as postoperative delirium, which can in turn lead to hospital falls, longer hospital stays, and cognitive decline in the years following surgery. Some of this risk stems from geriatric-specific factors, like cognitive decline and physical frailty.4 There are also age-related inequities in social determinants of health that can limit distribution and delivery of healthcare for older adults.5,6

Addressing the unique needs of older surgical patients requires an expanded and better-trained anesthesia workforce. To address this need, the American Society of Anesthesiologists (ASA) planned to use their Diagnostic Excellence Initiative to:

1. Develop free continuing medical education (CME)-accredited virtual learning products to train anesthesiologists on the use of important diagnostic tools to assess older patients for cognitive impairment, frailty, and delirium and improve their care;

2. Create a marketing and communications campaign that broadly promotes the use of the toolkit; and

3. Conduct a survey to measure the impact of the implementation of geriatric screening tools by practitioners.

Accomplishments

ASA developed and recorded three CME-accredited webinars and a live one-hour virtual town hall. Learners also had access to accompanying tools. ASA promoted the webinars and town hall to its members and other interested parties through email, its website, its newsletters, and social media.

American Society of Anesthesiologists SOCIETY SUMMARIES

Participation exceeded ASA’s initial goal of educating 200 physician anesthesiologists. At the conclusion of ASA’s funded project, nearly 3,400 individuals had enrolled in the live town hall, and more than 1,500 had completed it.

ASA administered pre- and post-test questionnaires to assess changes in webinar participant knowledge. The results indicated knowledge improvements: Depending on the webinar, the average pre-test score was between 36 and 67%, and the average post-test score was at least 95%.

ASA has begun applying learnings from this grant to additional educational activities that will benefit individuals involved with perioperative geriatric care.

Key Learnings

• Iterate and collaborate: ASA learned that changing practice requires ongoing assessment, responsiveness to feedback, and collaboration among healthcare professionals, patients, caregivers, and administrators.

• Be proactive and flexible: The project’s planning committee and participating faculty had busy schedules that made it difficult to find times to meet and to record content. ASA mitigated this by scheduling meetings and recordings far in advance, offering many dates and times for participation, and expanding the team to spread out responsibilities.

Project Products

• Webinars about:

o Pre-operative cognitive screening,

o Frailty assessments, and

o Post-anesthesia care unit delirium.

• Live town hall on perioperative communication

1 The Administration for Community Living. 2020 profile of older Americans. 2021. https://acl.gov/ sites/default/files/Aging and Disability in America/2020ProfileOlderAmericans.Final_.pdf

2 Etzioni D, Liu J, Maggard M, Ko C. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177. doi:10.1097/01.SLA.0000081085.98792.3d

3 Chaturvedi R, Patel K, Burton B, Gabriel R. Geriatric patients undergoing outpatient surgery in the United States: a retrospective cohort analysis on the rates of hospital admission and complications. Cureus. 2021;13(12):e20607. doi:10.7759/cureus.20607

4 Mahanna-Gabrielli E, Zhang K, Sieber F, et al. Frailty is associated with postoperative delirium but not postoperative cognitive decline in older non-cardiac surgery patients. Anesth Analg. 2020;130(6):1516-1523. doi:10.1213/ANE.0000000000004773

5 Fulmer J, Reuben D, Auerbach J, Fick D, Galambos C, Johnson K. Actualizing better health and health care for older adults. Health Aff. 2021;40(2):219-225. doi:10.1377/hlthaff.2020.01470

6 National Center for HIV Viral Hepatitis STD and TB Prevention. Frequently asked questions, Office of Health Equity at CDC’s NCHHSTP. 2019. https://www.cdc.gov/nchhstp/socialdeterminants/faq.html

Promoting

Improving the Communication of New Cancer Diagnoses

American Society for Clinical Pathology

Goals and Motivation

In the United States, nearly 2 million new cancer cases are diagnosed each year.1 Of these, about 7% are seriously misdiagnosed, which includes delayed or missed notifications of a cancer diagnosis.2 These diagnostic delays lead to treatment delays that, in turn, raise rates of morbidity and mortality and increase healthcare costs.3,4

There is a lack of standardization of how and when pathologists should notify treating clinicians of new cancer diagnoses. Recommendations from the Clinical Laboratory Improvement Amendments (CLIA), College of American Pathologists (CAP), and The Joint Commission (TJC) are not specific; rather, they direct institutions to develop their own policies about what constitutes a critical and unexpected finding (like a new cancer diagnosis) and how and when these findings should be communicated and documented.5

Proactively improving handoffs of new cancer diagnoses is a reliable way to avoid missed or delayed notifications. Making these improvements requires an exploration of current and best practices among diverse laboratories and wide dissemination of these findings. To address this need, the American Society for Clinical Pathology (ASCP) designed their Diagnostic Excellence Initiative to:

1. Translate CLIA, CAP, and TJC requirements for communicating new cancer diagnoses into best practice guidance for pathologists;

2. Identify high-priority communication problems that are a barrier to timely notification of new cancer diagnoses;

3. Improve communication between pathologists and clinicians to reduce delayed notifications, missed diagnoses, and related diagnostic errors;

4. Promote the pathologist’s role in advancing diagnostic excellence along the diagnosis-to-treatment trajectory; and

5. Implement best practices resulting from this project to improve timely notification of new cancer diagnoses within institutions.

