What is premature diagnostic closure?

From the Guidelines

Premature diagnostic closure should be avoided by maintaining a differential diagnosis list, actively seeking disconfirming evidence, and regularly reassessing diagnostic reasoning, as it can lead to delayed proper treatment, unnecessary interventions, and patient harm. To minimize the risk of premature diagnostic closure, healthcare providers must be aware of the potential for cognitive errors and take steps to mitigate them. This includes recognizing the limitations of initial findings and being open to alternative explanations as more information becomes available. The importance of timely follow-up and diagnostic testing is highlighted in a systematic review from the PROSPR consortium, which notes that prompt diagnostic testing can enable the detection of cancer earlier in its course and potentially reduce mortality risk 1. However, this review also emphasizes the need for evidence to guide the timeliness of diagnostic testing after a positive screening test, underscoring the complexity of balancing the benefits of rapid follow-up with the potential drawbacks, such as increased resource utilization. Key strategies to prevent premature diagnostic closure include:

• Maintaining a broad differential diagnosis list to consider all possible explanations for a patient's symptoms
• Actively seeking disconfirming evidence to challenge initial diagnostic impressions
• Regularly reassessing diagnostic reasoning as new information emerges
• Implementing diagnostic time-outs to pause and reflect on the diagnostic process
• Consulting colleagues for second opinions to bring fresh perspectives to the case
• Acknowledging and addressing cognitive biases that can lead to premature closure. By adopting these strategies, healthcare providers can reduce the risk of premature diagnostic closure and improve patient outcomes by ensuring that diagnoses are accurate and timely, and that appropriate treatment is initiated without unnecessary delay.

From the Research

Premature Diagnostic Closure

• Premature diagnostic closure is a significant contributor to diagnostic error, and developing strategies to mitigate it could reduce diagnostic errors and improve patient care 2.
• The pursuit of an "endpoint diagnosis" can be used as a cognitive forcing strategy to avoid premature diagnostic closure, which involves identifying an underlying causative explanation for a patient's signs, symptoms, and laboratory and radiographic data that exhausts additional relevant diagnostic evaluation 2.
• There are four contexts in which the error of not pursuing an endpoint diagnosis most often occurs:
  • Diagnoses that appear to result in the same treatment regardless of etiology
  • Cases that are particularly complex
  • Clinical scenarios that are vulnerable to systems errors
  • Situations in which patients' problems are attributed to uncontrolled underlying risk factors or an exacerbation of a known condition 2

Avoiding Premature Closure

• A more reliable way to avoid premature closure is to discontinue testing only when the lower bound for the probability of the leading hypothesis reaches an acceptably high level, such as 70% 3.
• Another reason to discontinue testing may be that further evidence can at best increase the probability of the leading hypothesis by a small amount, for example, if the probability of the leading hypothesis is 72%, with a lower bound of 65% and an upper bound of 75% 3.
• Factors associated with the ability to process information in ways that overcome premature closure and result in accurate diagnosis include the mean number of items in the differential, tendency to persist, and openness to switch diagnoses 4.

Diagnostic Accuracy

• Diagnostic accuracy was associated with the mean number of items in the differential, tendency to persist, and openness to switch diagnoses, regardless of level of training or clinical experience 4.
• The use of large language models, such as the Articulate Medical Intelligence Explorer (AMIE), can improve clinicians' diagnostic reasoning and accuracy in challenging cases, and can assist in generating a differential diagnosis alone or as an aid to clinicians 5.