Clinical Trials Logo

Clinical Trial Summary

10 to 35% of patients admitted to an emergency department receive an incorrect diagnosis. Not surprisingly, given the wide variety of health conditions encountered in emergency medicine, physicians often do not consider, remember, or know all possible diagnoses that fit the patient's symptoms. Nowadays, computer software (CDDS) is able to support physicians with a list of possible diagnoses by matching entered patient data to a large database with diagnoses. However, it is still unclear how the use of such a CDDS actually affects the diagnostic quality and workflow in 'real world' ER routine care. Therefore, the aim of this cluster-randomized cross-over trial is to evaluate the consequences of CDDS usage on diagnostic quality, patient outcomes and diagnostic workflow within the ER. Four ER's will provide a CDDS to the diagnosing physicians for specific periods (randomly and alternatingly allocated) in which physicians will be asked to use it for all included study patients. Outcomes between periods with and without the CDDS will be compared. Primary outcome is a diagnostic quality risk score composed of unscheduled ER revisits, unexpected hospitalization (both within 14 days), unexpected intensive medical care unit admission if hospitalized and diagnostic discrepancy between the ER discharge diagnosis and the current diagnosis after 14 days. In total, 1'184 patients will be included.


Clinical Trial Description

Background: Misdiagnosis occurs in about 5% of outpatients, and in 10% to 35% of emergency room (ER) patients, sometimes with devastating medical and economic consequences. Nowadays, computerized diagnostic decision support programs (CDDS) exist, which suggest differential diagnoses (DDx) to physicians and thus have potential to improve diagnoses and hence, outcomes of patient care. The effects of such CDDS in 'real-world' ER settings are unknown. Controlled clinical trials investigating their effectiveness and safety are absent. In addition, most available CDDS are overcautious and suggest a wide variety of diagnostic options, likely increasing diagnostic resource consumption. Objectives: With this project, the investigators aim to understand the intended and unintended consequences of CDDS use by physicians on diagnostic quality and workflow in emergency medicine - on the micro-level, how CDDS affect diagnostic quality by physicians in individual emergency patients. - on the meso-level, how CDDS affect the diagnostic workflow in emergency departments. - on the macro-level, the economic and educational impact of CDDS utilization in ERs Outcomes: Details given below Design: Cross sectional, multi-center, four-period cross-over controlled cluster-randomized trial. Four ER sites will randomly be allocated to one of two sequences with alternating intervention and control periods (ABAB vs. BABA) with each period lasting for two months. Recruitment will target 74 patients per period and cluster and 1'184 patients total. Inclusion / Exclusion Criteria: Details given below Intervention period: Details given below Control period: Details given below. Measurements and procedures: For the primary outcome, data will be extracted from the electronic health records (i.e. ER diagnosis, intensive care unit admission or diagnosis after 14d if patients are still hospitalized). Additionally, patients and their general practitioner will be contacted via telephone by study nurses after 14d of study inclusion in order to collect information about patients' current diagnoses, and re-visits or hospitalization related to the initial ER visit. Data for secondary endpoints will be retrieved from the routinely collected data in the electronic health record system (e.g mortality, time to ER diagnosis, resource consumption). Additionally, interviews and focus groups with physicians will be performed to investigate diagnostic workflow changes, physician confidence and other process outcomes. Statistical Analysis: Statistical analysis will be based on multi-level general linear mixed modelling (GLMM) methods using appropriate post hoc techniques (e.g for subgroup analyses). For the primary outcome (presence or no presence of a positive diagnostic quality risk score), a generalized linear mixed model (GLMM) with a binomial distribution family and exchangeable correlation structure will be performed. The GLMM takes into account a random effect for each site, resident and attending physician. Diagnosing resident and attending physicians are nested within sites. The condition (intervention and control) and the period (period 1 to 4) will be included as fixed factors under the assumption of equality of carry-over effects. Additionally, presenting chief complaint, patient's age, sex and comorbidity index will be added as covariates. For all secondary endpoints, summary statistics appropriate to the distribution will be tabulated by treatment group. Analysis of secondary endpoints will parallel the primary analysis. ;


Study Design


Related Conditions & MeSH terms


NCT number NCT05346523
Study type Interventional
Source Insel Gruppe AG, University Hospital Bern
Contact
Status Completed
Phase N/A
Start date June 9, 2022
Completion date July 13, 2023

See also
  Status Clinical Trial Phase
Completed NCT05552989 - Towards Better Preparedness for Future Catastrophes - Local Lessons-learned From COVID-19
Not yet recruiting NCT04915690 - Investigation on the Practice Status of Emergency Stuff
Not yet recruiting NCT03424096 - Primary Palliative Care Education, Training, and Technical Support for Emergency Medicine N/A
Completed NCT02534324 - The Effect of Pre-discharge Blood Pressure of Patients With Asymptomatic Severe Hypertension in Emergency Department N/A
Completed NCT00991471 - The Effect of an Physician-Nurse Supplementary Triage Assistance Team on Emergency Department Patient Wait Times N/A
Recruiting NCT03257319 - Inhaled vs IV Opioid Dosing for the Initial Treatment of Severe Acute Pain in the Emergency Department Phase 3
Recruiting NCT05005117 - Laparoscopic Approach for Emergency Colon Resection N/A
Recruiting NCT03917368 - Ultrasound Evaluation of the Jugular Venous Pulse (US-JVP) N/A
Completed NCT04601922 - Qualitative Study of Long Term Cardiovascular Risk Prediction in the Emergency Department
Recruiting NCT05497830 - Machine Learning for Risk Stratification in the Emergency Department (MARS-ED) N/A
Active, not recruiting NCT06220916 - The Greek Acute Dance Injuries Registry
Recruiting NCT05496114 - Medical Checklists in the Emergency Department N/A
Recruiting NCT06072534 - Evaluation of Effectiveness of Two Different Doses of Mivacurium in Rapid Sequence Intubation N/A
Recruiting NCT05543772 - Evaluation of Blood Sampling From a Pre-existed Peripheral Intravenous Catheter Line Phase 4
Not yet recruiting NCT05528211 - Safety and Efficacy of Emergent TAVI in Patients With Severe AS
Completed NCT05818215 - Impact of the Qatar 2022 FIFA World Cup on PED Use and Misuse Patterns
Recruiting NCT04615065 - Acutelines: a Large Data-/Biobank of Acute and Emergency Medicine
Active, not recruiting NCT05221697 - Effect of an ML Electronic Alert Management System to Reduce the Use of ED Visits and Hospitalizations N/A
Active, not recruiting NCT04648449 - Artificial Intelligence (AI) Support in Medical Emergency Calls
Not yet recruiting NCT04431986 - ER2 Frailty Levels and Incident Adverse Health Events in Older Community Dwellers