American Society for Clinical Pathology

Accomplishments

ASCP convened a learning collaborative of 11 pathologists from varied practice settings serving diverse patient populations. The collaborative participated in five virtual meetings during which they reviewed published literature, case studies, and other evidence; discussed their current practices; and identified barriers to effective and timely communication of cancer diagnoses. The group then developed a list of best practice recommendations for effective and timely communication. ASCP compiled the recommendations into a downloadable resource guide and published the guide on its website. By the end of ASCP’s project, more than 350 users had downloaded the resource guide. Users provided positive feedback, agreeing that communication is an important issue and appreciating the guidance.

ASCP disseminated the learning collaborative’s findings in several additional ways. They conducted a live webinar, which 267 people attended. More than 500 learners also accessed the webinar recording by the end of ASCP’s project. Of the webinar learners who responded to an evaluation survey, a majority reported gains in their understanding of definitions and examples of urgent and significant/unexpected diagnoses, knowledge of guidelines and best practices, and confidence in being able to apply recommended best practices.

ASCP recorded a podcast episode, which was designed to support collaboration between clinical partners and highlight opportunities for improving communication. By the end of ASCP’s project, the episode had nearly 1,900 downloads.

ASCP presented a session at their 2024 Annual Meeting. Twenty-eight learners attended the live session, and 117 learners accessed the session recording. Attendees who completed an evaluation survey reported increases in knowledge and confidence.

Finally, ASCP shared a series of 8 social media posts highlighting lessons learned from the learning collaborative and information from the resource guide. Across Facebook, LinkedIn, and Twitter/X, the posts had a combined reach of 26,085 views and 678 interactions by the end of ASCP’s project.

American Society for Clinical Pathology

Key Learnings

• There is variation in how pathologists communicate diagnoses to treating clinicians: They may use chat tools, secured messages, email, or a phone call.

• Pathologists need support to make connections between policy and practice: Project participants were aware of policies around pathologist-clinician communication, but they did not have details on how to implement these policies or how to address potential implementation barriers.

• Change takes time: Implementing ASCP’s recommendations will require time to gain buy-in, secure required approval from institutional leadership, and plan and prepare for changes to infrastructure like laboratory information systems.

Project Products

• Resource guide

• Webcast and accompanying slides

• ASCP Inside the Lab podcast episode

• Live and recorded session at 2024 ASCP annual meeting

1 Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73(1):17-48.

2 Newman-Toker DE, Nassery N, Schaffer AC, et al. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf. 2024;33:109-120.

3 Meyers D, Brady J. Advancing diagnostic safety: an AHRQ leadership conversation. October 25, 2021. Accessed July 17, 2023. https://www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html.

4 Yang D, Fineberg HV, Cosby K. Diagnostic excellence. JAMA. 2021;326(19):1905-1906.

5 Nakhleh RE, Myers JL, Allen TC, et al. Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2012;136:148-154

Promoting the Use and Understanding of the New eGFR Clinical Algorithm

American Society of Nephrology

Goals and Motivation

More than 37 million Americans have kidney diseases, with people of color being at greater risk of kidney failure.1 Evaluation of kidney function is a critical part of screening, early detection, and management of kidney diseases. For the past two decades, nephrologists have measured kidney function using the estimated glomerular filtration rate (eGFR) clinical algorithm. Until recently, this algorithm took race (defined as “Black or non-Black”) into account, inappropriately treating race as a biological construct.

In 2020, the American Society of Nephrology (ASN) and National Kidney Foundation (NKF) formed the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease, with the goal of developing a better and race-free approach to estimating kidney function. The Task Force published their recommendations in 2021. These recommendations represented a significant change in clinical practice and interpretation. Therefore, many clinicians needed information and support to effectively implement the recommendations.

ASN used their Diagnostic Excellence Initiative to develop a toolkit of existing and new resources to support implementation of the NKF-ASN Task Force recommendations.

Accomplishments

ASN began their project by hosting two roundtable discussions (one with clinicians from various medical specialties, the other with nephrologists in private practice) to identify knowledge gaps related to the race-free eGFR algorithm. The resulting insights informed the organizing framework and contents for the eGFR Toolkit. The Toolkit included six topical chapters:

• Glomerular Filtration Rate,

• Limitations of Creatinine and Cystatin C as Filtration Markers,

• Removal of Race from the eGFR Equation,

• Current Recommendations for Evaluation of GFR,

• eGFR and Drug Dosing, and

• eGFR Lab Reporting.

American Society of Nephrology

Experts from the project steering committee developed new content to include in the Toolkit. They also compiled existing resources, including links to publications and patient education materials.

In addition to the topical content, the Toolkit includes a chapter with key takeaways from across topics, a compilation of all supportive materials and references across topics, an evaluation form, and an option to obtain a certificate of completion.

ASN promoted the Toolkit through e-mail, social media, organizational publications, and its online discussion forum. NKF and the members on the ASN Diagnostic Excellence: eGFR Toolkit Steering Committee also promoted the Toolkit.

Information from the Toolkit evaluation form (including learner characteristics, Toolkit effectiveness and utility, and suggestions for additional information to include) automatically flows into ASN’s project management software. ASN plans to review this information quarterly to identify opportunities for improvement. As of January 2025, evaluation feedback was positive, and ASN incorporated the minor Toolkit revisions users suggested.

Key Learnings

• Nephrology is relevant for many medical specialties: ASN found that the assessment of kidney function was relevant across many areas of medical and surgical care. This made it important to have broad input into the development of educational materials, ensure that materials were useful and understandable for clinicians from other specialties, offer a learning experience that users can customize based on relevance and interest, and promote the Toolkit to organizations outside of nephrology.

