• Michael Usher, Nishant Sahni, Dana Herrigel, Gyorgy Simon, Genevieve B Melton, Anne Joseph, and Andrew Olson.
• Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA. mgusher@umn.edu.
• J Gen Intern Med. 2018 Sep 1; 33 (9): 1447-1453.

BackgroundStudying diagnostic error at the population level requires an understanding of how diagnoses change over time.ObjectiveTo use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.DesignDiagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.ParticipantsPatients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.Main MeasuresWe identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.Key ResultsDiscordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001).ConclusionsDiagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

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