Blog | Friday, May 8, 2015

The danger of admission diagnoses


Now that is a strange title. How can a diagnostic label cause problems? Yet, our current insurance environment actually causes diagnostic delays and errors.

As I understand it, patients need an admission diagnosis to justify admission to insurance companies. Often in the hospital “quality assurance” representatives require me to assign a diagnosis so that the insurance company will “approve” the admission.

When I started, we admitted patients because they were sick and we needed to figure out what was causing the illness. A tweet stimulated this post. One of our favorites (@medicalaxioms) tweeted:

Call from ER resident: “I'm admitting this guy for pneumonia. Only thing missing is infiltrate on CXR. And fever. But he does have a cough.”

Once patients have a label attached, thinking is often stifled. Cognitive psychologists call this the “anchoring heuristic.” Too often we take comfort in an assigned diagnosis, and proceed to start treatment without questioning the diagnosis. We all do that.

But often the admission diagnosis is merely a guess. Our residents know that I assume all CAP (community acquired pneumonia) admissions have something else. I personally find this the most dangerous admission diagnosis. But many admission diagnoses are incorrect, because many diagnoses take time to become clear.

Why do we have to provide an admission label? Again quoting our tweet master:

I'm just as happy to admit “cough fever SOB looks sick.” Happier, actually.

We, who receive admissions, must avoid premature closure. Listing symptoms allows us to develop a diagnostic strategy.

If we hope to decrease diagnostic errors, we must emphasize not labeling patients with a diagnosis until we have sufficient certainty. Now how do we explain that to the insurance companies and the “quality assurance” department?

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.