• Align the format of materials to the ways clinicians access and share information: With widespread cell phone use, ASN had to ensure that materials were easily accessible by phone but could also be attached to e-mails and printed. Also, given constraints on clinician time, ASN needed to make their Toolkit easy to read, with options to access more in-depth information if needed.

• It is difficult to engage busy clinicians in a timely manner: This underscored the need for the Toolkit to be easy to access and read.

• Use project management software: This allowed ASN to align deliverables and complete them on schedule, despite their large scope and tight timelines.

Project Products

• ASN eGFR Toolkit

1 https://www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats

Improving the ICU Ward Handoff – ATS ICU-PAUSE Program

American

Thoracic Society

Goals and Motivation

Patients transitioning from the intensive care unit (ICU) to a hospital ward are at elevated risk for adverse events and near-miss patient safety events. ICU patients are medically complex and there can be high diagnostic uncertainty concurrent with a changing clinical team and communication between teams that is highly variable, unstandardized, and often incomplete. In addition, it is possible that clinician biases about underrepresented gender, racial/ethnic, and age groups lead to inequities in the ICU-to-ward transition.

Existing tools like the IPASS (for end-of-shift handoffs) and standard hospital discharge summaries are insufficient for ICU-to-ward transfers because they do not address the complexity of ICU care. To address this need, a member of the American Thoracic Society (ATS) and her colleagues recently partnered with internal medicine residents to create an electronic health record tool, ICU-PAUSE.1 This communication framework involves documenting:

• ICU admission reason,

• Code status,

• Unprescribing,

• Pending tests,

• Active consultants,

• Uncertainty measure,

• Summary of major problems and to-dos, and

• Exam at the time of transfer.

ATS used their Diagnostic Excellence Initiative grant to undertake a national ICUPAUSE implementation strategy. Specifically, they aimed to:

1. Create a pre-implementation educational curriculum targeting trainees, intensivists, hospitalists, and advanced practice providers regarding patients’ vulnerability to diagnostic error and implicit bias at transitions of care;

2. Implement the ICU-PAUSE communication framework broadly and nationally; and

3. Conduct post-implementation analysis of penetration of the intervention and equity metrics.

American Thoracic Society

Accomplishments

ATS developed a continuing medical education (CME)-accredited training module, as well as an accompanying toolkit and podcast episode. At the time of their grant completion, ATS had shared the ICU-PAUSE program with at least 42 sites nationally. Twenty-four of the sites had completed and were sustaining implementation, and 10 additional sites were in the process of doing so. ATS was also about to launch its first international site in India. ATS’s efforts to collect and analyze post-implementation intervention and equity metrics were ongoing.

ICU-PAUSE has been featured in various national publications, including ATS Scholar, Diagnosis, BMJ Quality & Safety, and an AHRQ issue brief. The project team also presented at the Ask Me Anything booth at the 2023 and 2024 ATS International Conferences, and they developed an ATS Scholarly Project Pod on transitions of care.

Key Learnings

• Build on existing relationships: The investigator who developed the ICU-PAUSE framework and championed this project was an ATS member whom the Society knew and trusted. ATS was confident they could share the work, and the existing relationship also promoted mutual buy-in.

• Think about projects holistically: In addition to those developing the educational module, this project required support from ATS’s finance, marketing, design, CME, and conference team members. These individuals helped ensure, for example, that the CME module was seamless, the website and graphics were attractive, and there was a marketing campaign to promote the module.

• If a project involves a research component, allow adequate time and funding for IRB approval: It was time-consuming for ATS to get approval from multiple local IRBs for this project. This led to varying implementation and data collection timelines across sites. Site-level staff are needed to support tasks like IRB applications.

Project Products

• Interactive video CME module

• Podcast episode

• Toolkit with:

o Informational packet,

o EPIC dotphrase,

o Examples of template modification,

o Postcard,

o Flyer,

o Instructional video, and

o Best practices tip sheet.

1 Santhosh L, Rojas JC, Garcia B, Thomashow M, Lyons PG. Cocreating the ICU-PAUSE tool for intensive care unit-ward transitions. ATS Scholar. 2022;3(2):312–323.

Promoting Diagnostic Excellence and Health Equity in Urology Care

American Urological Association

Goals and Motivation

In the United States, prostate cancer is the most commonly diagnosed noncutaneous malignancy among men, with significant racial and ethnic disparities in diagnosis and outcomes.1 Although Black men comprise 13% of the U.S. population, they account for 30% of U.S. prostate cancer deaths.2 This disparity likely stems from biological, socioeconomic, and healthcare system factors. Critical among these factors are variation in diagnostic practices and a lack of resources to support urologists, primary care providers (PCPs), and Black men in the early detection of prostate cancer.3,4,5

Given the racial/ethnic disparities in prostate cancer and the lack of resources to address them, the American Urological Association (AUA) designed their Diagnostic Excellence Initiative to:

1. Develop educational resources for urologists related to diagnostic excellence in general, with a focus on how these principles apply to addressing historical disparities in the early diagnosis and outcomes of prostate cancer in Black men;

2. Create concise and user-friendly materials for primary care settings to promote awareness of the increased risk of prostate cancer in Black men and AUA’s recommendations for early detection of prostate cancer; and

3. Develop culturally sensitive and easily understandable patient-facing materials to aid patients in decision-making for prostate cancer screening.

