End Diagnostic Overshadowing: Understanding and Reducing Diagnostic Error in Patients with Disabilities - Through our End Diagnostic Overshadowing: Understanding and Reducing Diagnostic Error in Patients with Disabilities program, we aim to identify mechanisms underlying diagnostic overshadowing and develop strategies for mitigation. Diagnostic overshadowing occurs when new or changing symptoms are attributed to an existing disability, mental health condition, or chronic condition rather than evaluated as a new or worsening condition. It contributes to diagnostic errors (i.e., missed, delayed, wrong diagnoses) that result in major causes of death in the US,12-14 and costs of >$100B/year.15 Some diagnoses are prone to diagnostic error including vascular events, infections, oral problems, and cancer.16 Specific populations of patents with disabilities (PWD) are known to be at increased risk, including those with major mobility impairments,17 severe mental health concerns,18,19 severe visual impairments,20 severe hearing loss,21 and intellectual and developmental disabilities.22 Diagnostic overshadowing may be influenced by patient-, provider-, and system-level mechanisms, including demographic characteristics, communication challenges, provider assumptions, and implementation of disability accessibility standards.26-34 We will use established methods, including analysis of Current Procedural Terminology (CPT) Evaluation and Management (E/M) code differences and Joint Commission-style individual mock tracers and systems-of-care tracers. We will analyze CPT E/M code differences by disability type and across demographic and clinical characteristics, including race, ethnicity, gender, and trauma exposure, followed by targeted retrospective chart reviews and staff interviews. We will develop and implement, across inpatient and outpatient settings, individual mock tracers following the care of patients with the specific listed disabilities, as well as systems of care tracers focused on evaluating the extent to which care systems incorporate accessibility, effective communication, reasonable accommodations, trauma-informed care,36and other processes that support timely and accurate diagnosis of conditions prone to diagnostic error. Mock tracer teams will provide formative evaluation of care to involved staff.44 Using inductive thematic analysis45 of chart reviews, interviews, and mock tracers, we will identify mechanisms underlying diagnostic overshadowing and how it contributes to diagnostic errors and then develop targeted education programs and EHR decision supports to reduce diagnostic errors among PWD. We will evaluate CPT codes (quantitative), chart reviews (mixed methods), and interview and tracer findings (qualitative) at Year 5 compared with Year 1 to assess changes associated with implementation of the intervention. We will evaluate mitigation efforts through 1) pre and post knowledge checks of usage of education programs and 2) descriptive pre and post data on use of specific EHR decision supports.47 If successful, we will have developed and implemented approaches to identify mechanisms underlying diagnostic overshadowing and developed and evaluated targeted educational programs and EHR decision supports to reduce diagnostic errors among PWD.
