Through our End Diagnostic Overshadowing: Addressing manifestations of ableism in the healthcare context
program we aim to identify and create understanding of mechanisms underlying diagnostic overshadowing and
mitigate and reduce its effects. Diagnostic overshadowing—attributing symptoms to disability rather than a
potentially new or comorbid condition—is a result of ableism. It contributes to diagnostic errors (i.e., missed,
delayed, wrong diagnoses) that result in major causes of death in the US,12-14 and are estimated to cost
>$100B/year.15 Some diagnoses are prone to diagnostic error including vascular events, infections, oral
problems, and cancer.16 Among people with disabilities (PWD), specific populations are known to be at-risk,
including those with major mobility impairments,17 mental health concerns,18,19 severe visual impairments/
blindness,20 severe hearing loss/deafness,21 intellectual and developmental disabilities (IDD).22 People from
marginalized racial and ethnic groups as a whole are at higher risk of diagnostic overshadowing,26-28 as are
people who have experienced trauma.29 And, PWD and people from marginalized racial and ethnic groups are
at higher risk for trauma.30-32 The intersections make PWD from marginalized racial and ethnic groups at
particularly high risk.33,34 We will use established methods of analysis of Current Procedural Technology (CPT)
evaluation and management (E/M) code differences and Joint Commission-style individual mock
tracers and environment of care tracers to identify underlying mechanisms of diagnostic overshadowing We will
analyze CPT E/M code differences by presence of the above specific disabilities and influenced by race, ethnicity,
gender and other intersectional identities followed by targeted retrospective chart reviews and staff interviews.
Using this information, we will update/develop and conduct in both inpatient and outpatient settings individual
mock tracers following the care of patients with the specific disabilities listed above and an environment of care
tracer focused on the environment surrounding diagnostic overshadowing. Mock tracer teams will provide
formative evaluation of care to involved staff.44 Using inductive thematic analysis 45 of notes from chart reviews,
interviews, and mock tracers, we will identify themes of mechanisms underlying diagnostic overshadowing. We
will partner with affected groups to confirm and prioritize themes through a Participatory and Planning Model
process46 and then develop targeted education programs and Electronic Health Record decision supports to
mitigate and reduce diagnostic overshadowing. We will evaluate CPT codes (quantitative), chart reviews (mixed
methods) and interviews and tracer results (qualitative) at Year 5 compared to Year 1 expecting changes. 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
a system for identifying and creating understanding of mechanisms underlying diagnostic overshadowing and
will have created specific means to mitigate and reduce its effects.