American Urological Association

Accomplishments

AUA created and distributed multiple resources for urologists, PCPs, and patients. They collaborated with three PCPs to develop an infographic that highlights disparities in prostate cancer and the risks and benefits of prostate-specific antigen (PSA) screening. The infographic is accompanied by a PCP-friendly algorithm illustrating key features of AUA’s guidelines on PSA screening. As of December 2024, this resource had 121 downloads, and AUA had distributed about 300 printed copies.

AUA partnered with the Urology Care Foundation (UCF) to create two patientphysician communication tools aimed at fostering shared decision-making around PSA screening. As of December 2024, the two tools had more than 1,100 downloads combined, and AUA had distributed nearly 1,900 print copies.

AUA also published a journal article and accompanying podcast targeted to urologists, designed to promote the concept of diagnostic excellence in urology. As of December 2024, the article had 86 views, and the podcast episode had 266 downloads.

AUA promoted their new resources at an American Academy of Family Physicians Family Medicine Experience meeting, as well as by leveraging paid promotional efforts.

Key Learnings

• PCPs have mixed awareness and understanding of PSA screening guidelines: PCPs often follow United States Preventative Services Taskforce guidelines, but some were confused about a shift in these guidelines in 2018. Many PCPs are unaware of AUA guidelines on PSA screening.

• PCPs have concerns about what happens after a urology referral for elevated PSA: Some are concerned about unnecessary biopsies and the potential for overdiagnosis and overtreatment of prostate cancer.

• PCPs want to be engaged in discussions about the diagnostic process: As PCPs are involved in the diagnostic process for many urologic conditions, it is imperative to include them in discussions about diagnostic processes and best practices. AUA gained valuable insights by collaborating with PCPs.

• PCPs are interested in learning from urologists: AUA was positively received at the American Academy of Family Physicians Family Medicine Experience meeting.

American Urological Association

Project Products

• Journal of Urology article, From Error to Excellence: An Evolving Paradigm for Improving the Diagnostic Process

• AUA News Inside Tract podcast episode, Diagnostic Excellence in Urology Care

• Screening algorithm and infographic, Advancing Diagnostic Excellence and Health Equity: The Role of PSA Screening in Early Detection of Prostate Cancer

• Patient-physician communication tools

o Prostate Cancer Screening: What You Should Know

o Prostate Cancer Screening: Talking to Your Health Care Team Assessment Tool

1 Centers for Disease Control and Prevention. Prostate cancer statistics. https://www.cdc.gov/cancer/ prostate/statistics/index.htm. Accessed July 25, 2023.

2 Vince RA Jr, Jamieson S, Mahal B, Underwood W 3rd. Examining the racial disparities in prostate cancer. Urology. 2022;163:107-111.

3 Sherer MV, Qiao EM, Kotha NV, Qian AS, Rose BS. Association between prostate-specific antigen screening and prostate cancer mortality among non-Hispanic Black and non-Hispanic White US veterans. JAMA Oncol. 2022;8(10):1471–1476.

4 US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(18):1901–1913.

5 Shungu N, Diaz VA, Perkins S, Kulshreshtha A. Physician attitudes and self-reported practices toward prostate cancer screening in Black and White men. Fam Med. 2022;54(1):30-37.

College of American Pathologists SOCIETY SUMMARIES

Patient-Centered Pathology Reporting

Goals and Motivation

A pathology report is an important document for cancer diagnosis and treatment, providing essential information to guide therapeutic decisions and prognostic evaluations. With the continued progress of cancer science, pathology reports have become increasingly detailed and complex due to the amount of information needed by the various stakeholders of a pathology report. They often use medical jargon and a complicated format. This can make it difficult for patients to be informed and active participants in their own treatment and possibly for members of the care team to apply findings to patient care.

In addition, a patient may not have immediate support for understanding their pathology report. Among other mandates, the 21st Century Cures Act gives patients immediate access to their final pathology and laboratory results. This often means that patients see their results well before they can discuss them with their care provider. In the absence of accompanying support from a medical professional, pathology reports can lead to patient anxiety, confusion, or psychological harm.1,2,3

In response to the increasingly complex nature of cancer pathology reports, the College of American Pathologists (CAP) executed two projects for their Diagnostic Excellence Initiative. Project 1 focused on colorectal cancer patients and was designed to:

• Capture patient-identified gaps in understanding their pathology results and reports, including the structure of the report, its language and content, and points of access to reports;

• Identify patient-recommended improvements to pathology reports based on their needs;

• Review potential changes or additions with both physician and patient stakeholder groups, ensuring that the critical information needed by oncologists and other treating clinical colleagues for decision making are maintained; and

• Develop dissemination plan recommendations to promote uptake of patient-suggested changes.

College of American Pathologists SOCIETY SUMMARIES

Project 2 focused on clinicians involved with the treatment of colorectal cancer and was designed to:

• Identify the essential elements of a pathology report for each member of the colorectal cancer care team from an array of specialties to assist them in timely and accurate diagnosis and treatment; and

• Disseminate best practices through education and engagement.

Accomplishments

PROJECT 1

CAP designed a survey to assess patient opinions on pathology report structure, content, and language, as well as their experiences with receiving these reports. The survey was tested by the CAP Quality and Clinical Data Registry Affairs Committee as well as members of three patient advocacy organizations. CAP then distributed the survey through these three advocacy organizations, as well as the Cancer Leadership Council and the Katie Couric Media newsletter.

