Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
School of Public Health, University of Texas Health Science Center, Houston, TX, USA.
J Gen Intern Med. 2018 Jan;33(1):103-115. doi: 10.1007/s11606-017-4164-1. Epub 2017 Sep 21.
BACKGROUND: Physicians routinely encounter diagnostic uncertainty in practice. Despite its impact on health care utilization, costs and error, measurement of diagnostic uncertainty is poorly understood. We conducted a systematic review to describe how diagnostic uncertainty is defined and measured in medical practice. METHODS: We searched OVID Medline and PsycINFO databases from inception until May 2017 using a combination of keywords and Medical Subject Headings (MeSH). Additional search strategies included manual review of references identified in the primary search, use of a topic-specific database (AHRQ-PSNet) and expert input. We specifically focused on articles that (1) defined diagnostic uncertainty; (2) conceptualized diagnostic uncertainty in terms of its sources, complexity of its attributes or strategies for managing it; or (3) attempted to measure diagnostic uncertainty. KEY RESULTS: We identified 123 articles for full review, none of which defined diagnostic uncertainty. Three attributes of diagnostic uncertainty were relevant for measurement: (1) it is a subjective perception experienced by the clinician; (2) it has the potential to impact diagnostic evaluation-for example, when inappropriately managed, it can lead to diagnostic delays; and (3) it is dynamic in nature, changing with time. Current methods for measuring diagnostic uncertainty in medical practice include: (1) asking clinicians about their perception of uncertainty (surveys and qualitative interviews), (2) evaluating the patient-clinician encounter (such as by reviews of medical records, transcripts of patient-clinician communication and observation), and (3) experimental techniques (patient vignette studies). CONCLUSIONS: The term "diagnostic uncertainty" lacks a clear definition, and there is no comprehensive framework for its measurement in medical practice. Based on review findings, we propose that diagnostic uncertainty be defined as a "subjective perception of an inability to provide an accurate explanation of the patient's health problem." Methodological advancements in measuring diagnostic uncertainty can improve our understanding of diagnostic decision-making and inform interventions to reduce diagnostic errors and overuse of health care resources.
背景：医生在实践中经常会遇到诊断不确定性。尽管它对医疗保健的利用、成本和错误有影响，但对诊断不确定性的测量却知之甚少。我们进行了一项系统综述，描述了医学实践中如何定义和测量诊断不确定性。
方法：我们使用关键词和医学主题词 (MeSH) 的组合，从 OVID Medline 和 PsycINFO 数据库中进行了系统检索，检索时间截至 2017 年 5 月。此外，我们还使用了特定主题数据库 (AHRQ-PSNet) 和专家意见进行了额外的搜索策略。我们特别关注那些（1）定义了诊断不确定性的文章；（2）从其来源、属性的复杂性或管理策略方面对诊断不确定性进行概念化的文章；或（3）试图测量诊断不确定性的文章。
主要结果：我们确定了 123 篇进行全文审查的文章，但没有一篇文章定义了诊断不确定性。诊断不确定性的三个属性与测量相关：（1）它是临床医生主观感知到的；（2）它有可能影响诊断评估-例如，当管理不当时，它会导致诊断延迟；（3）它是动态的，随时间而变化。目前在医学实践中测量诊断不确定性的方法包括：（1）询问临床医生对不确定性的感知（调查和定性访谈），（2）评估医患接触（例如通过审查医疗记录、医患沟通的转录和观察），以及（3）实验技术（患者病历研究）。
结论：“诊断不确定性”一词缺乏明确的定义，也没有用于医学实践中测量诊断不确定性的综合框架。基于审查结果，我们建议将诊断不确定性定义为“对无法准确解释患者健康问题的主观感知”。在测量诊断不确定性方面的方法学进展可以提高我们对诊断决策的理解，并为减少诊断错误和过度使用医疗资源的干预措施提供信息。
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