Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

OBJECTIVES: The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach. METHODS: SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared. RESULTS: There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits. CONCLUSIONS: Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.

Background Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy. Methods We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO's proprietary taxonomy. Results A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases. Conclusions Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

BACKGROUND: An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI. METHODS: We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older. RESULTS: We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses. CONCLUSIONS: Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

Intraventricular thrombolysis in intracerebral hemorrhage requiring ventriculostomy: a decade-long real-world experience.

BACKGROUND AND PURPOSE: Intraventricular thrombolysis (IVT) is a promising treatment in facilitating intraventricular clot resolution after intraventricular hemorrhage. We examined in-hospital outcomes and resource utilization after thrombolysis in patients with intraventricular hemorrhage requiring ventriculostomy in a real-world setting. METHODS: We identified adult patients with primary diagnosis of nontraumatic intracerebral hemorrhage requiring ventriculostomy from the Nationwide Inpatient Sample from 2002 to 2011. We compared demographic and hospital characteristics, comorbidities, inpatient outcomes, and resource utilization measures between patients treated with IVT and those managed with ventriculostomy, but without IVT. Population estimates were extrapolated using standard Nationwide Inpatient Sample weighting algorithms. RESULTS: We included 34 044 patients in the analysis, of whom 1133 (3.3%) received IVT. The thrombolysis group had significantly lower inpatient mortality (32.4% versus 41.6%; P=0.001) and it remained lower after controlling for baseline demographics, hospital characteristics, comorbidity, case severity, and withdrawal of care status (adjusted odds ratio, 0.670; 95% confidence interval, 0.520-0.865; P=0.002). There was a trend toward favorable discharge (home or rehabilitation) among the thrombolysis cohort (adjusted odds ratio, 1.335; 95% confidence interval, 0.983-1.812; P=0.064). The adjusted rates of bacterial meningitis and ventricular shunt placement were similar between groups. The thrombolysis group had longer length of stay and higher inflation-adjusted cost of care, but cost of care per day length of stay was similar to the non-IVT group. CONCLUSIONS: IVT for intracerebral hemorrhage requiring ventriculostomy resulted in lower inpatient mortality and a trend toward favorable discharge outcome with similar rates of inpatient complications compared with the non-IVT group.

Rising annual costs of dizziness presentations to U.S. emergency departments.

OBJECTIVES: Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency department (ED). Little is known about the aggregate costs of ED evaluations for these patients. The authors sought to estimate the annual national costs associated with ED visits for dizziness. METHODS: This cost study of adult U.S. ED visits presenting with dizziness or vertigo combined public-use ED visit data (1995 to 2009) from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and cost data (2003 to 2008) from the Medical Expenditure Panel Survey (MEPS). We calculated total visits, test utilization, and ED diagnoses from NHAMCS. Diagnosis groups were defined using the Healthcare Cost and Utilization Project's Clinical Classifications Software (HCUP-CCS). Total visits and the proportion undergoing neuroimaging for future years were extrapolated using an autoregressive forecasting model. The average ED visit cost-per-diagnosis-group from MEPS were calculated, adjusting to 2011 dollars using the Hospital Personal Health Care Expenditures price index. An overall weighted mean across the diagnostic groups was used to estimate total national costs. Year 2011 data are reported in 2011 dollars. RESULTS: The estimated number of 2011 US ED visits for dizziness or vertigo was 3.9 million (95% confidence interval [CI] = 3.6 to 4.2 million). The proportion undergoing diagnostic imaging by computed tomography (CT), magnetic resonance imaging (MRI), or both in 2011 was estimated to be 39.9% (39.4% CT, 2.3% MRI). The mean per-ED-dizziness-visit cost was $1,004 in 2011 dollars. The total extrapolated 2011 national costs were $3.9 billion. HCUP-CCS key diagnostic groups for those presenting with dizziness and vertigo included the following (fraction of dizziness visits, cost-per-ED-visit, attributable annual national costs): otologic/vestibular (25.7%; $768; $757 million), cardiovascular (16.5%, $1,489; $941 million), and cerebrovascular (3.1%; $1059; $127 million). Neuroimaging was estimated to account for about 12% of the total costs for dizziness visits in 2011 (CT scans $360 million, MRI scans $110 million). CONCLUSIONS: Total U.S. national costs for patients presenting with dizziness to the ED are substantial and are estimated to now exceed $4 billion per year (about 4% of total ED costs). Rising costs over time appear to reflect the rising prevalence of ED visits for dizziness and increased rates of imaging use. Future economic studies should focus on the specific breakdown of total costs, emphasizing areas of high cost and use that might be safely reduced.

25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank.

BACKGROUND: We sought to characterise the frequency, health outcomes and economic consequences of diagnostic errors in the USA through analysis of closed, paid malpractice claims. METHODS: We analysed diagnosis-related claims from the National Practitioner Data Bank (1986-2010). We describe error type, outcome severity and payments (in 2011 US dollars), comparing diagnostic errors to other malpractice allegation groups and inpatient to outpatient within diagnostic errors. RESULTS: We analysed 350 706 paid claims. Diagnostic errors (n=100 249) were the leading type (28.6%) and accounted for the highest proportion of total payments (35.2%). The most frequent outcomes were death, significant permanent injury, major permanent injury and minor permanent injury. Diagnostic errors more often resulted in death than other allegation groups (40.9% vs 23.9%, p<0.001) and were the leading cause of claims-associated death and disability. More diagnostic error claims were outpatient than inpatient (68.8% vs 31.2%, p<0.001), but inpatient diagnostic errors were more likely to be lethal (48.4% vs 36.9%, p<0.001). The inflation-adjusted, 25-year sum of diagnosis-related payments was US$38.8 billion (mean per-claim payout US$386 849; median US$213 250; IQR US$74 545-484 500). Per-claim payments for permanent, serious morbidity that was 'quadriplegic, brain damage, lifelong care' (4.5%; mean US$808 591; median US$564 300), 'major' (13.3%; mean US$568 599; median US$355 350), or 'significant' (16.9%; mean US$419 711; median US$269 255) exceeded those where the outcome was death (40.9%; mean US$390 186; median US$251 745). CONCLUSIONS: Among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes. We found roughly equal numbers of lethal and non-lethal errors in our analysis, suggesting that the public health burden of diagnostic errors could be twice that previously estimated. Healthcare stakeholders should consider diagnostic safety a critical health policy issue.