CAP also conducted individual interviews with four survey respondents to further discuss their experiences and feedback. Key themes from these interviews included:

• Patients want to know why tests were done and what the results mean;

• Patients want to know the implications of test results for treatments and clinical trial participation; and

• Pathology reports should promote transparency and trust and should prime patients to ask the right questions.

Following the patient interviews, CAP developed three sample revised pathology reports. CAP shared these reports, as well as an unrevised report, with two patient focus groups. Their feedback led to a list of potential pathology report modifications.

PROJECT 2

CAP convened technical expert panels (TEPs) composed of professionals from clinical specialties involved with colorectal cancer, including oncology, radiation oncology, gastroenterology, primary care, endoscopy, and surgery. The TEPs provided input on the challenges they and their patients face with pathology reports. CAP supplemented this input with a review of scientific literature about improving pathology reports and patient experience, as well as data from their patient survey. CAP’s findings included:

• Pathology reports are becoming too dense and potentially harder to read;

• Improvements to pathology reports would benefit not only patients and caregivers, but also nurses, trainees, and medical students;

• Clinicians agreed with patient recommendations from Project 1; and

• Clinicians were concerned about the burden to pathologists if the patient recommendations were implemented.

College of American Pathologists

Next, CAP solicited pathologists’ feedback on how to implement patient suggestions for improving pathology reports. CAP surveyed attendees of the 2024 Pathologist Leadership Summit and also convened a workgroup of pathologists. These activities yielded information about the feasibility, value, and challenges of implementing the patient recommendations; how the recommendations would impact pathologists; and how to implement and disseminate prioritized recommendations. Findings included:

• Pathologists were concerned about the burden of some recommendations;

• Pathologists were concerned about potential role confusion/conflict with other clinicians on patient care teams; and

• Pathologists agreed that it would be most valuable and feasible to add a glossary of terms, a plain-language summary, and a list of patient resources to pathology reports.

CAP used the information they gathered to develop an initial plan for rolling out their patient-centered recommendations for improving pathology reports.

Key Learnings

• Patients do not understand existing pathology reports: 80% of patient survey respondents found it difficult to understand a pathology report, 93% found it difficult to understand report terminology, and more than half found it difficult to identify the diagnosis within the report.

• Do not “dumb it down” for patients: Patients did not want their pathology reports to use vocabulary that was different from vocabulary that is used by clinicians. They preferred to have supplemental explanations of technical terms. Patients also preferred to have as much information in the report as possible.

• Most patients think it would be helpful to have their cancer diagnosis in bold at the top of the report, a brief explanation of their cancer diagnosis, and a glossary of medical terms: These features were endorsed by 58%, 74%, and 58% of patient survey respondents, respectively.

• Features of medical information systems can complicate change efforts: Differences between varying laboratory information systems make it difficult to implement change recommendations in a consistent way.

• System maintenance is a sustainability challenge: CAP’s experts were unsure who would be responsible for keeping patient glossaries and resource lists up to date after their initial development.

Project Products

College of American Pathologists SOCIETY SUMMARIES

• List of patient recommendations to improve pathology reports

• Data from CAP’s survey at the annual Pathologist Leadership Summit, about feasibility of patient recommendations to improve pathology reports

• Data from CAP’s survey of the project’s pathologist workgroup, about prioritizing patient recommendations to improve pathology reports

• Podcast episode about the need for more patient-centered pathology reports

• Presentation and panel at the 2023 CAP annual meeting

• Conference research posters

1 Shaha M, Cox C, Talman K, Kelly D. Uncertainty in breast, prostate, and colorectal cancer: implications for supportive care. J Nurs Scholarsh. 2008;40(1):60-67.

2 Woods S, Schwartz E, Tuepker A, Press N, Turvey C, Nichol W. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study. J Med Internet Res. 2013;15(3):e65.

3 Zhang Z, Citardi D, Xing A, Luo X, Lu Y, He Z. Patient challenges and needs in comprehending laboratory test results: mixed methods study. J Med Internet Res. 2020;22(12):e18725.

“How We Do It”: CHEST Experts Weigh In

American College of Chest Physicians

Goals and Motivation

About 400,000 people in the United States are affected by interstitial lung diseases (ILDs), a group of more than 200 diseases that cause lung inflammation or permanent scarring. The mean survival rate for patients diagnosed with ILD is 3 to 5 years.

A timely ILD diagnosis and subsequent treatment are critical for prolonging lung function and maintaining quality of life. However, diagnosis of ILD is challenging: early-stage disease may be asymptomatic, symptoms can be similar to those of more common lung diseases, and symptoms may be dismissed due to advanced age. Differential diagnosis requires a physician with appropriate expertise and, often, input from multiple specialties. Patients who live in rural areas and patients with inadequate health insurance, in particular, may have difficulty accessing the appropriate clinicians.

Given the benefits of and barriers to timely ILD diagnosis, the American College of Chest Physicians (CHEST) designed their Diagnostic Excellence Initiative to:

1. Educate clinicians about ILD symptoms, appropriate tests to validate suspicion of ILD, and coordinating care for ILD patients;

2. Raise clinician awareness of health inequities that are important to factor into ILD diagnosis and care; and

3. Translate recent guidelines addressing various ILDs into more actionable and implementable guides for the practicing clinician.

Accomplishments

CHEST curated a set of four published articles on ILD diagnosis and management to serve as the core of its continuing medical education (CME) series and wrote and published an editorial to accompany the articles. CHEST then collaborated with article authors and the CHEST journal CME editorial board to develop a set of assessments to test readers’ knowledge and offer CME credit. CHEST promoted the CME, as well as its other products, via targeted email campaigns, CHEST and journal websites, and social media. By the end of CHEST’s project, the articles had been downloaded nearly 44,000 times, and 168 individuals had accessed the quizzes.

American College of Chest Physicians

Next, CHEST convened a group of three ILD experts to discuss important considerations and challenges of ILD diagnosis and management, with a focus on health inequities and how to account for them in patient care plans. The experts detailed their recommendations in a podcast episode, and CHEST developed an accompanying test to assess listener knowledge and offer CME credit. By the end of CHEST’s project, the podcast had 850 downloads, and 82 individuals had accessed the accompanying quiz.

CHEST then brought together five experts to develop and review an interactive clinician guide for implementing recent ILD clinical guidelines. The resulting infographic was viewed nearly 5,000 times by the end of CHEST’s project.

Key Learnings

• Community-based clinicians and academic clinicians may have differing access to resources: CHEST learned that community pulmonologists might not have the same access to imaging as academic clinicians, which can lead to disparities in ILD diagnosis.

• The most passionate partners are often the busiest: CHEST laid out timelines before obtaining formal agreement from partners, and they notified them of meetings in advance. They tried to accommodate busy schedules and be flexible when possible.

• Unchecked excitement can lead to expansions of project scope: The project’s chair expressed interest in developing a second, more in-depth series of articles. This was not feasible with CHEST’s current timeline and funding, but they look forward to continuing this work in the future.

Project Products

• CME with four journal articles and accompanying quizzes

• Journal article: The Way Forward: Improving Timely Diagnosis for Interstitial Lung Disease

• Podcast episode, Diagnostic Excellence in ILD, with accompanying CME quiz

• Interactive digital tool for the diagnosis and management of ILD

1 Eldawy HO, Elrehany M, Bekhit A, Thabet K. Interstitial lung disease: a review. J Adv Biomedical Pharm Sci. 2025;8(1):1–6. doi:10.21608/jabps.2024.320282.1222

Improving Speed, Accuracy, and Clinician Communication in Sepsis Diagnosis

Society of Critical Care Medicine

Goals and Motivation

In 2017, more than 11 million people worldwide died from sepsis,1 making it the leading cause of death.2 In the United States, sepsis is the third-leading cause of death.2

Sepsis is one of the most time-sensitive medical diagnoses.2 Unfortunately, key procedures for the early recognition of sepsis often happen slowly, leading to treatment delays3,4 that can heighten the risk for septic shock and mortality.5 There is a need for the development and dissemination of educational materials to promote best practices in early sepsis detection.

Care and outcomes for sepsis patients may also improve if there is better communication between multiprofessional clinician teams. Specifically, if clinicians who receive a patient with sepsis provide feedback to referring clinicians, this may improve the clinical performance of the referring clinicians. However, there is a significant gap in research related to clinician feedback after patient transfers to higher-level care; it is unclear which types and modes of feedback are best.

Given the importance of, and gaps related to, sepsis diagnosis and treatment, the Society of Critical Care Medicine (SCCM) designed their two Diagnostic Excellence Initiative projects to accomplish the following goals:

PROJECT 1

Society of Critical Care Medicine SOCIETY

• Develop and deliver diagnostic excellence education to improve early sepsis detection and reduce delays and errors in diagnosis;

• Develop and deliver an education program that addresses clinician implicit bias that may impact delays and errors in diagnosis, ensuring a safer, more equitable healthcare environment;

• Develop and deliver an education program for healthcare leadership that describes the impact of diagnostic delays and errors, sepsis, and septic shock on the organization’s bottom line and reputation in the community; and

• Disseminate just-in-time strategies and toolkits that impact patient outcomes and reduce delays and errors in diagnosis, particularly when ruling out sepsis and septic shock.

PROJECT 2

• Survey SCCM members to determine the most relevant types of feedback to provide clinicians and the most acceptable and effective methods of providing this feedback;

• Gain additional feedback from survey respondents;

• Triangulate data from the surveys and additional feedback; and

• Disseminate findings via peer-reviewed journals, social media, webcast, podcast, and clinician toolkit.

Accomplishments

PROJECT 1

SCCM hosted a series of live webcasts and podcasts featuring sepsis subject matter experts (SMEs). These sessions were interactive and offered opportunities for real-time discussion. By the completion of Project 1, the four webcasts had nearly 5,000 views and the four podcasts had more than 44,000 listens.

SCCM also collaborated with SMEs and SCCM’s cross-departmental clinical team to develop four toolkits that addressed preventive measures for diagnostic errors, sepsis, and septic shock.

SCCM disseminated their educational materials via social media and other marketing and communication channels.

Society of Critical Care Medicine

PROJECT 2

SCCM surveyed its members who either refer (N = 96) or receive (N = 433) septic patients. This provided valuable information about the optimal and actual feedback that receiving clinicians provide to referring clinicians. SCCM shared survey insights via a podcast episode and webcast.

SCCM used the survey findings to inform the development of a toolkit to guide clinicians who receive sepsis patients in providing feedback to referring clinicians. Three clinicians provided feedback on the draft toolkit, and SCCM revised the toolkit based on their feedback.

As of February 2025, SCCM was in the process of writing a manuscript about their findings. They expected to complete this manuscript and submit it to a peer-reviewed journal in April 2025.

Key Learnings

• Sepsis is a topic of interest for critical care clinicians: This is evidenced by the high number of views and listens for SCCM’s webcasts and podcasts.

• Most referring clinicians say it would be helpful to receive feedback from receiving clinicians: 77% of referring clinicians surveyed said that “opportunities for improvement in diagnosis and management in the referring unit” would be a helpful type of feedback.

• Most receiving clinicians want to provide feedback to referring clinicians: Only 4% of receiving clinicians did not want to give feedback.

• There are several barriers to providing feedback: Receiving clinicians who did not provide feedback to referring clinicians said that this was due to time limitations and lack of an efficient feedback process. Some clinicians also felt awkward about providing feedback.

• Keep clinician surveys brief: SCCM’s survey took less than 10 minutes. This likely contributed to the high levels of participation and depth of responses.

Project Products

• Five webcasts

o Mitigating Diagnostic Delays and Errors

o Implementing the Sepsis Hour-1 Bundle

o Mitigating Implicit Bias in Diagnosing Patients with Sepsis

o Engaging Healthcare Leaders in the Fight Against Sepsis

• Five podcast episodes

Society of Critical Care Medicine SOCIETY

o Survey Insights: Referring and Receiving Patients with Sepsis

o Mitigating Diagnostic Delays and Errors with Emphasis on Sepsis

o Optimizing Sepsis Care Hour-1 Bundle at a Time

o Clinicians, Patient Outcomes, and Implicit Bias

o Strategies for Preventing Sepsis and Septic Shock in the Hospital Setting

o Bridging the Gap: Communication During Sepsis Transfers

• Five comprehensive implementation toolkits

o Mitigating Sepsis-Related Diagnostic Delays and Errors Through Improved Communication in the ICU

o Implementing the Hour-1 Bundle Using a Multiprofessional Approach

o Addressing and Mitigating Implicit Bias in the ICU

o Engaging Hospital Leaders in Sepsis Prevention, Identification, and Management

o Developing Feedback Systems for Clinicians of Patients with Sepsis

1 Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet. 2020 Jan 18;395(10219):200-211.

2 Balch B. Sepsis is the third leading cause of death in U.S. hospitals. But quick action can save lives. Association of American Medical Colleges. Published October 10, 2023. Accessed October 20, 2023. https://www.aamc.org/news/sepsis-third-leading-cause-death-us-hospitals-quick-action-can-savelives

3 Husabø G, Nilsen RM, Flaaten H, et al. Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: an observational study. PLoS One. 2020 Jan 22;15(1):e0227652.

4 Kuye I, Rhee C. Spotlight: overdiagnosis and delay: challenges in sepsis diagnosis. Patient Safety Network. Published October 1, 2018. https://psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-anddelay-challenges-sepsis-diagnosis.

5 National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care National Academies Press; 2016.

Crowdsourcing to Develop an Educational Intervention on the Diagnostic Process: Special Emphasis on Mitigating Racial Disparities in Diagnosis

Society of General Internal Medicine

Goals and Motivation

Cardiovascular disease (CVD) is the leading cause of death in the United States and worldwide, and ischemic heart disease (IHD) is the main cause of CVD mortality. IHD often manifests as acute coronary syndrome (ACS), presenting as epigastric pain, nausea, and vomiting. Clinicians must promptly recognize and address ACS to preserve myocardial perfusion.1 Unfortunately, ACS is underdiagnosed; in a recent simulation study, only 56% of physician volunteers correctly diagnosed ACS.2

The underdiagnosis of ACS may stem, in part, from implicit bias. Implicit bias is the collection of unconscious and unintentional mental associations individuals make about social groups, often rooted in systemic discrimination.3,4 Implicit bias can impact clinician communication and decision-making and ultimately lead to health disparities.5

To address the link between implicit bias and ACS diagnosis and treatment, the Society of General Internal Medicine (SGIM) designed their Diagnostic Excellence Initiative to:

1. Identify physician behaviors in simulated patient encounters that lead to disparities in the diagnostic process and diagnostic errors;

2. Crowdsource solutions to improve those behaviors;

3. Explore lay community members’ perspectives of simulations and suggestions for instruction; and

4. Develop and pilot a curriculum in equity in diagnostic excellence.

This project was grounded in previous studies of clinicians’ implicit bias using simulated encounters with Black and White patients.2

Society of General Internal Medicine

Accomplishments

SGIM reviewed existing simulation videos to identify those that would be most appropriate for teaching about the diagnostic process. Then they developed a scoring rubric that facilitated video review by other relevant parties, including students, trainees, faculty, diagnostic experts, and regional meeting attendees. Finally, SGIM used crowdsourcing at regional and national workshops and surveys to solicit input on the videos, including how respondents might use the videos in their own curriculum and other techniques and resources they could recommend.

At the conclusion of their funded grant project, SGIM was finalizing three curriculum modules. These will be available on GIM Learn, SGIM’s learning platform. SGIM plans to eventually promote the modules through articles, workshops, and regional and national meetings.

Key Learnings

• Address sensitive topics in a non-blaming way: In their equity-focused work, SGIM took the stance that all clinicians are doing their best. Their messaging was that clinician training often focuses on patients who are White, male, cisgender, and middle-class, but that that perspective leaves out a lot of people. This may unconsciously and unintentionally lead to biased behavior. SGIM’s materials emphasized that clinicians should have empathy for themselves and for their patients.

• Be specific about behavioral change: SGIM knew they needed to do more than ask trainees to “be better” or “be nicer.” They needed to give them specific behaviors to model and practice. They also needed to be explicit about how their equity-focused framework differed from other patient-centered care frameworks.

• Segment instructional content: SGIM found that content related to incorporating health equity needed to be discussed separately from content about the basic diagnostic process; otherwise, the cognitive load was overwhelming for participants.

Project Products

• Three curriculum modules (in-progress)

• Crowdsourcing tool for video review

1 Anderson JL, Morrow DA. Acute myocardial infarction. N Engl J Med. 2017;376(21):2053-2064.

2 Gonzalez CM, Ark TK, Fisher MR, et al. Racial implicit bias and communication among physicians in a simulated environment. JAMA Netw Open. 2024;7(3):e242181. doi:10.1001/jamanetworkopen.2024. 2181

3 Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. 1995;102(1):4-27.

4 Feagin J, Bennefield Z. Systemic racism and U.S. health care. Soc Sci Med. 2014;103:7-14.

5 Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.

Advancing Diagnosis and Staging for Early Detection and Treatment of Peripheral Artery Disease to Prevent Amputation

Society for Vascular Surgery

Goals and Motivation

Each year, approximately 185,000 amputations occur in the United States. Peripheral artery disease (PAD) is one of the potential precursors to amputation. PAD is common among the aging population, and chronic limb-threatening ischemia (CLTI) represents the end stage of the disease. In addition to limb loss, CLTI can lead to pain, diminished health-related quality of life, and death.1,2 However, early diagnosis, accurate severity staging, and timely treatment of PAD/CLTI can prevent the need for invasive intervention, reduce morbidity and mortality, and save costs for patients and payers.1,2,3,4,5

The Society for Vascular Surgery (SVS), in partnership with the European Society of Vascular Surgery and the World Federation of Vascular Societies, has published the Global Vascular Guidelines (GVG), an evidence-based clinical practice guideline to advance CLTI care.

SVS designed their Diagnostic Excellence Initiative to promote the translation of the GVG into practice by conducting educational sessions for vascular healthcare teams. SVS planned for their educational activities and materials to take multiple forms, such as expert faculty discussions with interactive questions, supportive brief didactic case presentations with downloadable guidelines, interactive patient assessment demonstrations, slides, pocket guides, and access to validated diagnostic and staging tools.

Society for Vascular Surgery

Accomplishments

SVS conducted a virtual educational session, Structured Decision-Making in the CLTI Patient: Understanding the PLAN (Patient risk, Limb severity, ANatomic complexity). Facilitators demonstrated three staging systems/calculators and discussed them in the context of patient cases. Eight hundred and seventy-four individuals registered for, and three hundred and seventy-five individuals attended, the live webinar. As of January 2025, the webinar recording had nearly 600 views on YouTube.

SVS also held an in-person educational session, Informed Decision-Making in CLTI Patients, at their 2024 annual meeting. The session focused on shared, patientcentered decision making to individualize treatment recommendations. Three CLTI patients participated in the panel discussion; they also participated in a videoconference call prior to the session, so the organizers could learn more about their histories, backgrounds, and preferences. As of January 2025, the session recording had 575 views on YouTube.

SVS conducted pre- and post-tests for both their webinar and in-person sessions. They found improvements in participant knowledge, confidence, and competence for both sessions.

Key Learnings

• Patients value specialty care: CLTI patients thought they should have been referred to a vascular surgeon earlier than they were, and they wanted vascular surgeons to provide follow-up care after treatment.

• Prioritize patience and collaboration: CLTI patients advised clinicians to be patient, repeat information as much as needed, and involve them in decisionmaking. (All three patients were very happy with their vascular surgeons.)

• Patient involvement in clinician education is essential: SVS found it very valuable to include patients and their values, preferences, and expectations in the in-person conference session.

• Budget appropriate time: It took project staff more time than expected to work with faculty and patients and to plan and implement educational sessions.

Society for Vascular Surgery

Project Products

• Webinar: Structured Decision-Making in the CLTI Patient: Understanding the PLAN

• Session at SVS Annual Meeting: Informed Decision Making in CLTI

• Two new folders in the SVS app

o CLTI management; includes previously developed calculators for classification and staging the disease before treatment

o CLTI; includes 4 treatment algorithms

• Summary of patient histories, backgrounds, and preferences from patient videoconference

1 Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guideline on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019 Jul;58(1S):S1-S109.e33.

2 Conte MS, Mills JL, Bradbury AW, White JV. Implementing global chronic limb-threatening ischemia guidelines in clinical practice: utility of the Society for Vascular Surgery Threatened Limb Classification System (WIfI). J Vasc Surg. 2020 Oct;72(4):1451-1452

3 McGinigle KL, Minc SD. Disparities in amputation in patients with peripheral arterial disease. Surg. 2021;169(6):1290-4.

4 Fereydooni A, Patel J, Dossabhoy SS, George EL, Arya S. Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes. Semin Vasc Surg 2023 Mar;36(1):9-18.

5 McDermott KM, Bose S, Keegan A, Hicks CW. Disparities in limb preservation and associated socioeconomic burden among patients with diabetes and/or peripheral artery disease in the United States. Semin Vasc Surg. 2023 Mar;36(1):39-48.

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